64 year old female CC: Trouble Breathing

Thanks go to Michael Herbert for this great case! As always, some details have been changed to protect patient privacy.

It’s late into your shift when the tones go off for breathing problems at a local extended care facility. Enroute you’re advised it is a 64 year old female with a “low O2 sat,” and to, “use the main entrance.”

As you arrive a staff member is waiting for you at the door and directs you to a familiar room. The patient, a larger woman well known to your unit, is noticably anxious and struggling to breathe even on a nasal cannula.

The staff informs you she’s not been feeling well all day, and only recently developed shortness of breath. Your partner places the patient on a non-rebreather at 15 L/min and grabs a quick set of vitals.

A quick look at the patient reveales pale skin, circumoral cyanosis, pink frothy sputum, and a respiratory rate in excess of 30. She has a long cardiac history, and is often transported by your service. Your partner relays her vitals:

  • Pulse: 120 bpm, weak radials
  • B/P: 110/74
  • SaO2: 78% on 2 L/min via NC
  • Resps: 36, shallow
  • BGL: 224 mg/dL

Auscultation of her lungs reveals rales in all fields.

Your partner asks if you’d like to put her on the monitor and you reply, “let’s get moving and get it in the truck.”

Once in the back of the truck you begin attaching the monitor, while your partner prepares CPAP. Her oxygen saturations have improved to 89% and her pulse and respirations have decreased noticably on the non-rebreather.

The rhythm strip is obscured due to patient movement, however, the 12-Lead prints out without issue.

You’re 20 minutes from a PCI capable center and 5 minutes from a community hospital where the patient’s physician often has her transported.

What does this 12-Lead ECG show?

What interventions does this patient need?

Do you need anymore information to make the appropriate treatment and transport decision?

46 Comments

  • Ben says:

    Sinus rhythm with 1st degree heart block. Significant acute ST elevation in v2-v5. Looks like lateral involvement as well due to hints of ST elevation in I & aVL with reciprocal depression in II, III & aVF. There is LAD and the QRS is widened however the morphology in I and v6 is not fitting for a LBBB.
    She needs aspirin, o2 support – ?cpap (not part of my normal interventions so unsure of indication/contraindications), IV access and transport to PCI centre. Consider GTN for symptom relief balanced against BP – i fthe BP improves then would try it if it stays borderline low then hold off.
    She is not in significant pain so hold off on the morphine unless this changes.
    I would guess that its a massive left ventricle infarct causing some form of LVF.

  • Steve says:

    The 12-lead shows an LBBB, so by our protocols, that excludes a STEMI. As she has an extensive cardiac history, I don’t imagine it is new. We’d transport to the local hospital. En route, I’m treating for CHF. CPAP, IV and nitro. I’m worried about her BP. It’s low for someone in afluid overload. I’d get the dopamine drip ready in case her BP crashes her into cardiogenic shock. I’d like to know her temp to officially r/o pneumonia but the pink frothy sputum pretty much tells me what I need to know. I’d like to see a meds list to really know her past history as well.

  • BigWoodsMedic says:

    Before reading Ben's comment, I called this a LBBB with 1st degree heart block, and V5 shows concordant changes. I never remember the changes for I and V6 for LBBB, so now I'm not 100% sure on the rhythm. Regardless, she's very sick. I'd like to know when this started, sudden or slow onset (hoping I don't get a "I dunno, I just came in!"). Per my local area/hospitals, I'd take this patient to the facility 20 minutes away because my community hospital 5 minutes away would start transport plans to that facility if I brought in a patient on CPAP, plus she relatively stable and improved with O2. ASA quick before CPAP. Before I started any nitro I'd make sure she can support her BP on CPAP, check a quick V4R and V8/V9. Contact with med command for possible lasix admin, contingent on BP of course. 

  • Joe says:

    15 Lead needs to be done before going to the truck and before NTG is given.

  • John C says:

    Hope you aren't going off "rabbit ears." Any BBB is confirmed with RSR prime. I agree with Ben. :)

  • harrison says:

    Stemi.
    Fix breathing first we can do that. The hospital deals with the blockage.
    Treat per stemi and dyspnea protocol
     

  • MNMedic says:

    Sinus rhythm, 1st Degree AV block, LBBB, ***ACUTE MI*** ST elevations in V2-V5. Activate cath lab. May need an IABP as well. She's in left-side heart failure as evidenced by acute pulmonary edema, likely secondary to the acute lateral MI.  Assuming no allergies: ASA 81mg x4 PO. No NTG due to no c/o CP and no HTN in need of tx…at this point. Could consider Lasix, depending upon protocols. Transport to PCI center. 

  • John says:

    Okay well first off this ECG is not your normal run of the mill, obviously why its made it to this website.  While I agree this has criteria for a bundle branch block most likely a left what sways me from that diagnosis is the right axis deviation which makes me think a RBBB.  I also am pondering the possiblity of LVH in this patient.  Yes both the BBB and LVH are clinical immitators of STEMI and most protocols will rule out STEMI based on this, the elevations in V4 and V5 are concerning.  These are not normal ST Elevations we'd see even with LVH or a LBBB and warrant immediate concern.  If this Pt is familiar to EMS what have her previous 12 leads look like?  Does the facility have a copy of a previous 12 lead or a results sheet from previous 12 leads?  Any cardiology consultation paperwork in her chart?  Do a little quick digging.  If this information is unavailable this Pt gets treated under an ACS and Pulmonary Edema protocol combined which his fairly easy.  She gets the CPAP, some ASA, NTG, and transport to the PCI facility.  We don't give this Pt Lasix because this most likely is not a fluid overload issue and lets face it most of our CHF Pt's don't need Lasix prehospitally anyways.  We treat her aggresively with the NTG and have your inotropes ready to go.

  • Brian says:

    I'm an EM Resident, so forgive the intrusion. This lady's got a big-ass Anterior MI as evidenced by her LBBB w/ excessively discordent ST Elevations in V2-V3 and concordant ST elevation in V4-V5. I'd argue for transfer to the PCI center w/ pre-hospital cath lab activation. I'm betting she'll be fine w/ just CPAP for transport. Give ASA now, hold off on nitro, lasix, etc. 

  • Newer EMT-I says:

    I think we have a LBBB with a STEMI as well which is causing the low O2 sats and Resperation issues.  Treat with CPAP for the breathing.  Since that seems to help her O2 sats and her respers rate…I wouldn't treat anyhing further other than ASA and hold off on Nitro at this point as I don't think her BP will be able to support it.  IV/O2 enroute.  Transport emergent to the PCI facility.  

  • Dr. Gary EM Attending says:

    Ok – I was going to stand by, but I have to respond….

    The questions you want to ask yourselves with the preamble in mind is this – old or new ekg? First this is a known patient. Assuming a good relationship with hospital the prudent EMS group might ask to have the EM Attending if this is a new LBBB. I doubt it. My guess this woman is in decompensated acute on chronic systolic failure. Lets say this woman has no old ekg to define this, and that is a big I DOUBT IT, it doesnt take 20 min to get an old ekg. – I would make a play to the local non PCI facility for stabilization. Your treatment response is fair at best. You have deminished pressures. I would suggest if you are agressive enough, dopamine or dobutamine can be started in the street after routine nitro and lasix knowing it will drop your pressure.

    My final answer – while she would probably hover to make it to the distant PCI facility, I am gonna gamble this EKG is not new. I am gonna state that she is probably beta blocked and ace inhibited hence the low bp, and frankly low EF. And if you make a play to the ER distantly – that QRS could be several things: not new, dig response – not mentioned but probably on it, and or electrolyte issues increased K or such.

    I say, treat stabilize, run to nearest ER and stabilize / reassess there.

  • Christopher says:

    John C,
    RBBB isn't defined by RSR', but it certainly is one of the possible morphologies in V1. Any terminal R wave in V1, which may be a qR in the case of an old MI, with a slurred S-wave in leads I and V6. That being said, this is decidedly not RBBB.

  • SeasideMedic says:

    I see 1st Degree AV, LBBB and possible atrial hypertrophy, with significant (>5mm) discordant ST elevation in V3, and concordant ST segment changes in V4-V5. With the patient's presentation, this patient is in acute left sided failure secondary to anterolateral MI. Using my services protocols, I would treat with high flow 02, two large bore IVs, and after dosing with ASA and NTG I'd move on to CPAP, given the patient's SBP stays above 90. Activation of PCI most definitely.

  • Eric says:

    Dr. Gary, what is your call on the EKG?

  • Dr. Gary says:

    Base rhyrhm – sinus
    Left NOT RIGHT Bundle branch block – note QRS width
    Note QS in V1-V4 – probably old Anteroseptal MI in past
    You cant really acknlowdge the inferior changes given:
    The axis is right not left – indicating probable pulm htn. poor ef and this is not new.

    final reading old stuff…..

    remember 20 of us might read that and have different opinons in hindsight. treat the patient not the ekg.

  • Dr. Gary says:

    One other thing – I am guessing the body habitus, breast size etc. has this ekg and the reading of leads all screwed up…..just a guess.

  • Dr. Gary says:

    How’d I do?

  • Jay says:

    Pt. appears to have a LBBB and a STEMI involving the anterior wall. Without a baseline EKG, it’s difficult to determine what changes if any have occurred from the previous injuries, and if the LBBB is a new event. My conclusion for management is 1) CPAP – she appears to have cardiogenic pulmonary edema, probably from left side heart failure. Whether that failure is due to previous injury or an acute event such as e apparent STEMI, is a moot point. Her poor SaO2 supports that presumption. CPAP in the prehospital setting has been shown to improve patient outcome and decrease the need for intubation in many patients . 2) ASA should be administered unless otherwise contraindicated. Although there is no evidence of a Rt wall MI, I’d still run a Rt side EKG to determine if a Rt wall MI was present. Presuming it isn’t, NTG could be administered as long as her systolic BP remained above 100. 3) transport her to the facility with PCI. Taking her to the local hospital does not do her any favors if she needs angioplasty or a CABG. It only delays her management while a transfer is arranged. The time difference of 20 minutes vs. 5 minutes is not a significant concern, but the higher level of care is. Issues over her physicians privileges and her records at the local hospital are insignificant. In today’s medical community, digital records can be transferred and her physician can be consulted. Just the opinion of a 40 year veteran of EMS, 30 of it as a Paramedic.

  • Ben says:

    as John rightly points out there is Right Axis Deviation – not as I said LAD ^_^
    @Bigwoodsmedic What I always remember from Garcia & Holtz is – RBBB should have slurred S wave in I and v6, LBBB should have 'identical' morphology in I & v6 – see this LBBB ecg http://library.med.utah.edu/kw/ecg/mml/ecg_12lead013.gif

  • Joanie says:

    Looks like anterolateral MI to me. ASA, NTG, CPAP and the 20 minute ride to the PCI facility. Especially since she appears to have improved after CPAP.

  • Almaateeq says:

    TRIFASCICULAR block. ACUTE STEMI ANTERIOR WALL

  • Alex says:

    Anterior septal MI, LBBB, ST elevation V2-V5…. LBBB does not exclude Stemi.. It should be considered a Stemi until proven otherwise. Stemi for sure. Transport to PCI hospital. EKG consistent with Left ventricular failure. CPAP, nitro, asa, lovenox/heparin (whichever your company uses). They need PCI

  • Steve says:

    Dr Gary, my thoughts of this case are in line with yours. I’ve been in EMS for 21 years, 15 as a paramedic. One thing I have learned about STEMI bypass, esprcially after a few (ahem) “false positives”, is that unless the STEMI is staring you in the face, get moving to the local facility and let the MD figure it out. We just don’t have the time on scene to waste hemming and hawing over what the ECG says. Besides, I’ve seen the local ER doc call the cath lab and fax the ECG himself because HE is uncertain. I’m all for furthering education and training of EMS personnel but sometimes it’s easy to over-think things. Sometimes, the KISS rule applies!

  • Dave says:

    I guess I'm confused by a lot of the comments on this one.  From everything that I have been taught on 12-lead interpretation, LBBB is a STEMI mimicker and STEMI cannot be diagnosed in the presence of LBBB.  That does not mean that the patient is not having an MI, just that you cannot call it a STEMI.
    Now, for this patient, we need more information.  What is her medical history?  since she is always on O2, probably CHF and/or COPD.   What medications is she on?  Dr. Gary probably has it right and she is on beta blockers for HTN which is keeping her BP down.  What other complaints does she have?  This could be exacerbation of her CHF alone or it could be from an new MI.
    One of the things that I see in the new emphasis on STEMI recognition is that we sometimes forget to look at the whole patient and remember how we recognized and diagnosed (yes, I said diagnose) MI's before we were doing 12-leads in the field.  Bottom line for this patient, prompt transport, continue O2, use CPAP if the NRB isn't effective enough, Lasix, morphine and if the BP comes up with decreased respiratory effort maybe some nitro paste.

  • It is good to see the discussion going on about STEMI versus NSTEMI due to the appearance of a so called "STEMI Mimic". I find the nomenclature of a "mimic" to be rather odd, considering LBBB rarely looks like a normal rhythm with a STEMI.

    A normal LBBB will have QS waves in the right precordials with discordant T-waves due to the secondary repolarization changes. It will also have broad, monomorphic R waves in the lateral leads with discordant T-waves again due to the secondary repolarization changes. The only way this would be confused with a STEMI would be if you blindly applied the ">1mm of ST-E" rule to the right precordials. I would say that a normal LBBB does not mimic a STEMI at all!

    In our case, does this look like an abnormal or a normal LBBB? And if it is abnormal, what's abnormal about it?

  • Dave B says:

    You may show an ECG to 20 different people and get 20 different interpretations, but only one of them will be right.
    For many of us, the closet appropriate facility for a patient experiencing a STEMI or STEMI equivalent will not be the closet local ED.  If we can read a STEMI or equivalent on a difficult ECG, or pick out a subtle STEMI we can get that patient to the proper place, a PCI hospital.  If we don't, it will mean delays in treatment, and time is muscle.  It matters. IMHO.

  • Dr.Tam says:

    Acute STEMI, and that explains her acute heart failure and pulmonary oedema (need good clinical examinations to rule out other stuff that causes s.o.b). ABCD Plus ACS drugs and contact the hospital with PCI facility to check if they are happy to receive her, if not then give streptokinase while on route to hospital.Tam/FY2

  • Prehospital RN says:

    Anterior STEMI … excessive discordance in V2 and probably V3 (although the QRS is cut off) indicates STEMI even in the presence of LBBB … major ST elevation in V4 & V5 … pt needs to go to PCI facility and she almost definitely has acute LAD occlusion, causing cardiogenic pulmonary edema.  Continue CPAP but use care to monitor for decreasing cardiac output and cardiogenic shock … pt may need IABP.  Also pt is diabetic and as such is likely to present without typical acute MI symptoms.

  • Device geek says:

    I agree with Dr Gary treat the pt not the ECG. Need H & P but that may be why ordered to bring her to a center where she has a history established. As for the ECG acute mi with anterior and possible posterolateral involvement. Just to throw a wrench in things consider if pt has a cardiac device. Malfunction and pseudomalfunction with or without lead migration/dislodgment can sometimes exhibit itself like this very case. Witnessed it several times myself. Just to mess with your heads on a Friday evening;)

  • RangerMedic says:

    CPAP, Morphine and ride to PCI.

  • VinceD says:

    STEMI w/ LBBB. The right-axis deviation is a bit odd, but not impossible. Usuaully there would also be an S-wave in V5 and V6 to parallel those in I and aVL, but it's plausible that we're not getting the best picture on account of her body habitus. Limb electrode misplacement is also a possibility, but my eyes see a normal p-wave axis, leaving that a bit less likely. I don't know for sure, but at least it doesn't affect my care.

    @Prehospital RN – Sorry to nitpick, but while I wouldn't be surprised if she was diabetic based off her description, I wouldn't necessarily assume so just because the BGL is 224 mg/dL. Even in non-diabetic patients, so called 'stress hyperglycemia' quite often results in an elevated BGL in the face of acute illness, including infection, MI, and stroke.

  • IACCP says:

    LVF. Can't call a STEMI in our area due to presence of LBB. Transport to nearest PCI facility. CPAP, IVx2, Nitro, ASA. Dopamine on the bench next to me just in case.

  • I agree with treat patient not monitor. Left ventric. heart failure. Iv, cpap, monitor, asa. Hold nitro and lasix. No dope, we don’t need to work the heart harder. Serial ecgs. I would transport to nearest facility. Have a quick workup done then have pt transported to pci if confirmed. It seems this patient is having an anterior mi, but this could be a number of things. People need to stop assuming that because the pt has an extensive cardiac hx that this is normal. Utilize all resources and treat your patient. Serial ecgs after cpap initiation.

  • Lance says:

     
    A known AMI is a contraindication to CPAP therapy due to increasing intrathroasic pressure could further occlude the coronary arteries.  I'm not saying its negligent to put your patient on CPAP but it certainly carries a risk / benefit analysis.  If the patient is saturating sufficiently, I would hold off on CPAP unless it was absolutely necessary.

  • Simon M says:

    I see a sinus rythm with 1st degree AV block (PR approx 0.24 s) and LBBB. More importanty I see an acute anterior STEMI. 2 of Sgarbossa’s criteria are present (only one is needed):
    1: concordant ST-elevation in V5 (perhaps V4 as well)
    2: ST-elevation >5 mm in V3 (using Dr. Smith’s “0,2-rule” I’d say both lead V2 and V3 causes for alarm, though the S-waves are cut in V3). 

    Based on lungsounds and low SpO2 I’d suspect pulmonary edema (loss of ejection fraction points towards STEMI as well).

    Treatment according to our protocols:
    Oxygen, ASA, heparin, ticagrelor. (heparin and ticagrelor after consulting on-duty cardiologist). 

    Rapid transport to PCI-facility. Combo-pads as precaution. 

    Unfortunately CPAP is not in our toolbox, so the assumed pulmonary edema could be handled by furosemid and NTG if BP allows. Fentanyl i.V. is available in my country for pain relief. 

    I’d argue the BGL could be strees induced. However it’s not the primary concern. 

    Serial ECGs would could reveal further development. I wouldn’t be surprised of V6 would show ST elevation shortly. 

  • In this case, the patients oxygen sats were below satisfactory. Rhonchi in all fields. BP is too low for NTG, and I would be cautious of Lasix… I would try CPAP if available and see if it results with positive change… I would almost say it would…

  • Doc Cottle says:

    Great EKG!
    I think Simon M hit it on the head. If you check out this case from Smith's blog, you can read about the classic Sgatbossa and the "modified" Sgarbossa rules.
    As for treatment, if the crew patched in to me with the call, I would suggest heading on down the road if we didn't have a cath team available. I say "suggest," since I don't have the patient in front of me, and can't really tell how crappy she is.
    She needs to have her LAD opened up – do whatever it takes to get her to the lab – CPAP, dopamine, acupuncture…

  • Night Heart Wach says:

    1. For the sake of ECG discussion, this is really an interesting ecg. Here is my take -
    ST at 110's, prolonged PRI (aka first degree heart block), probable LAE, Right axis deviation vs left posterior fascicular block (LPFB), complete LBBB,  antero-lateral wall MI.
    The rS in 1 and aVL, RAD and qR in III and aVF are all tell tale indicators for LPFB but QRS duration (>120 ms) goes against it so this is could only be an RAD.
    The ST elevation in dicoradant lead (V3 – ~ 5 mm) and the ST elevation in concordant leads V4 and V5 all satisfies the Sgarbossa criteria. Also there is a Q wave in V4.Must be the LCA
    RAD + LBBB is a rare combination. In a report of 36 pts from a database of 636,000 ecg, most of the patients had dilated cardiomyopthy with biventricular enlargement.
    2. FOr case management this patient presented with left sided heart failure. Gentle diureses (unloader) would help, betablocker to reduce the heart rate (decrease O2 demand), ASA,  O2 and yes need to open up that LAD. Nitrates – I am cautious. Prepare pressors and pads just in case along the way. This ecg morphology brings a heart with low EF's.

  • Dan says:

    I am new here, great EKG! I am curious why everyone is on the LBBB band-wagon, though.  There is no notched R'R in V5 or V6, with no Qs in V1.  I see a RBBB.  Also, let's keep in mind that LBBB does not exclude a STEMI, it simply means that you cannot diagnose AMI based solely on the EKG.  Nonetheless, this is most likely a large Anterolateral MI.  Comments? I would appreciate some feedback on my question!

  • Dan,

    Good catch on the abnormal morphology for a left bundle branch block. However, as V1 has no terminal R-wave it could not be RBBB. When you have a wide QRS without the presence of an LBBB or RBBB it is referred to as an intraventricular conduction defect or IVCD instead.

    I think it helps to point out that an ECG in general is not really sensitive for an AMI but it can be very specific for an occlusion!

    Reframing your comment, would the presence of LBBB exclude the diagnosis of an occlusion through the ECG?

  • Dan says:

    Also… I would not be compfortable giving this patient any nitrates… I do not believe they are indicated in the slightest.  This patient is in cardiogenic shock secondary to AMI. This patient is getting 325 MG ASA and needs to be started on a Dopamine drip.  Morphine is probably a good bet as well, along with CPAP and maximum oxygenation.  Clearly, a PCI center is the ultimate goal here.

  • robert says:

    Interesting 12 lead.
    STach, 1st degree block, IVCD (rule out LBBB due to non broad monophasic R waves in lateral leads, specifically I), and ischemic patterns based on sgarbossas criteria.
    Definately go to the PCI center, if you ran on this patient before, then hopefully you have prior 12 leads, or they have them at the PCI center, which you could send via bluetooth.
    Treatment: CPAP and start preparing a bag of Dopamine in case she starts bottoming out. I wouldn't be too concerned with ASA, as i'm sure she already is on a blood thinner due to her extensive cardiac history. I would absolutely not give her nitrates, given the fact she is a CHF'errr, then you would expect for her pressure to be significantly elevated… which it is not in this case.

  • Simon m says:

    A note to the right axis deviation..
    I believe the most plausible explanation to that would be LPFB.
    Initially I thought of S1Q3T3-pattern, but it’s difficult (for me) to tell whether or not q-waves in lead III are significant enough for that (and what are the odds of having STEMI and PE at the same time?).
    rS complexes are seen in the high lateral leads, I and aVL, and qR complexes are seen in the inferior leads, II, III and aVL, so LPFB would be guess :)

  • Night Heart Wach says:

    1. You are correct in the possibility of LPFB but other cardiac conditions can present with same ecg configuration. So exclude other conditions before committing LPFB. One possibility could be a lateral infarction. Also another criterion for pure LPFB is the QRS duration should be less than 120 ms.
    2. For the LBBB argument – V1 is broad and notched as well as V5 and V6. no r wave in V2 then the wide S. The time for the R wave to peak in V6 is about 60 ms. All of them satisfies LBBB.

  • Simon M says:

    Ok, thanks for settling that straight.

    It seems there is disagreement on the axis deviation for LPFB. Some say >90, some say >120 degrees, but it was just a thought.
    As I noted in my first comment, I initially said LBBB and anterior, or anteriorlateral infarction. I pointed out that it would not surprise me that serial ECGs would reveal STE in V6.
    However, I wasn’t sure if Christopher ruled out LBBB in his comment, and called it an intraventricular conduction defect, or if he simply stated that it could be a possibilty.
    Regarding LBBB I have been taught that one of the criterias for diagnosing LBBB is a broad R wave i lead I. Couldn’t this ruin the diagnosis of LBBB on this ECG?

  • Heidi says:

    Is LBBB with RAD indicative of congestive cardiomyopathy? I remember reading that somewhere ….

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