Found on the Lifenet Receiving Station

Is there anything about this ECG (other than the poor data quality) that interests you?

The patient was a 90 year old male, fall with injury. Also complaining of pain between the shoulder blades.

*** UPDATE ***

This ECG caught my eye because it satisfies one of Sgarbossa’s criteria for the identification of AMI in the presence of LBBB. Specifically, the concordant ST-segment depression in lead V3 is a highly suspicious finding.

As a stand-alone finding, concordant ST-segment depression in a right precordial lead gives this ECG a score of 3 out of 10 (probability of AMI 66%).

I personally don’t think it’s necessary to score the ECG. As far as I’m concerned, an ECG that meets any of the criteria should be considered equivalent to an ECG showing acute STEMI, especially when you consider the depth of the S-wave in leads showing discordant ST-elevation (see previous posts on this issue).

So was this patient experiencing an acute STEMI? Here’s what I found out.

Patient (90 y.o.) arrived via EMS from XXXXXXXX after falling; there was no LOC, but did complain of back pain between the shoulder blades and diffuse abdominal pain. Extensive PMH: AAA, non-operable, HTN, CAD, CABG, LBBB, anemia, cardiomyopathy and dementia. The ED physician spoke to the daughter extensively who did not want her father worked up, but did consent to a thoracic x-ray and stated she only wanted him to receive pain medication and return transport to the XXXXXXXX and did not want any further diagnostics noting that his dementia worsens when he is out of his environment. He has a living will /advanced directive on file and with him a DNR order.

He was given pain medication in the ED, the thoracic film showed no acute injury and a prescription for Lortab was written and he was sent back to the nursing home. He did not have an EKG performed on this visit or any other diagnostics. The patient was here for an admission in 6/2009 and it appears that the EKGs are very similar.

Interesting!

When designing a STEMI program you have to make difficult choices when it comes to exclusion criteria like age, DNR status, and neurological status. Was this patient experiencing an acute thrombotic event in an epicardial coronary artery? I guess we’ll never know.

It’s possible this ECG finding was old and it’s possible it was secondary to aortic dissection or aneurysm.

See also:

80 year old male CC: Chest pain

Excessive discordance as a marker of acute STEMI in LBBB

80 year old male CC: Chest pain – Conclusion

58 year old female CC: Chest pain

58 year old female CC: Chest pain – Conclusion (meets all 3 of Sgarbossa’s criteria)

62 year old male CC: Chest pain (LBBB with ST-elevation > 0.2 the QRS complex)

Identifying AMI in the presence of LBBB – Sgarbossa’s Criteria Part I

Identifying AMI in the presence of LBBB – Sgarbossa’s Criteria Part II

“New” LBBB – What’s the big deal?

Discordant ST-segment elevation in LBBB or paced rhythm

Sgarbossa’s Criteria – New Graphic

11 Comments

  • Billy says:

    The biphasic T waves in V2 and V3 are classic Wellen's syndrome. I also don't like that the T waves in V1 are positive, and that they are taller than V6, though since there is a LBB present this may be a normal variant. With the pain between the shoulders and the abnormal T waves I think this patient has an acute MI developing and should have serial EKG's taken.

  • SoCal Medic says:

    I don't like the bi-phasic t Waves and the bradycardia in a 90 year old male. But I am sure there is something here I have not learned yet and I am anxious to see your response..

  • Nicky G says:

    Non diagnostic quality? 0.05hz – 0.4hz is required for ST changes. there for the ST depression in V3456 is questionable, but im really guessing. Also LBBB makes it really difficult to distinguish STEMI but im pretty sure that is depression anyway. Rx symptomatically and try for a better quality ecg…oh yeah not sure what wellens sign is either, outof my pay grade :P

  • Jesse says:

    My measurements: HR~55; Axis~-30;PR~200;QRS~160;ST depression in V4,V5,V6; Depression with T wave involvment in I,V3,aVL; Mild ST elevation in II; More significant elevation in III,V1,V2,aVR.Given how diffuse the ST segment changes are, there are a number of things that could be considered.Starting with Billy's thoughts, I kinda see where you get the idea for Wellen's. While I didn't see the biphasic T waves in V2, there are certainly some T abnormalities in V3, along with no q waves and normal R/S transition. However, ST elevation isnt commonly seen in Wellens, and there are lots of elevation (and what appears to be some reciprocal depression). So I discarded Wellens as a theory.Next, given how diffuse the ST changes were, I thought pericarditis. But the other common signs, such as non-reciprocal ST changes and PR depression in II, and PR elevation in aVR, aren't present, so I tossed that one too.Final thought? SB with LAD, and borderline 1deg AVB (unknown if these are new or not), as well as septal-inferior AMI (elevation >= 2mm in V1,V2 and mild elevation in II, with elevation >= 1mm in III and reciprocal depression in aVL)with posterior myocardial involvement (significant depression in V3 with the classic "tombstone T" appearance when the ecg is flipped, and depression in V4). Its my speculation that V2 would show signs of posterior MI as well, were the anterior infarct not superseding its affects on the ecg.

  • Jesse says:

    Ick. I left out that pesky QRS duration. Given that the ST changes dont meet the criteria for AMI in the presence of LBBB, then Im led to believe the patient's LBBB is new in onset; a very bad sign when associated with AMI. Combined with all his other indications, Id say this good sir needs to get to the cath lab. Now. Go Go Go.PS- I apologize for my novel-esque entries. Bad habit?

  • Tom B says:

    Jesse -I don't have a problem with novel-esque entries! Just glad you're leaving comments.I do have a question though. What makes you say this ECG does not meet the criteria for AMI in the presence of LBBB?Look again very carefully….Tom

  • Brian T says:

    Concordant ST changes (most pronouced in V3 here) are concerning for STEMI in the presence of LBBB (Scarbossa criteria).

  • Tom B says:

    Nicky G – As long as the low frequency (high pass) filter is set to 0.05 Hz you should get accurate ST-segments. The high frequency (low pass) filter can be 40 or 150 Hz.Tom

  • Tom B says:

    Brian T -That's what I was looking for! The concordant ST-segment depression in lead V3 satisfies one of Sgarbossa's criteria. As a stand-alone finding it would get a score of 3 (probability of AMI 66%).Tom

  • Mark P says:

    Nice ECG. It’s a little hard to apply the Sgarbossa criteria when the patient has had previous CABG, but the ST depression is convincing. He also has the Sign of Cabrera – notching of > 0.05s in V3 or V4. So it is very likely that he has scar. And probably has a new occlusion.

  • Tom B says:

    Hey! Thanks for the comment, Mark P.! I appreciate your insight.

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

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Comments
know it all parapup
83 Year Old Male: Shortness of Breath
@ Kyle I would question your authority to call out people for not having a license or being a know it all parapup when your tx basically entails "call medical control." I think we can both agree that his cardiac output is not great at all. I assume your reluctance to give him any other…
2014-10-30 20:26:11
Kyle
83 Year Old Male: Shortness of Breath
Well st elevation in avr and v1 associated with anterior and lateral depression would call for possible posterior wall MI. 15 lead would be in order. Also check all the leads for appropriate placing. If v7, v8, and v9 show the elevation i would treat as a STEMI per my protocol. Asprin only until medical…
2014-10-30 18:14:05
Tim
The most awesome STEMI test on the internet!
Thanks for the app. It made me think about all that one may see in the field. The only problem was I never got a score or saw the results of how I did other than saying I had completed the test. Anyway a great way to get the old brain working.
2014-10-30 13:14:27
Brian
83 Year Old Male: Shortness of Breath
I mostly agree with dustin. I believe this is may be an isolated posterior MI. The R wave in V2 points to it being a posterior MI. otherwise it is a 1st degree av block with a LAHB. I am somewhat concerned with the concordant t segment depression noted and in fact if you were…
2014-10-30 04:22:44
Karl Brennan
Understanding Amiodarone
Great article , however in VF caused by hyperkalemia it should be avoided along with lidocaine , Since it shuts down the K channels, the eiteiology of the arrest hyper K, K channels are needed to exchange K in the cell. Calcium , Bicarbonate, dextrose and insulin should be used to decrease K levels along…
2014-10-30 03:04:45

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