58 year old female CC: Chest pain – Conclusion

Here’s the conclusion to the 58 year old female with chest pain and left bundle branch block.

To refresh your memory here is the 12-lead ECG.

2010_07_23_Bwm

And for those of you who requested lead V4R.

LBBB_STEMI_V4R

This ECG meets all 3 of Sgarbossa’s criteria to identify acute STEMI in the presence of left bundle branch block.

Sgarbossa

Slide1-1

Slide2-1

Slide3

Keep in mind, it only has to meet one criterion in one lead!

(Please note: One criterion has been modified from its original form. Instead of discordant ST-elevation > 5 mm we are looking for discordant ST-elevation > 0.2 the depth of the S-wave. This is known as the ST/QRS ratio. Credit to Dr. Smith of Dr. Smith’s ECG Blog.)

Angiography revealed 100% occlusion of the LCX and 99% occlusion of the RCA.

Thanks to everyone who commented on the case!

5 Comments

  • akroeze says:

    Thanks so much for this real world example Tom!I have actually made printouts of the graphics you use for the three criteria and taped them to the back cover of my protocol book since for some reason I have a hard time committing them to memory. I encourage others to do the same.I'm not sure how things will go the first time I find one of these though as the patient would not meet my current protocol… so I guess I would be at the mercy of the physician knowing what I'm talking about!

  • Tom B says:

    My pleasure, Alex. I'm amazed it took this long.

  • Do you have a refrencve for the "newer: criteria ST greater than 0.2 of S wave

  • Tom B says:

    Bostonmedic109 -Initially it was 0.25 the QRS complex.For a reference see:Circulation. 2008;118:S_578ACS: Initial Assessment-Old and New ToolsAbstract 551: Ratio of Discordant ST Segment Elevation or Depression to QRS Complex Amplitude is an Accurate Diagnostic Criterion of Acute Myocardial Infarction in the Presence of Left Bundle Branch BlockSince then Dr. Smith has reported on his blog that more cases and further analysis have revealed that using 0.2 increases the sensitivity while maintaining the same specificity.Tom

  • Vrhegyi Mrton says:

    Nice and useful article!:-)

    Any q/Q waves in left-sided leads (I, aVL, V5-6) and other markers of necrosis in LBBB (Cabrera's sign etc.) might also be important, however, can be the result of prior myocardial infarction or atypical form of LBBB.

4 Trackbacks

Leave a Reply

Your email address will not be published. Required fields are marked *

EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Comments
Sharon Sinclair
The 12 Leads of Christmas: V3
As a technician, I absolutely love how comprehensive these posts are. Although I do not have the advanced knowledge or understanding of a licensed provider, I try to absorb as much as I can from posts like these. Maybe one day I will muster the courage to transition to a more advanced position in cardiac…
2015-02-28 20:40:17
A visit to Johns Hopkins #EMSToday2015 | EMS 12 Lead
Episode #11 – Are we harming patients with oxygen?
[…] might remember Mike from one of our most popular EMS 12-Lead podcasts Episode #11: Are we harming patients with oxygen? We finished up the night with food and adult beverages in the […]
2015-02-25 14:33:03
Rollo
The Trouble with Sinus Tachycardia
Had a pt today with a rate @ and around 160, it was indeed sinus tachycardia. The tachycardia was secondary to a stimulant which caused over stimulation of sympathetic nervous system ie sympathomimetic O.D. The treatment was fluid and a benzo. Problem solved.
2015-02-25 00:14:18
Jeff Reader
The 12 Leads of Christmas: V3
When looking at how the heart sits in the chest and how things are named remember they were probabily named during autopsys when the cadaver was on its back.
2015-02-24 16:55:04
darren
58 year old female CC: Chest pain
I would be inclined to ignore QTC as rate is above 100 and unreliable to interpret less than 50 or more than 80. ST segments are interesting as is the history. PE was my first impression AnterioSeptal MI second impression but I'm inclined to consider LV Aneurysm as third Impression as no reciprocal changes?
2015-02-24 04:01:24

STEMI Expert?

  • Click here to find out!
  • 12-Lead ECG Challenge Smartphone App

    Photobucket

    12-Lead ECG Challenge Smartphone App - $5.99

  • Apple iOS
  • Android
  • Amazon
  • Web Based

  • FRN-TV video review
  • iMedicalApps.com review
  • Interested in resuscitation?

    FireEMS Blogs eNewsletter

    Sign-up to receive our free monthly eNewsletter

    Visitor Map / Stats

    Locations of visitors to this page


    LATEST EMS NEWS

    HOT FORUM DISCUSSIONS