Posted by: medicblog999 | April 8, 2010

ECG Geek 7

heart-angiogram-sd3453-gaI am always collecting ECGs for my learning file. I like to keep them so that I can use them to teach others, but sometimes I need to keep them so that I can drop into the coronary care department to ask those who know more than me to confirm or deny what I think I am seeing in the ECG.

These ECG`s are currently sitting in my pocket, waiting to show a cardiologist so that I can find out if my impressions were correct.

But, now that I have a huge resource in all of you wonderful knowledgeable readers I thought I would post them here too.

Firstly, this was not my patient, but was one of my colleagues who brought the ECG to me as they couldn’t see anything too worrying from the ECG. It is from late last year, but we dont see each other that often as we are in different divisions, hence the delay. Lets see if you came to the same impression that I did?

History.

The patient is a 47 yr old male who had a 2 hour history of severe central chest pain. Described as a heavy pressure which radiated to his jaw and into his left arm. He looked pallid, was very diaphoretic and was mildly short of breath. In short, he looked shocking!

The pain had come on at rest and had gradually got worse over the first 20 minutes of this episode. He stated that he had a number of similar episodes over the last 3 days, but these were not as severe and only lasted 10-15 minutes each time. He had no significant medical history and certainly no previous cardiac history although both of his parents had developed coronary artery disease in their early 50`s.

He was also noted to be noticeably overweight, although not obese.

Observations were within normal parameters, despite his clinical presentation.

The first 12 lead was captured which showed the following:

ECG Geek 8.1

Click to enlarge

The quality of tracings remain poor due to the difficulty in drying the patient and getting the ECG electrodes to adhere well due to his excessive sweating. Based on the initial ECG, the patient did not fit criteria for direct transport and referral to the regional PPCI centre, however, the crew was so concerned about him, they attempted to persuade the PPCI centre to accept the patient based on clinical presentation.

They were unsuccessful in this, so transported the patient to the local hospital and Coronary Care Unit.

Further ECG`s were captured during the transport :

ECG Geek 8.2

Click to enlarge

ECG Geek 8.3

Click to enlarge

The patient remained in pain throughout the transfer despite the standard cardiac care and Morphine IV. The following ECG was captured just prior to leaving the ambulance and moving the patient down to the ward.

3 minutes after this last ECG the patient arrested in the corridor of the hospital. A pre-cordial thump, then 1 DC shock brought about a return of circulation and the patient regained consciousness.

ECG Geek 8.4

Click to enlarge

My question to you all, is to take a close look at this sequence of ECG`s and let me know your interpretation. In my humble opinion there are some obvious abnormalities that should be easy to spot, but what I want to know is if any one picks up what I ‘think’ I can see happening. Im not going to give any further information at this time as I dont want to influence you rightly or wrongly.

In the next post, I will honestly give my thoughts even if I am proved to be completely wrong.

So, over to you guys. Do me proud like you always do when I post ECG Geek posts. Hopefully my friend Tom Bouthillet will stop by and share the definitive answer too (hint, hint Tom)

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Responses

  1. I really have no idea Mark. The first strip looks like the patient could patient have atrial fibrillation. So could a clot have formed then become dislodged and blocked blood supply, causing the arrest?

  2. Not knowing what a PPCI is, this pt appears to be an excellent candidate for the Cath lab. Even with the poor quality of the ECG, and based on the observations described, I am figuring an Anterior MI.

  3. ok, i'll give this my best shot, I havent been in this job more than 2 years, but had a very similar thing happen recently, my interpretation of the ECG is that it either a NON STEMI or very early anterior infarct, so early that the ST segmant hasnt risen but there are hyperacute T-waves in the anterior leads, the patient arreted,and the precordial thump dislodged the clot and saves his bacon! the only differece I had wih my patient is that it was possibly an inferior,(No st elevation but hyper acute T's) and we didnt use the precoridal thump, we shocked him, but the outcome was a clear ECG post arrest

  4. ok, i'll give this my best shot, I havent been in this job more than 2 years, but had a very similar thing happen recently, my interpretation of the ECG is that it either a NON STEMI or very early anterior infarct, so early that the ST segmant hasnt risen but there are hyperacute T-waves in the anterior/lateral leads, the patient arreted,and the precordial thump dislodged the clot and saves his bacon! the only differece I had wih my patient is that it was possibly an inferior,(No st elevation but hyper acute T's) and we didnt use the precoridal thump, we shocked him, but the outcome was a clear ECG post arrest

  5. The age, history is suggestive of AMI. There are (as far as I can see) no significant ST-elevations, however in the left lateral leads there are ST-depressions which I think might be reciprocal, in addition to developing RBBB. Possible right-sided STEMI – record V4R!

  6. […] *  Those of you who are paramedics, do you save your ECG strips that you run on your patients?  Mark Glencorse, better known as Medic999 does, and he tells us why he saves them HERE. […]

  7. New onset LBBB can often “hide” any septal st elevation one may see… dx: septal AMI with new onset LBBB

  8. Atrial fibrillation was my guess/ with clot that caused the sudden arrest. He did have a good sinus rythum. And had this problem days before which could have already formed clots, looks like the shock put him back in to normal sinus rythum, But what damage has this caused the p.t.I would suggest a pacemaker defibulator posible..

  9. With those preliminary ECGs, I wouldn't have been concerned that the guy was going to arrest. Are there changes? Sure. Panic-worthy changes? Nope. But, luckily, we treat our patients, not the monitor! The fact that the pt arrested indicates that something was wrong (in fact, we don't have unequivocal evidence that his problem was in fact an MI – though – from what it sounds like, it probably was). Need more data! Cardiac markers? Electrolytes? Risk factors?

  10. Based on the patient's presentation and EKG findings, I'm gonna take a shot and say anterior wall MI with new onset LBBB which resulted in the cardiac arrest.

  11. Sinus with LBBB. Possible patho Qs in V2, V3. Does not meet MI criteria of ST > 20% preceding S-wave. However, the PVC may be indicative of something. It is a new concept to me, but very well explained on Dr. Smith's blog.

  12. The rhythm is to regular to be A-FIb. I think it looks very similar to a LBBB. I was also thinking possible Sepal/Anterior infarct.

  13. stab in the dark and say anterior/septal infarct.

  14. NSR/(boarderline)1st degree AVB Septal MI with new onset RBBB (may also have some anterior wall components; reciprocal changes noted in serial EKG's).Serves to remind us that there's always an exception to the rule and to look at the patient not the machine (they're telling us what's wrong with them the data should support that in the vast majority of cases), doesn't it? 🙂

  15. I'm seeing obvious ST depression in all the lateral leads…so I'd be suspicious of a possible posterior wall MI or maybe a R. sided one.Definitely like to do a “posterior” 12 lead and see what it shows…and a quick vR4 and vR5. If nothing else then it rules out 2 possibilities.I'd like to know what his BP was too. DaveO

  16. There are visible P waves so it is NOT a-fib. The QRS is not greater than 120 ms so no BBB. No ST elevation in inferior leads, so no inferior MI. There IS poor R wave progression leading me to believe there is something happening in the anterior leads. Look at the final 12 lead, in particular leads v2 and v3. I believe those to be huge Q waves, and you can see the Q waves in the previous 12 leads. Looks to me that the “pains” that the pt. felt over the past couple of days may have been actual MIs that lead to necrosis (hence Q waves), leading to irritable heart (PVCs as seen in the initial 12 lead). My “Guess” is that the necrosis caused irritability which lead to an R on T and the pt. coded. I bet there were more PVCs that the subsequent 12 leads did not capture.

  17. septal/anterior MI which lead to the BBB. Change in last strip could very well be from the medication given. Also if anyone wants one. Follow the link to a 12 lead template that I created. One the local hospitals in my area liked it so much they made a bunch of them and gave them to the local EMS units. Just cut out the white areas in each lead. Laminate. then just place the template over your strip. Really helps at 3 in the morning.https://docs.google.com/fileview?id=0B5rOi4BYpD

  18. I'm no expert in this and limited experience with ekg's, but looking over lead II, I don't see any p or t waves and looks over the place like atrial fib. after you shocked him the one time on the last strip you can see the both p and t waves again… So I'm kinda thinking in the same lines as Squeezey here? And that maybe a clot had formed during the A-Fib which then broke away leading to a blockage causing a direct MI?

  19. Mark – Thanks for the “shout out”. I do have an opinion or two about these ECGs, but I'll give others a chance to chime in before I elaborate.In the meantime I'll just say that:1.) This isn't LBBB, but it does have something in common with LBBB.2.) The ECGs are not suspicious for acute STEMI. However, the AHA's recent policy statement suggests that patients who are post-arrest should be emergently cathed.Tom

  20. Thanks for the initial input Tom.So far Zumstin, has come the closest to what I was wondering about (hint hint!).Im sure that everyone is looking forward to your thoughts just as much as I am!

  21. Mark,Before Tom comes over from his blog, figure I would give this a shot. I would agree with your crews, something really wrong here. Just to many changes to note, but with that said, nothing that meets our STEMI Criteria. The first one has some ST segment Depression noted in I, aVL, V6 with elevation suspected in V1 and aVR (difficult to tell because of the data quality). Vitals are not given, but skins are in poor condition. PVC noted in V1, appears to be from the right ventricle if my memory serves (may be way off on this). Changes in the strips remain the same with the most clear picture being the last. Depression now in I, aVL, V5, V6, with minor elevation noted in III (very minor at that), with elevation in aVR, and V1. R Wave progression delayed throughout.Because of his skins, complaint with diff breathing, recent episodes of chest discomfort, I am betting on something bad happening. His changes on the 12 Lead do not meet the criteria, but I will go on the fence and say that we might see more on the right side of his heart if the leads were moved. I would try as your friends did to place them in a PCI capable center and do another 12 Lead with the leads moved. Arrest with ROSC, especially considering the above, needs a cardiac care centerI just found your blog and it is excellent, let alone your work with Chronicles, congrats!Now I shall wait for Tom to comment…..

  22. The most obvious abnormality that I see is a Left Anterior Fasicular Block. There is also a decent case for Left Ventricular Hypertrophy. I think this is driving the high left axis deviation, and the poor r wave progression, as well as the somewhat pronounced T waves deflections in some leads.I do not see any evidence of a bundle branch block–new or otherwise. Where is the wide (>.12 sec) QRS? Similarly, I don't see atrial fibrillation: this is an extremely regular (barely even a sinus arrhythmia) sinus rhythm.Also, oldman–ppci=cath (primary percutaneous coronary intervention).

  23. Very good, Matt! LAFB is a possibility, but I strongly suspect LVH for a couple of reasons. In the first place, it's a left axis deviation, which is a very insensitive marker of LVH. More important is the presence of T-wave discordance throughout the ECG, or the so-called “strain pattern”. Poor R-wave progression can be associated with LAFB but this is more than just poor R-wave progression! R-waves are absent in leads V1-V3, We are left with the conclusion that the patient has a history of anteoseptal MI.Having said that, there are definitely changes in ST/T morphology prior to the arrest and changes in QRS morphology following the arrest, which means this is a primary cardiac event, and we can't rule out the possibility of an occlusive thrombus, even though the ECG does not show an obvious STEMI.The frontal plan axis shifts leftward (QRS is mostly positive in the first ECG, mostly negative in the second ECG), the R-wave amplitude increases in leads I and aVL, a strange wave appears on the QRS complex in the right precordial leads, and the T-waves decrease in size, particularly in leads V1-V4.A heart rate over 100 and continuing pain despite optimal therapy in the setting of suspected ACS is not a good thing and dramatically increases your odds of being cathed! But there's nothing like a cardiac arrest to move you to the front of the line, at least in my region of the United States! Tom

  24. Hey Tom,Not sure if you'll see this, but I just wanted to continue the debate on LVH vs. LAFB, with me leaning toward LAFB. There's a couple reasons why I feel that way, one being that limb lead QRS complexes are big (possible for both), but those lateral precordials aren't as large as I'm used to seeing in LVH. Also there's small R's in 2,3,aVF like in LAFB, however I can't tell if there's small Q's (which you'd expect for LAFB) or just artifact in I and aVL. On the side of LVH, there is left axis deviation, which can occur with both, however not to the extent expected for LAFB (usually around -60). It seems to be more like -30, but like you said, it changes as the QRS morphology changes. Anyway, it may seem like a minor quibble when the ultimate outcome was a cardiac arrest, but it's an interesting academic question that probably can't be answered from a couple messy ambulance ECG's.Now if it's actually LAFB and not LVH, I'd start to worry more about the ST-depression that shows up convincingly and regularly in all the lateral leads. Actually, even with LVH the depression in the first and second printouts seems a little too discordant (note: I'm not taking the effort to count out the boxes and get an actual ratio for QRS vs. depression, so take my opinion there as merely that). I'm not seeing much in terms of elevations to say AMI, but I'd be interested in seeing V4R (even if I'm not sure I would have actually bothered at the time had the guy not arrested) just to see what's happening over there, especially with the hints at elevation in V1.Also, the appearance of an old anteroseptal MI with those big Q's doesn't help the assessment of the situation.Finally, a shot-in-the-dark question for you: any chance those QRS changes in V2-V3 in the last printout could have anything to do with an incomplete RBBB (a RBBB not being an uncommon coupling with LAFB). I'm still new to this whole field and defer to your knowledge and experience in the end, but figured a little more input on the case, even if ultimately misguided, case wouldn't hurt in a learning exercise.

  25. a-fib with a regular rhythm?

  26. i guess we have more aggresive protocols than some. No doubt in my mind i would have taken him to the closest pci center. Im no Doctor but it looks like an Anterior septal MI. it looks more like artifac than atrial fib. I've had a patient just like this. Regardless of quaility on the ECG we have to look and assess our patients. The ST elevation is enough for me to send this patient to a cath lab. Im not judging by no means, always remember your basics if your patient looked as bad as he sounded than most likely it is an MI. I would have called a code STEMI and errored on the patients behalf. Patient advocacy should always be our first proirity.

  27. Hi EMSgirl.As I mentioned in the post the crew did try to get the patient in the PPCI centre (cath lab). Unfortunately though, it is the consultants decision on if to accept a patient or not, and in this case, despite the crews efforts to persuade him otherwise (based on the patient presentation and not the ECG) he was declined PPCI as the ECG is not diagnostic of an STEMIPatient advocacy is indeed one of the most important parts of our role, but unfortunately, we can only take advocacy so far sometimes.Thanks for the comment.

  28. i agree with matt… there are a few things going on here.. this pt has left axis deviation, which is the same as a left anterior fascicular block, the pt also has a first degree heart block, which is significant during an ACS, plus V1 is borderline LBBB, and hyperacute T waves in V3 V4, which may be an early sign of anterior wall MI…as they say, when you use the word BLOCK, more than once in a sentence, ( LAFB and 1degree heart block in this case), better pay close attention to that pt, because they may deteriorate into 3HB or even arrest if the pt is having ACS…..

  29. Sir what can I see are the ff: SR, LAFB, lateral wall ischemia, can also see prolonged QT by eye-balling (QT interval more than half of the RR interval). Suspecting also WPW pattern as I can see delta waves

  30. agree with poor R wave progression., anteroseptal wall MI. Can you see delta waves? no bundle branch block. QRS is not prolonged

  31. Hey, Vince! I replied in the follow-up thread. Thanks!Tom

  32. Arnel -The more I look at these ECGs (including the side-by-side close-up in the follow-up thread) the more I'm leaning toward incomplete LBBB.Tom

  33. The more I look at the tracings the more I get confused. It is really a diagnostic challenge – LAFB in anterior infaction. The #4 ecg showed QS or QRS pattern. There could really be anterior MI + clinical signs – LAFB + and anterior MI. The 2 criteria for LAFB was satisfied – LAD + rS and qR patterns but adding the intrinsicoid delay in aVL (which is only 40ms) sways my vote away LAFB. The instrinsicoid delay study (regional delay concept could be wrong). Hard to tell incomplete LBBB since the the slurring is not so pronounced though there is QS in V1. Slurring on V6 can be part of the intrinsicoid delay – part of LAFB. Though you can also be right. That is what I like in EP conference. No body is really is saying that somebody is wrong but would just say that it could be a possiblity.

  34. i't look like atrial fibrillation. but if you really analyze the ecg there is still a p wave, well we can say the cause of this chaotic rhythm is because the pat. is in the ambulance so there is some movements or disturbances on the leads. there is no ecg patter when they transferring the pt. to the ward. my opinion is the pt. had suffered ventricular fibrillation which is the cause of cardiac arrest.

  35. patterns look like pt. has an anteseptal AMI. which is more visible in v2 to v4. the cause of arrest is ventricular fibrillation

  36. In the clinical setting, this could be MI. Anteroseptal MI with LAFB or MI witha new LBBB. Definitely no AF. Could be incomplete LBBBv(variant). The left axis deviation is part of the variant. The slurring in V6 (initial upstroke) is called pseudodelta wave in incomplete LBB. Agree that post-arrest pts should be cath. New LBBB in MI confers an increased risk for mortality. Though could not find the criteria of MI in LBBB in the strips. Initially thought that it was the Cabrera sign in V3 but not.

  37. In the clinical setting, this could be MI. Anteroseptal MI with LAFB or MI witha new LBBB. Definitely no AF. Could be incomplete LBBBv(variant). The left axis deviation is part of the variant. The slurring in V6 (initial upstroke) is called pseudodelta wave in incomplete LBB. Agree that post-arrest pts should be cath. New LBBB in MI confers an increased risk for mortality. Though could not find the criteria of MI in LBBB in the strips. Initially thought that it was the Cabrera sign in V3 but not.


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