Posted by: medicblog999 | March 17, 2009

ECG Geek Episode 2 – You make the decision!

heart-angiogram-sd3453-ga

I had a job last year that really made me think about the best course of “definitive treatment” for my patient. It was certainly one of the jobs which stand out for me, mainly because of the constantly changing ECG the patient presented with and also because of the decision that I made (which I am very happy with), which is where you come in.

I will present the case, along with the ECGs, and will lead you on the journey to a specific point where two options are available to you. Let me know which one you take (remember you can post annonymously and leave the email field blank) and then I will post what happened next in a few days time.

Sitting comfortably?…….The I`ll begin.

Called to a male patient in their early 40`s, complaining of central/left sided chest pain, described as like a heavy indigestion like pain. Scored at a 4 on a 0-10 pain scale. Patient looks well, not pallid, no sweating, all observations normal.

He is really anxious and it is difficult to get his consent to do most of our observations and he most certainly will not allow me to place 100% O2 on him. Myself and my crew mate spend a few minutes calmly talking through everything that we need to do and why, and he soon settles down and lets us complete our full assessment.

The first ECG taken at on scene looked like this:

ecg1-st-depression

Obviously with the ST depression in the anterior/lateral leads (V2, V3,V4,V5, I and aVL) the patient is suffering with a pretty good ischaemic event, so we explain this to him and how we need to step things up a bit so that we can get him to hospital quickly to get him sorted out. His pain score remains at 4 whilst we insert a buccal GTN. The patient has already taken 300mg aspirin prior to our arrival due to the advice given from our control room. I am also a little concerned with the way the ST segment looks in the inferior leads as they looked like they were on their way up, but at the time there is not the 1mm of elevation required for diagnosing an acute ST elevation MI.

Tom is placed on the carry chair and is moved to the back of the ambulance. Once on the ambulance, I take another quick 12 lead to see if anything has progressed. The ECG looks the same as the first one

I am now so sure that I think this man is about to infarct that I decide to ring the PPCI centre and try and get them to see Tom as I am confident something is just about to happen. Just as I am getting the phone out, I ask Tom what his pain score is now, he replies

“0, the pain has gone off now”

Right, okay…….Another 12 lead ECG :

ecg2-sr-pain-free

Everything here now looks pretty normal so it looks like this is probably a case of unstable angina. However, now, on the presence of this ECG, he is definitely not for PPCI at this point in time, so I send the ECG to the local hospitals coronary care department, but they have no beds so we are instructed to go to the A&E (ER) department for further assessment.

A short 10 minute blue light transfer is undertaken and we arrive at the A&E department. I notice that Toms colour has suddenly gone a bit pallid and ask him how he is feeling.

” The pains just come back ”

I decide to do another quick 12 lead so that I can pass on another tracing when he is in pain. This time it looks like this :

ecg3-starting-inferior

Now, here is the decision time. There is definitely some ST elevation in the inferior leads (>1mm) therefore the patient is now suitable for PPCI. Tom is now telling me that his pain is now referring through to his back.

I am 30 seconds away from a fully manned, A&E department or approximately 25 minutes away from the PPCI centre. To put another spanner in the works the ECG machine will not transmit the ECG to the PPCI centre for some reason and so the decision is going to have to be made by me without the clinicians at the PPCI centre being able to see a copy of the 12 lead ECG.

What would you do?

  1. Go into the A&E department and hand the patient over to the doctors and consultants there who will provide some initial treatment and then arrange an emergency transfer to the PPCI centre once the patient has had their initial assessments or
  2. Don’t take the patient off the back of the ambulance, phone the PPCI centre, tell them your diagnosis, without the aid of them being able to see a copy of the ECG, turn around and drive 25 minutes to the PPCI centre without letting the docs see the patient at the A&E unit that you are parked outside?

Lets try and have a bit of a discussion on this one! There is definitely an argument to both sides and it is definitely a judgement call on the part of the paramedic, so what would you do??? Leave a comment and lets see what the majority would do.

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Responses

  1. Are you able to thrombolise the patient?

    Incidentally it is our policy in EMAS to do a repeat ECG on arrival at A&E and if there is a change suggesting AMI then we don’t offload and we make it across town to CCU – and PCI. However for us this is a 5 min ride on the lights.

    Had you pre alerted A&E for this patient on the grounds of the first ECG?

    Incidentally have you heard of the STREAM trial at all? Can’t remember if it is NWAS or NEAS that is involved in it.

  2. Hi Mart,
    We had tenectaplase taken off us last year when PPCI became fully operational. I think they wanted to take away any chance that we may use it “for the best interests of the patient” if we thought they may not make it to the PPCI centre and of course it was removed following guidance from our regional cardiac network.
    I hadn’t pre-alerted the A&E as the last 12 lead I took before the one with elevation on was back to normal, but had transported him on lights and sirens.
    I haven’t heard of the STREAM trial. Whats that all about then??

  3. Mark,
    My decision would be based on whether his second presentation matched his first one.
    Although the traces look very similar, if the nitro worked before, I think the definitive care for this heart is a cath and a scope. With a stable BP I say reroute to the advanced center.
    In my experience the ER will do everything we do and just call another ambulance.
    I’ve been known to drive past 2-3 hospitals to get to a good stroke center.

    My experience tells me with minor changes in Lead I and V1 V2, we’ve got time so long as he’s on O2 and the nitro is working.

    HM

  4. Hi Mark

    I’m a noob here, but not such a noob in terms of medicine. However, I am not sure there is a right answer in this case. My gut feeling would be to pop in to the A&E Dept and get them to hook him up to an ecg machine while he is still on the trolley. Get the doc to have a squint, and then off to the PPCI Centre. Then you are covered if he arrests en route. However, it will depend on your thoughts on the quality of the Dept you are outside, and how well you get on with the team in there. My department would have swung this one around in 3 minutes (did it on Monday), and so there would not have been a significant delay.

    Be interested in other’s thoughts…

  5. I choose option 2! definitely straight to angioplasty. He has a frondy clot blocking one of his coronary arteries that is coming and going a bit. If you have heparin you can give IV bolus en-route.
    thoracic dissection with occlusion of coronary vessels much less likely in view of age (unless he is an extremely heavy smoker or has connective tissue disorder).

  6. I might go into the ED/ A&E just to give the Cath Lab a chance to get ready for the patient. Also to administer some more meds., such as Heparin and Clopidigrel. If these are already carried on the ambulance and the Cath Lab can be notified en route, then it seems to just delay definitive care. The Hospital ECG isn’t more special than the Pre-Hospital one. I think Basics Doc is right in that it depends on the Department. I’ve been delayed for 30-40 minutes in an A&E Dept. confirming the type of AMI we already said it was. Either option could be the correct one depending on a few different factors.

  7. Hey, I’d probably go with option 2, sounds like the guy needs a cath, and there’s probably no point in delaying it further by going to a hospital that can’t fix him. True that they could start heparin/nitro drips or what have you, but they’d probably waste some time before that happens. How much nitro can you guys give prehospitally? In my service in the states, it’s pretty much unlimited with good BP and can put on nitro paste as well.

  8. A tricky one. In my service we have the option of tenectaplase if we are greater than 20 minutes from hospital (in country Australia this is every time). However, if I had a fully staffed ED on my doorstep it would be my first stop. We’ve all had a patient arrest in the truck and it’s no fun at all.

    • Some of out rural stations have been begging for the option to still carry TnK for use on the patients who look like they may not make it for the 1 hour drive to the PPCI centre, however, the cardiac networks are staying with the evidence base that waiting for the PPCI is still more beneficial than the TnK. I guess that’s the whole point of going down the route of “evidence based practice” though.

  9. […] Geek – Part 2, The conclusion So, where were we? Click here if you need to read what happened up to this point. So I’m standing in the back of the […]

  10. Very cool! Just curious, what was the computerized interpretation? Did this fool the GE-Marquette interpretive algorithm? At some point in the process did it identify acute posterior MI? I’ve seen it give the nonspecific ST abnormality, and I’ve also seen it call posterior MI. Great case! I can’t get enough of these.

    Tom

    • Hi Tom,

      If I remember rightly, the Lifpak gave the good old ‘abnormal’ interpretation, and that was it.

      Kudos back to you on your blog too by the way, Ive learned more than a couple of things from you and your blog.!!

  11. Interesting! I’m working out a “STEMI Alert” protocol for my organization right now, and I’m trying to make sure it includes a provision for isolated posterior STEMI.

    I’m glad you like blog! Thanks for the positive feedback. I’m enjoying yours, too!

    Tom

  12. I love the first ECG in this case! It's one worth referring to often, because it shows acute posterior STEMI. At this point there was no corresponding ST-elevation in the inferior leads but you can see downsloping ST-depression in the high-lateral leads. Dr. Smith at Dr. Smith's ECG Blog states that ST-depression in the right precordials is more likely to be posterior injury than anterior ischemia, whereas ST-depression in the left precordials is more likely to be ischemia. Regardless, this is where obtaining a modified 12-lead with electrodes in the V7, V8, and V9 positions can give you the evidence you need to divert to a PCI center straight away. Awesome case! I see that the comments for “Part 2, the conclusion” are still around, but I have a hard time believing that no one commented on Part 1 of this case! For all I know I did. LOL! :)Tom

  13. I love the first ECG in this case! It's one worth referring to often, because it shows acute posterior STEMI. At this point there was no corresponding ST-elevation in the inferior leads but you can see downsloping ST-depression in the high-lateral leads. Dr. Smith at Dr. Smith's ECG Blog states that ST-depression in the right precordials is more likely to be posterior injury than anterior ischemia, whereas ST-depression in the left precordials is more likely to be ischemia. Regardless, this is where obtaining a modified 12-lead with electrodes in the V7, V8, and V9 positions can give you the evidence you need to divert to a PCI center straight away. Awesome case! I see that the comments for “Part 2, the conclusion” are still around, but I have a hard time believing that no one commented on Part 1 of this case! For all I know I did. LOL! :)Tom

  14. I love the first ECG in this case! It's one worth referring to often, because it shows acute posterior STEMI. At this point there was no corresponding ST-elevation in the inferior leads but you can see downsloping ST-depression in the high-lateral leads. Dr. Smith at Dr. Smith's ECG Blog states that ST-depression in the right precordials is more likely to be posterior injury than anterior ischemia, whereas ST-depression in the left precordials is more likely to be ischemia. Regardless, this is where obtaining a modified 12-lead with electrodes in the V7, V8, and V9 positions can give you the evidence you need to divert to a PCI center straight away. Awesome case! I see that the comments for “Part 2, the conclusion” are still around, but I have a hard time believing that no one commented on Part 1 of this case! For all I know I did. LOL! :)Tom


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