59 Year Old Male–"Lifting Boxes": Part II, with a twist!

This is part II to 59 year old male–"Lifting Boxes". You may wish to review the case.

Let's review the ECG:

There is sinus rhythm at about 90 bpm. Some of you saw a slight bit of ST elevation in the inferior leads, and maybe an abnormal aVL. Perhaps? Perhaps not? V1-V4 look possibly abnormal, but there is an awful lot of artifact. There appears to be a bit of ST depression in V5-V6. Is this an ischemic ECG? Looks concerning from what we can decipher.

Sometimes on blog posts, we get used to crisp ECGs and tidy scenarios. Nothing wrong with that. Sometimes, though, our cases on the street just don't go like that. Often there is much to learn from those, but I digress.

 There are a couple of real concerns with this case;

  • As correctly pointed out in the comments, the quality of the ECG is poor. This leads to all sorts of interpretation problems. If we put effort into it, we can usually get a pretty good tracing. On occasion though, it can be tough.
  • Another issue is that the 12 lead was not acquired early on. The crew acquired the ECG in the ambulance after the following: assessment, history, physical exam, O2, ASA, bathroom break, change of clothes, etc. This is not what we are after, and we could miss important findings by waiting this long.

As most of the comments reflect, the timing of the ECG and poor quality make it tough to interpret, and tough to activate the cath lab. I know some of you saw findings that led to you say you would activate, but doing so based on this one poor quality ECG is tough to do. Just is. 

So off to the community hospital he went. 

Calls are run like this every day. We all know it. In fact, it is one of the reasons we discuss cases such as this.

Could this patient have benefited if the call was handled differently? 

Fortunately, we know that he did!

In a contrasting plot twist, this call was actually handled quite differently:

In reality the crew obtained the history and vitals previously mentioned. However, undaunted by the patient's reluctance they convinced him to allow a 12 lead to be acquired immediately. This is what they found:

Due to the patients girth and breathing patterns, it was difficult for the crew to acquire a totally clean ECG. However, this one clearly shows ST elevation inferiorly, as well as V5 and V6. We can also see ST depression in V2-V4 with tall R waves. There is also slight ST depression in aVL: Infero-postero-lateral STEMI. 

The crew acquired another 12 lead with V4R which revealed about 1mm of ST depression in V4R:

The ECGs were transmitted, and the patient was emergently transported to the cath lab, where he underwent PCI and had a successful outcome.

For comparison, note how much the ST segments resolved from the first 12 lead to the one acquired in the ambulance:

After just a short period of time from the first ECG,  obvious ST elevation in II and III has mostly resolved. Timing is everything!

The point of all of this is to clearly illustrate the importance of early 12 leads and good data quality. The prehospital care of this patient could have gone either way. We see it every day. How we handle those first minutes, and the quality of the data we acquire will have a huge impact on the care our patients receive.

What are your thoughts? I'm sure you have experiences similar to this one!

 

 

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EMS 12-Lead

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Comments
Dominic
Conclusion to 59 Year Old Male: Unwell
Great discussion on a difficult 12lead! I follow these very closely and based on pt presentation and 12lead tracing, this was a difficult or to treat with impending heart failure, hypotension, and trouble breathing. Thanks for the follow up and look forward to next week!
2015-07-06 20:53:35
Billy
Conclusion to 59 Year Old Male: Unwell
Hmmmm, I was fairly close. Sounds like most of the treatment occurred IN Hospital. Love case studies, and that one was good.
2015-07-06 20:28:25
Kori
59 Year Old Male: Unwell
There's the point! There is are no P waves, and the rhythm is irregulary-irregular-atrial fibrillation. If you look, it is rsR phenomen-RBBB, BUT there are huge ST elevations on all leads from V1-V5 (that's why the QRS complexes look so broad). I and aVL is clearly ST elevation suggesting STEMI. In limb leads you can…
2015-07-06 10:12:16
Vince DiGiulio
Conclusion to 59 Year Old Male: Unwell
I'll expand on this in the next post but unfortunately I actually wasn't present for this case so I can't give my direct account of how things happened. That said, from the notes I read and word-of-mouth from those involved (which I suspect painted things in a better light than I would have viewed them),…
2015-07-06 04:09:22
Matt King
Conclusion to 59 Year Old Male: Unwell
Hey Vince thanks for the through follow up with this case. I am curious how his rate was controlled since he was hypotensive and maybe an unknown onset of when his A-Fib stated(thinking anticoagulation first)? As you know the wrong approach could be devastating in this PT with risks of further infarction, stroke, or death…
2015-07-05 14:10:57

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