Interesting EKG from ride time, check it out:

[fiznat]

Dispatched for the leg pain s/p fall. O/A found 56 y/o female c/o 10-10 leg (actually stump- left BKA) pain after falling out of her wheelchair about 10 mins ago. She is absolutely screaming in pain. We eval her leg/stump, no deformity/contusions/lacerations/swelling etc. Pt notes increasing pain on palp (screamed our ears off). GCS 15, mentating normal according to family on scene. Lung sounds clear bilat, pupils PEARRL, good circulation/sensation/movement x 4 extremities. Skin warm pink dry.

As we're loading her onto the stretcher, pt notes "a little chest pain too" dull in nature, increasing on palp, and radiating down left arm. She regards the chest pain as a mere annoyance compared to her leg pain, only a 2-10 compared to the 10-10 in her leg.

Hx:
DMII
S/P CABG X 2 3 years ago
L BKA

Rx:
Insulin

Vitals:
BP: 120/60
HR: 40!
RR: 20


Noting the HR while getting her BP, we throw her on the monitor:

Go here for a much larger version: http://www.project-mayhem04.com/CP2big.JPG


I ask the medic if we should get a 12 lead, he thinks we should get going instead. IV with NS, 12lpm O2 via NRB. Vitals no change enroute, no change in MS either- patient still (loudly) complaining mostly about her leg.

Backing into the bay at the ED we print one more strip:

Larger version here: http://www.project-mayhem04.com/CP1big.JPG


The ED's 12 lead interpreted it as a 3rd degree AV block with some scattered PACs. We had to leave cause we got another call, but I was around long enough to see them applying the pacing pads...


Wondering what you guys think. I'm just starting cardiology but I've read the Dubin book and it doesnt seem like an AV block to me at all. ...Especially not a 3rd degree AV block, the rhythm is way too regular. My best guess was that it was just a slow junctional rhythm but I'd really like to hear what you guys think. Looking at the EKG I cant help but be amazed at her presentation. No apparent perfusion problems whatsoever, you'd never know she had a cardiac issue just looking at her-- seemed like a normal leg pain s/p fall.

Watcha think?




EDIT: what, we're not allowed to imbed images here?

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[a_ditchdoc]

It is difficult to see any atrial complexes buried in the rythm, but my impression when first glancing at the rythm was 3rd degree block. 3rd degree blocks are indeed regular, as are the p-waves, they just have nothing to do with one another. And although the auto-analysis of the 12 leads is awesome, it is not always right...

Perhaps it is a sinus arrest with a junctional escape rythm. Some of you guys let me know what you think....

 

[fiznat]

Yeah I suppose it could be 3rd degree-- hell, I'm sure that machine is much better at this than I am after having read only one book haha.

Still though, given the information on that strip right there its hard to say its a 3rd degree simply because there MAY be (disassociated) p-waves somewhere in that rhythm. The rate isnt that good on this strip (non diagnostic quality to be sure), so who knows if theyre really there are not. Seems like given the apparant absence of the atrial complexes, a junctional escape rhythm would seem reasonable?

Wish we got that 12 lead

 

[DrMom]

I fixed it so that you could have the images in the post.

 

[12R34Y]

3rd degree heart blocks are often times wide (most always) it is essentially a bi-bundle block right? If the block is below the AV node it is usually always a wide complex rhythm. However, you can have complete heart block with a junctional pacemaker which would them have narrow complexes.

First strip on top looks to me like probably junctional rhythm (rate is correct at 40 which fits) it's regular (junctionals are) , its narrow complex and I think I see an inverted P wave on the third beat in lead II on the top strip with a short PR interval (also fits junctional).


The second strip does NOT look like a 3rd degree heart block either (it is irregular).

That perhaps looks like a junctional rhythm with PAC's or perhaps progressing into a 2nd degree block of sorts.

interesting strip.

later

 

[a_ditchdoc]

The second strip does NOT look like a 3rd degree heart block either (it is irregular).

I agree, the second strip is not 3rd degree. The patient obviously has a variable block. If you will look closely at the first strip, you can see what look like several evenly spaced p-waves following the T. Who knows, maybe it is artifact. I couldn't see it in the rest of the strip....

 

[fiznat]

I fixed it so that you could have the images in the post.

Thank you!

What do you guys think about the possibility of hyperkalemia? Extremely flat p-waves (guess you could call them that), peaked tenting T waves.

?

 

[12R34Y]

Thank you!

What do you guys think about the possibility of hyperkalemia? Extremely flat p-waves (guess you could call them that), peaked tenting T waves.

?

Could be hyperkalemia. really wishing you'd done a 12-lead now

 

[Gatewayhoward]

I'm on the same page with everyone. I saw the first on and thought, Junctional escape possible changing back and forth to a second degree block when looking at #2. Point is dangerous/borderline rhythm.

 

[southerndoc]

Thank you!

What do you guys think about the possibility of hyperkalemia? Extremely flat p-waves (guess you could call them that), peaked tenting T waves.

?

My first thoughts. What was the patient's potassium? Is she on dialysis or on potassium-sparing diuretics (ACE inhibitors, spironolactone, etc.)?

The T waves are definitely peaked, and the QRS is widening. The P wave is difficult to identify (if present at all). The potassium level very well could be high enough that it is progressing to a sine wave. If so, this patient is only hours away from death if rapid intervention is not performed.

Did this patient have a crushing injury to her leg or have evidence of anything that could cause rhabdomyolysis, thereby leading to hyperkalemia? Was her "fall" more of a crush injury? Usually rhabdomylolytic induced potassium release is easily self-corrected with adequate renal function, but this patient likely has compromised renal function given her history of age and diabetes (especially if her amputation was from diabetic complications).

Interesting strip. Too bad there wasn't a 12-lead done. In my opinion, a pre-hospital 12-lead was warranted in this situation. I would have probably been critical of you not performing one had I received this patient.

 

[viostorm]

Interesting strip. Too bad there wasn't a 12-lead done. In my opinion, a pre-hospital 12-lead was warranted in this situation. I would have probably been critical of you not performing one had I received this patient.

Ok so I'll go out on a limb on this one and disagree with Southern Doc.

My opinion 12 leads are inappropriate for *rhythm interpretation*, only delay care in EMS when used in this capacity and should be used cautiously in that manner such that it does not delay lifesaving interventions.

12-leads are for early detection of AMI and activation of cardiology staff to reduce door to balloon time.

This patient had a rhythm disturbance and no 12-lead was required to realize a significant pathology was present, and if you say the patient's heart rate is 40, they should be plenty prepared at the ED anyway.

I think it is a stretch to see hyper K in your ECG. Hyper K is pretty rare prehospitally especially compared with things like a-fib. Really there is not enough info for any of us to make an educated decision which is why Southern Doc would have liked an 12 lead ECG. It would have made his job easier had it been his patient.

So I guess what I'm saying, if your patient has a screwed up heart rhythm, it is nice to have a ECG and will earn you points w/ the ED physician. I would not delay transport or treatment to obtain 12-lead in this instance. I guess, don't lose the forest through the trees, I have actually seen a 12-lead done by a paramedic of a patient in v-fib ... seriously ... a really low priority in that.

I don't think that there is any research that shows 12-leads reduce morbidity and mortality for arrythmias. There is for recognition of AMI.

I get a 12-lead in the following instances:

Always:

* CP or "anginal equivalent" patients
* Wide complex tach (to aid ED physician/cards to differentiate VT vs SVT w/ abberancy)

Nice but not mandatory in my opinion:

* SVT
* Bradycardia (note watch out for AMI in this, go back to CP above)


My vote for your ECG: junctional escape .... too regular to be afib which would definitely be on my differential. When no p-waves are present prehospitally ... it is usually a-fib. I'll also say like R1234 most likely not 3rd degree, the ventricular complexes in 3rd degree are usually wide because the ventricular complexes originate from the ventricles.

 

[viostorm]

Went back and read your post again ...

You gotta do a 12-lead if she was having CP. Bad paramedic!

 

[fiznat]

She was complaining of CP though, although it did seem like an afterthought compared to her leg pain.

Again I am just a medic-in-training at this point, but I think your argument can be used for a lot of our prehospital treatments/procedures. Starting an IV was obviously a good idea, but not like she was going to get any drugs right away, and certanly not before she got her 12 lead done- so why even do that? ASA might also have been a good idea (although my medic didnt do it), but why bother when the hospital is <5 minutes away?

Of course there is the argument that transport to the ED doesnt necessairly have to be delayed to start an IV or give ASA, but 90% of the medics Ive worked with (and I've worked with alot) generally elect to sit on scene and get the stick.

Of course I am all for getting the patient to the ED as quickly as possible, and if I ever get good enough at this I will do my best do do everything enroute. Truth is, this isnt how a lot of medics operate, and given that we're already sitting on scene for that time, why not throw on the extra leads too right?

 

[mastamark]

I think the gain has to be turned up on that puppy. Either that or the leads are misplaced or not sticking. Those peakes could be a mixture between occasional PVCs and/or Tenting T waves also
(hyperKalemia). I think it's just faulty placement. But who knows?

 

[viostorm]

Fiznat, I think it goes back to "medicine is an art not a science" ... especially in urban EMS where hospital is down the block. I think you gotta decide, is patient having symptomatic chest pain ... if so ... go the symptomatic bradycardia protocol. If you think the CP is not her problem and it is her leg, throw her in the bus and run up the street. It would be hard to argue CP is not serious with that crazy ECG. I typically treat the more serious of the complaints that I consider legit in a "life before limb" way.

As far as why bother with 12-lead, lots of studies have shown reduced door-balloon times in AMI when EMS does a 12-lead. Even in urban systems with short transport times. So that is why I always do one in setting of CP.

You are going to be a great paramedic because you are so concerned with these things and willing to ask others for help.

Good luck in your training!

(I just want to make sure you know I'm just teasing, I've rolled in w/ many a patient I should have done more or less for!)

 

[fiznat]

Either that or the leads are misplaced or not sticking.

Its not that. Placement is good, I did it myself (and I know how to do a 3 lead lol). Not to mention if a lead isnt sticking or reading for some reason the LP12 will catch it and warn you. Plus look at the isoelectric line... not junky at all.

You are going to be a great paramedic because you are so concerned with these things and willing to ask others for help.

Good luck in your training!

(I just want to make sure you know I'm just teasing, I've rolled in w/ many a patient I should have done more or less for!)

Thanks man! And yeah, I know you're teasing- dont worry about it

 

[docB]

I think it is a stretch to see hyper K in your ECG. Hyper K is pretty rare prehospitally especially compared with things like a-fib.

The first thing I thought when I saw this strip was hyperkalemia as well. I agree with you that you have to treat the patient and not the EKG, 12 lead or not. But, I'd say hyperkalemia is more common than you think. The problem is that that diagnosis is not made until the K comes back from the lab, about 1 - 1.5 hours after presentation at my houses. EMS is long gone by then so many hyperK patients will not be known as such to EMS.

 

[southerndoc]

Vio, thank you for your comments.

It's been my anecdotal observation that a lot of arrhythmias have, in fact, been caused by ischemic events. Secondly, we do not know if there are repolarization abnormalities that could explain the peaked T waves -- again a 12-lead would be helpful in diagnosing this.

You are correct in that it makes my job a lot easier. I frequently activate the cath labs and treat patients based on pre-hospital EKG's. It often times saves 10 minutes off treatment times. Sometimes I've seen "benign" patients triaged to higher acuity areas because of pre-hospital EKG's.

Fiznat, you may take vio's advice as you want, but please remember if you transport a CP patient or any patient with an arrhythmia to the facility where I work, you will likely be called on not performing a 12-lead. You can get a 12-lead enroute, especially if you are not running ligths and siren. When I was a paramedic, I frequently did them enroute. Perfect time to do one while stopped at a traffic signal.

Do they change pre-hospital management? Very rarely so.

 

[mastamark]

Its not that. Placement is good, I did it myself (and I know how to do a 3 lead lol). Not to mention if a lead isnt sticking or reading for some reason the LP12 will catch it and warn you. Plus look at the isoelectric line... not junky at all.





Thanks man! And yeah, I know you're teasing- dont worry about it

I wasn't attacking your skills. I was just putting in my 2 cents. If you say you placed them correctly than I believe you. I was just making a suggestion. It is interesting though.

 

[viostorm]

But, I'd say hyperkalemia is more common than you think.

Agreed, I can count on one hand how many times I've had lab values on a 911 call.

SouthernDoc ... you always have great advice and a wise perspective on things! Enjoyed the discussion.

 

[emtcsmith]

I'm also a medic student who recently finished a good deal of our EKG stuff in the program. I don't claim to be great at the AV blocks but the first thing I thought was junctional. It didn't look regular, I couldn't see any good P's, etc. Now for most blocks I have to sit and look at all the parts but either way it just looked bad and I can only imagine my reaction if it was my patient.

 

[niko327]

Couple of thoughts, was the patient on digoxin?

Looks like some atrial fibrillation in that ECG, yet the ventricular activity appears to be regular, so perhaps consideration of digitalis toxicity may be in order. Dig toxicity can sometimes present as afib with clock regularity of the ventricular activity, as is the case in rhythm strip #1.

I can see what you are saying about the pointy looking T waves, but I'd feel better about a preliminary diagnosis of hyperkalemia if the QT interval was shorter. Critical hyperkalemia can give you shortening of the QT and sinusoidal QRS complexes as the QRS and the T wave appear to fuse together.

Finally, if you look closely at the second strip, you'll see that the morphology of the QRS complexes are not the same. The second strip seems to have the emergence of some irregularity. In fact there are actually two separate QRS morphologies present. Comparison with the first strip reveals that the QRS morphology of rhythm strip #1 is identical to the first QRS morphology on strip #2. But the second QRS complex on strip #2 is different than the QRS complex that immediately precedes it. This may mean worsening of the digitalis toxicity block (if it is digitalis induced block), suggested by the emergence of some other escape complexes as the overall rate starts to slow. Or it may be some break through of the atrial fibrillations causing a ventricular response since the QRS complexes still appear to remain narrow. The strip is quite short, making interpretation difficult.

But then again I might be wrong completely......

 

[fiznat]

If she was on dig, she didnt tell us. Insulin was the only Rx she told us about, and all we could find in the house. Interesting idea though, although my understanding of dig is that it can pretty much do anything with a cardiac rhythm- so I imagine it'd be hard to determine which aspects of a strip are specifically related to the toxicity alone.

 

[niko327]

You are right, Digoxin can cause any number of EKG abnormalities. The ones I tend to think about are heart block as in third degree, st-t abnormalities like "scooped" depressions and shortening of the QT interval.

 

[joemedic]

We have a lot of people on dialysis (sp?) in our area and had a pt with a similarly funky rhythm (and she called because she had twisted her ankle.) She had a K+ of 7.2. An ER doctor said that if we had a patient like that again, start her on an albuterol breathing treatment, and call for orders for sodium bicarb and calcium chloride.

Without a 12-lead, it's hard to see what is going on. You might check back with ER and see what the pt's 12-lead showed and her lab values.

My advice would be to use a little right foot medicine no matter what the patient was complaining of.

joemedic