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Your email address will not be published.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
Ken Grauer, MD
Understanding Digoxin
Digoxin is used much less frequently these days than in the past - when it was a drug that virtually every patient with heart failure was taking. As a result - many clinicians in modern times are far less familiar (and comfortable) with how to dose Digoxin. Digoxin pharmacokinetics are linear - You double the…
2015-04-16 03:27:43
Ralph A
Transcutaneous Pacing Success!!! Part 1
Oh that was great....!!
2015-04-11 01:34:07
Ivan Rios
Understanding Amiodarone
I like your thought process. A Its not that Amiodarone is contraindicated in Hyperkalemia. In the event of arrest, Hyperkalemia usually leads to PEA and asystole. The Hyperkalemic effects on Action potential and Sodium potassium atpase channels should be addressed first in order for Amiodarone to work effectively. Once this is achieved, proper depolarization and…
2015-04-09 18:28:22
C galliher
Understanding Amiodarone
I hate cook book medics. I just do what my protocols say”.
2015-04-09 18:25:40
Chris g
Understanding Amiodarone
Cook book medic. I just do what my protocols say”.
2015-04-09 18:24:27

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