The 12 Leads of Christmas: Lead III
This article is the third in our latest series, The 12 Leads of Christmas, where each day we examine a new finding particular to an individual electrocardiographic lead.
Lead III
Lead III is great at identifying STEMI’s. In patients presenting with signs and symptoms concerning for ACS but no clear ischemia on the initial ECG, it’s one of the three leads I usually choose to display on the monitor (the other two are aVL and V3).
There’s three major reasons I like lead III in ACS.
First, when a patient is experiencing an inferior STEMI, it is usually the lead that shows maximal ST-deviation in the form of ST-e...
Source: EMS 12-Lead - December 28, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 12-Leads of Christmas 360 Degree Heart Original Articles Vince DiGiulio Source Type: research
The 12 Leads of Christmas: Lead II
This article is the second in our latest series, The 12 Leads of Christmas, where each day we examine a new finding particular to an individual electrocardiographic lead.
The Lead II Sign
Yesterday we covered the lead I sign, so it’s only fitting that today we discuss the lead II sign.
There’s a “lead I sign” in lead II.
It’s a commonly described finding but I’ve never seen that term used anywhere else; however, it seems fitting considering our last post. What we see here is looks a lot like the lead I sign except it’s in the wrong spot. Could this be a trick of the vectors ...
Source: EMS 12-Lead - December 27, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 12-Leads of Christmas Original Articles Vince DiGiulio Source Type: research
The 12 Leads of Christmas: Lead I
This article is the first in our latest series, The 12 Leads of Christmas, where each day we examine a new finding particular to an individual electrocardiographic lead.
The Lead I Sign
This patient has COPD.
So does this patient.
How do I know that? Well, I met the patients and they told me, but there’s also a very specific (but not very common) sign of COPD present on both tracings: the “lead I sign.” This manifests as nearly isoelectric complexes in lead I with barely any visible P, QRS, or T-waves.
Often termed “Schamroth’s sign” or “Schamroth’s pattern,&...
Source: EMS 12-Lead - December 26, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 12-Leads of Christmas Original Articles Vince DiGiulio Source Type: research
The role of 12 lead ECG in Pediatric Pulmonary Hypertension
A 10 year old male presents to the Emergency Department with complaint of substernal chest pain, 6/10, unable to describe the sensation but non-radiating, which started during a basketball game, while running.
Primary assessment:
Patent airway
Adequate respiratory effort with no signs of distress
skin is pink, warm and dry, with no signs of hypoperfusion
Pertinent medical Hx:
Chronic Interstitial Lung Diseases secondary to Human T-cell Lymphotropic Virus (HTLV)
Secondary Pulmonary Hypertension
No allergies reported
Medications:
Acetaminophen PRN
furosemide 20mg
Flovent
Baseline vital signs:
Heart rate: 112 bea...
Source: EMS 12-Lead - December 17, 2014 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg pediatrics pulmonary hypertension Source Type: research
What it looks like: inferior STEMI
No mysteries here today – this is an inferior STEMI! But I thought that prehospital provider might like to see what happens “on the inside” during an MI.
The Case:
A 60-something female had a few days of feeling not quite right, so she did some Googling, and she began to worry about a heart attack. Therefore, when she acutely developed neck and jaw pain, she figured that her self-diagnosing was probably correct, and she called 911 without delay. Time from symptom onset to first medical contact (FMC) was about 30 minutes.
The ECGs
EMS captured an initial 12-lead:
ST elevation in III and aVF, reciprocal ST ...
Source: EMS 12-Lead - December 13, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Conclusion to Snapshot Case: 85yo M – Chest Pain
This is the conclusion to the Snapshot Case from a couple of days ago. If you haven’t already done so, I suggest reviewing the very brief initial case description.
Here again is the EKG from Tuesday’s case.
This tracing is nearly pathognomonic for true occlusion of the left main coronary artery (LMCA), resulting in a “left main STEMI.”
Since this a Snapshot case with no follow-up this diagnosis cannot be confirmed, but it is a rather unique pattern I have yet to see mimicked by any other form of ACS. I’m not surprised that few, if any, readers were familiar with this presentation. It is not c...
Source: EMS 12-Lead - December 12, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: 360 Degree Heart Cases Snapshot Tom Bouthillet Vince DiGiulio Source Type: research
Register for #EMSToday2015 win an iPad mini!
Here’s a blog post so promotional that it may crash Facebook’s throttling algorithm!
In case you weren’t aware, the EMS Today conference is back in Baltimore and is scheduled to take place February 25-28, 2015. In my last blog post I wrote about some of the reasons I love Baltimore and why I believe it’s the “spiritual home” of EMS Today (even though I really enjoyed Washington, D.C.).
Have you been thinking about attending?
Good news! If you register through one of the JEMS/PennWell EMS blogs, you not only receive a $100.00 discount from the regular price ($15.00 in addition to the...
Source: EMS 12-Lead - December 10, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized 12-Lead ECG Challenge app EMS Today EMS Today promo code Source Type: research
Register for #EMSToday, win an iPad mini!
Here’s a blog post so promotional that it may crash Facebook’s throttling algorithm!
In case you weren’t aware, the EMS Today conference is back in Baltimore and is scheduled to take place February 25-28, 2015. In my last blog post I wrote about some of the reasons I love Baltimore and why I believe it’s the “spiritual home” of EMS Today (even though I really enjoyed Washington, D.C.).
Have you been thinking about attending?
Good news! If you register through one of the JEMS/PennWell EMS blogs, you not only receive a $100.00 discount from the regular price ($15.00 in addition to the...
Source: EMS 12-Lead - December 10, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized 12-Lead ECG Challenge app EMS Today EMS Today promo code Source Type: research
Snapshot Case: 85yo M – Chest Pain
Snapshot cases are EKG’s where we do not have good patient follow-up—or sometimes even clinical information—but still feel there are worthwhile learning points to convey.
This is an old case we’ve actually featured on the blog before, but today we’re going to do so with a different focus.
This ECG is from an 85-year-old male, presumably experiencing chest pain.
Don’t worry about the rhythm. I’m going to keep the presentation simple this time because the tracing is actually pretty particular to a specific pathology.
This patient is experiencing a STEMI. Where is the culprit lesion?
...
Source: EMS 12-Lead - December 9, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Uncategorized Source Type: research
Mark your calendars: EMS Today is back in Baltimore!
Those of you who miss the Pratt Street Ale House, Slider’s Bar and Grill, Pickles Pub, “Natty Boh”, Maryland crabcakes, the Inner Harbor, and Fell’s Point will be glad to know that EMS Today is back in Baltimore Feb 25-28, 2015!
I like the Smithsonian as much as the next guy (all right, probably more than the next guy) but Baltimore feels like the spiritual home of EMS Today! That’s probably because of all the great times we’ve had there in years past. Remember “EMS 2.0″ and solving the world’s problems over a couple of beers at Uno’s Pizza? Were we naive back the...
Source: EMS 12-Lead - November 28, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized EMS Today Source Type: research
Anterior T wave inversions and PE.
Last week, I described the case of a middle-aged male with a vague history of heart failure who had been having progressive shortness of breath for 4-5 days. On the day he called 911, he had been walking a short distance when he syncoped. EMS obtained an ECG:
Inverted T waves are seen in III and aVF, as well as V1-V4.
Compared with the prior ECG, the anterior T wave inversions appeared new.
Subtle S1Q3T3, but no ATWI
What can cause anterior T wave inversion (ATWI)?
There are some rare entities that show up with ATWI; e.g. ARVC. Young women can also have a benign variant, the so-called persistent juvenile T wave pattern.
Bu...
Source: EMS 12-Lead - November 18, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
100 yof CC: Rib pain and intermittent spasms
EMS is called to a local nursing home for a 100 year old female patient who had been complaining of rib pain and intermittent spasms for 3 days.
Vital signs were assessed.
RR: 14
Pulse: 80
NIBP: 138/68
Temp: 98.8
SpO2: 97% on room air
A 12-lead ECG was recorded.
A minute later a change was noted on the monitor and another 12-lead ECG was obtained.
About 30 seconds later the abnormality resolved.
The patient was discharged the same day from the emergency department.
What could account for these unusual looking T-waves? (Source: EMS 12-Lead)
Source: EMS 12-Lead - November 16, 2014 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized Source Type: research
Not just S1Q3T3: Look at the other 10 leads!
It was a slow morning in the ED, so I was able to catch the medic as she came in with the patient. “Hey Leigh, what do you have for us? Got an interesting ECG?”
“Well, maybe,” she replied as she wheeled by with a comfortable looking middle-aged male, “here, take a look at it while I give report to the nurse.” She handed me the 12-lead:
After leaving the patient with the RN, Leigh came back. “This is a guy with a history of CHF, with an AICD placement. He’s had shortness of breath for 4 days, worse when he walks. He passed out today when he was walking, so his family called u...
Source: EMS 12-Lead - November 14, 2014 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
What it Looks Like: Cardiac Arrest
Conclusion
It’s heavy work watching these sorts of videos but it’s important for what we do. Prompt recognition of cardiac arrest is the first link in the Chain of Survival and early CPR and defibrillation are absolutely vital to achieving good outcomes for these patients. Here’s a few final take-home points:
Sudden cardiac arrest is just that—sudden—and can occur without warning.
It is surprisingly difficult to differentiate seizures from early cardiac arrest.
Sudden cardiac arrest that self-resolves is called syncope (H/T to Amal Mattu).
It is nearly impossible to distinguish benign syncope from ca...
Source: EMS 12-Lead - November 11, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Original Articles Source Type: research
Conclusion to 83 Year Old Male: Shortness of Breath
Last week we presented the ECG of a patient experiencing progressively worsening shortness-of-breath over the course of a day and some marked ECG abnormalities. If you haven’t done so already, it would probably be a good idea to check out the original post first. Strap in, this is going to be a thorough discussion.
Here again is the patient’s initial ECG:
Not a STEMI-equivalent.
This ECG shows:
Sinus tachycardia at a rate of 96 bpm.
First-degree AV-block (PRi of approx 240 ms).
Left anterior fascicular block (LAFB), resulting in…
Left axis deviation (mean frontal QRS axis approx -60 degrees), and…...
Source: EMS 12-Lead - November 6, 2014 Category: Cardiology Authors: Vince DiGiulio Tags: Cases aVR LMCA occlusion ST-elevation in lead aVR subendocardial ischemia Vince DiGiulio Source Type: research
