59 Year Old Male: Unwell

It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.

When you arrive on scene you encounter a middle-aged man in obvious distressed lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrs; unable to catch his breath or get up off the couch with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.

His radial pulse is faint, rapid, and irregular while his skin cold and moist.

  • HR – 150 bpm, irregular
  • SpO2 – Unable to get a clear waveform
  • BP – 72/42 mmHg
  • RR – 26. labored
  • Temp – 36.6 C (97.9 F)

Breath sounds reveal crackles bilaterally.

Multiple 12-lead ECG’s are performed but suboptimal due to the patient’s increased work of breathing and inability to stay still. This is the best of the bunch:

Initial 12-Lead

BGL is 156 mg/dL.

He is a bit lethargic but properly oriented and answers questions appropriately, albeit slowly.

  • S – As above
  • A – No known drug allergies
  • M – None
  • P – Appendectomy @ 24yo
  • L – Soup 45 min prior, which he vomited soon after
  • E – Can’t recall—states he has felt terrible “all day.”

Regarding the chest heaviness…

  • O – Gradually through the morning
  • P – Nothing makes it better or worse
  • Q – Heaviness
  • R – None
  • S – Unable to quantify
  • T – Worsening x 8 hrs

What are your management priorities for this patient?

What is your interpretation of the ECG?

 

 ***UPDATE (2015/6/29/ 14:00 EDT)***

After carefully transferring the patient to the ambulance and finding him a position of comfort (head-of-bed at 60 degrees—he doesn’t like to lie flat), you succeed in obtaining a cleaner EKG. Does this change your approach to the case?

02 - 12-Lead 02

How to be successful at IV therapy – some advice for paramedic students

IV start
Image credit: Wikimedia Commons

In a recent thread at EMT Life a paramedic student wrote:

Just entering my 2nd semester of paramedic school. So far I’ve found the coursework to be the easiest part. Instead of being stressed over tests I’m stressed over IV’s. 170 sticks in overall my % sucks. Granted most of those were just “oh I wonder if that vein could be hit with this gauge” attempts to find what could and couldn’t be done. Now that I’m on the truck I know what veins are my go to. Still struggling mentally with it but over the last 45 sticks my % is approx. 75% first attempt success. I have no clue what is going on, it seems so easy but I wind up screwing it up somehow. From my standpoint I’m getting flash but I’m blowing it on insertion still. I know to still go that little bit more but I’m wondering if I’m pulling the needle back while inserting the cath. Anyone else struggle like this this late in medic school? Really tired of getting made fun of when I can’t secure access first attempt.

It seems to me that a 75% success rate on the first attempt (for a paramedic student in his second semester) is actually not too bad.

Here is the advice I offered.

The habits you develop right now will last your entire career (good or bad). Lay out your equipment and spike your IV bag using the proper aseptic technique. Shut down the roller clamp prior to squeezing the drip chamber. It helps prevent air bubbles in the IV line. There is no need to remove the cap when you charge the line. Lower the side rail on the gurney and take a knee alongside the patient. Place the arm in a dependent position (below the patient’s heart). Apply the tourniquet in such a way that the tails are pointing superiorly (not toward your work space). Cleanse the area with alcohol. Once that is done don’t palpate again without re-cleansing. Hold the skin taught with the thumb of your left hand below the target vein. Make your first “stick” count (you should strive to get a flash with the initial stick). Then give a “bump” to ensure that the bevel clears the lumen (omitting this step is a very common error). As you advance the catheter look for the secondary flash. If you always do it this way you will become highly skilled at IV therapy. Conversely, I have seen paramedics with poor technique after 5, 10, 15 years in the field.

I’d love to hear your tips in the comments section!

DNRs, Falsifying Official Documents, and Compelling Reasons

FDNY_medics
Image credit: Billie Ward – Creative Commons

I originally posted this on my personal Facebook page but there appears to be a lot of interest so I decided to post it here also.

The Staten Island Advance newspaper reported on May 22, 2015:

Two FDNY paramedics are accused of lying about administering aid to a dying 71-year-old Dongan Hills man — aid they didn’t provide because they sympathized with the patient’s wife, who didn’t want him to be revived but couldn’t find his “do not resuscitate” paperwork, sources familiar with the case said.

I’m not excusing the falsification of patient care records but antiquated protocols and administrative laws that mandate paramedics perform a resuscitation attempt on terminally ill patients because a piece of paper cannot be located are morally and ethically wrong.

It needlessly places us in a difficult situation and distracts us from focusing on palliative care and supporting a grieving family. Our professional associations should take a strong position on this. With or without a DNR, if a resuscitation attempt is futile, inappropriate, or inhumane, we should not be doing it.

This issued is handled very well by our colleagues in King County Medic One in Washington State.

End of Life Toolkit

See “Compelling Reasons” (PDF) on Page 7 of the Resuscitation Academy’s End-Of-Life Toolkit.

Compelling reasons permit EMS personnel to withhold resuscitation from a patient in cardiac arrest when two criteria are BOTH present. These are:

1. End stage of a terminal condition
2. Written or verbal information from family, caregivers or patient stating that patient did not want resuscitation

Here is what the law says in South Carolina:

“SECTION 44-78-40.

Full resuscitative measures required in absence of order.

In the absence of a “do not resuscitate order for emergency medical services”, EMS personnel shall give full resuscitative measures as are medically indicated in all cases.”

The key phrase here is “as are medically indicated”. Get on the phone with Online Medical Control! The wording should be changed. We shouldn’t have to exploit a loophole to do the right thing.

What If We’re Wrong? Prehospital ECG Interpretation

This article is part of a special one-day EMS blogging event called the What If We’re Wrong a-Thon. Spearheaded by Brandon Oto over at EMS Basics, the WIWWAT is an exercise in self-reflection where EMS writers examine a topic on which that they’ve historically taken a strong stance, but from the opposite point-of-view. For more posts from around the EMS community as part of the What If We’re Wrong a-Thon, check out this page.

Click image for source.

Click image for source.

The Question

Despite years dedicated to cause of prehospital STEMI recognition and EMS interpretation of electrocardiograms, what if we’re wrong? What if there’s a better, safer, and more efficient method of triaging which patients need emergent PCI that doesn’t rely on the prehospital provider’s interpetation of the ECG? Perhaps the time and energy we spend in and out of the classroom training medics how to recognize ischemia could be better spent on other topics where we really can make a difference.

So the question we want to ask is “Should prehospital providers be identifying STEMI’s?”

The answer is “No.”

 

The Evidence

Bhalla MC, Mencl F, Gist MA, Wilber S, Zalewski J. Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. 2013 Apr-Jun;17(2):211-6. doi: 10.3109/10903127.2012.722176. Epub 2012 Oct 15. [PubMed]

These authors looked at 200 prehospital ECG’s from patients who were treated at their facility—100 from patients who were sent to the cath lab and 100 randomly selected controls who were not deemed to have experienced a STEMI. The golden standard was the emergency physician’s decision whether or not to activate the cath lab. The specificity of the ***ACUTE MI SUSPECTED*** message was found to be 100% (100/100; 95% CI 0.96-1.0) while its sensitivity was 58% (58/100; 95% CI 0.48-0.67).

  • Computers were 100% specific but they missed 42% of physician-activated STEMI’s in this study.

 

de Champlain F, Boothroyd LJ, Vadeboncoeur A, Huynh T, Nguyen V, Eisenberg MJ, Joseph L, Boivin JF, Segal E. Computerized interpretation of the prehospital electrocardiogram: predictive value for ST segment elevation myocardial infarction and impact on on-scene time. CJEM. 2014 Mar;16(2):94-105. [PubMed]

This study was performed in Canada. It looks at 1,247 prehospital ECG’s acquired by Primary Care Paramedics (PCP’s) over a 2-year period and examines the accuracy of the computerized interpretation provided by the GE-Marquette 12SL algorithm. The program was found to have a sensitivity of 69.2% (59.0-78.5) and a specificity of 98.9% (98.1-99.4).

  • The computer performed quite well in this study compared with some of the others. The sensitivity is still rather poor but the specificity is great.

 

Kudenchuk PJ, Ho MT, Weaver WD, Litwin PE, Martin JS, Eisenberg MS, Hallstrom AP, Cobb LA, Kennedy JW. Accuracy of computer-interpreted electrocardiography in selecting patients for thrombolytic therapy. MITI Project Investigators. J Am Coll Cardiol. 1991 Jun;17(7):1486-91. [PubMed]

Prehospital ECG’s were examine for 1189 patients with chest pain of suspected cardiac etiology. 52% (202/391) of patients diagnosed with AMI on discharge (not necessarily STEMI) were read as STEMI by the computer, compared with 66% (259/391) read as STEMI by the cardiologists. 98% (785/798) of patients diagnosed as not having experienced an MI were correctly excluded by the computer while 95% (757/798) of patients were excluded by the cardiologists.

  • Computers are again less sensitive but more specific than human interpreters. Also of general interest, most patients with suspected cardiac chest pain are not experiencing an acute MI.

 

Swan PY, Nighswonger B, Boswell GL, Stratton SJ. Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary InterventionWest J Emerg Med. 2009 Nov; 10(4): 208–212. [PubMed]

During the study period paramedics in Orange County, California triaged 548 patients for the cath lab. 393 (74.3%) were considered true-positives by the presence of coronary lesions treated with angioplasty or CABG while 136 (25.7%) were considered false-positives, either because the emergency physician cancelled the activation (121 patients; 22.9%) or because no culprit was found on cath (15 patients; 2.8%). The key to this study is that the act of the paramedics activating the cath lab was determined solely by the computer generating an ***ACUTE MI SUSPECTED*** message. For more on the particulars seem Tom Bouthillet’s analysis.

  • This paper was surprising for the number of false-positives since computerized algorithms in general seem to have a pretty good specificity. The exception here might be that one particular brand fell out as being responsible for a preponderance of the false-positive activations.

 

Mencl F, Wilber S, Frey J, Zalewski J, Maiers JF, Bhalla MC. Paramedic ability to recognize ST-segment elevation myocardial infarction on prehospital electrocardiograms. Prehosp Emerg Care. 2013 Apr-Jun;17(2):203-10. doi: 10.3109/10903127.2012.755585. Epub 2013 Feb 12. [PubMed]

Paramedics were administered a survey with 10 ECG’s: 3 STEMI’s, 2 normal tracings, and 5 STEMI mimics. 472 medics responded with an overall sensitivity of 75% (95% CI 73%-77%) and specificity of 53% (95% CI 51%-55%) for the recognition of STEMI.

  • Paramedics in this study were 75% sensitive but only 53% specific for the detection of STEMI. That’s terrible.

 

Cantor WJ, Hoogeveen P, Robert A, Elliott K, Goldman LE, Sanderson E, Plante S, Prabhakar M, Miner S. Prehospital diagnosis and triage of ST-elevation myocardial infarction by paramedics without advanced care training. Am Heart J. 2012 Aug;164(2):201-6. doi: 10.1016/j.ahj.2012.05.009. [PubMed]

This study was designed to assess the ability of Primary Care Paramedics (a designation unique to Canada) to recognize and manage suspected STEMI. 134 patients were triaged for urgent PCI by the medics involved. 106 cases were deemed to be true STEMI’s in follow-up. The computerized interpretation recognized 98 of the 106 true STEMI’s but was fooled by 17 of the 28 false-positives. There was agreement between the prehospital provider’s interpretation and that of the physician 90% of the time.

  • The computer showed excellent detection of STEMI in this case but poor ability to discern mimics. This is a bit of an outlier compared with other ingestigations of computerized algorithms. The medics performed well in this study but their experience and training is difficult to compare with that of the U.S. EMS system.

 

Kontos MC, Kurz MC, Roberts CS, Joyner SE, Kreisa L, Ornato JP, Vetrovec GW. An evaluation of the accuracy of emergency physician activation of the cardiac catheterization laboratory for patients with suspected ST-segment elevation myocardial infarction. Ann Emerg Med. 2010 May;55(5):423-30. doi: 10.1016/j.annemergmed.2009.08.011. Epub 2009 Sep 20. [PubMed]

This study looked at 249 cath lab activations initiated by emergency physicians at their center. 188 patients (76%) were diagnosed as experiencing a true STEMI but only 5.2% of activations were deemed “inappropriate” by cardiology.

  • Be careful how you define “false-positive” and “appropriate” with regards to STEMI activation. I think that’s all we can say about this one.

 

O’Donnell D, Mancera M, Savory E, Christopher S, Schaffer J, Roumpf S. The availability of prior ECGs improves paramedic accuracy in recognizing ST-segment elevation myocardial infarction. J Electrocardiol. 2015 Jan-Feb;48(1):93-8. doi: 10.1016/j.jelectrocard.2014.09.003. Epub 2014 Sep 16. [PubMed]

130 paramedics were tested for their ability to recognize STEMI on 12 randomly selected prehospital ECG’s; 6 with an accompanying baseline ECG and 6 without. The addition of old ECG’s improved the paramedics’ accuracy from from 75.5% to 80.5%.

  • Paramedics were 75% accurate in recognizing STEMI, but that could be improved with the addition of old ECG’s (as are available in-hospital).

 

Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics. Emerg Med J. 2002 Jan;19(1):66-7. [PubMed]

7 London paramedics were tested in their ability to recognize “ST-elevation” (not necessarily STEMI) in 100 ECG’s as compared with the gold-standard to two cardiologists. The medics were 97% sensitive, [CI 0.94–0.99] 91% specific [CI 0.53–1.0], and 95% accurate [CI 0.88–0.98].

  • It seems these medics did quite well but quoting from the paper’s discussion: “This study was performed using a group of well motivated and enthusiastic paramedics from a single ambulance station with a close connection to a teaching hospital. The same results might not be obtained if all paramedics were trained in this skill.” Also, they were not specifically tested for their ability to recognize STEMI but rather a few rather specific patterns of ST-elevation they had been taught in a class 12-months prior. It pays to read the full paper and I think these numbers are grossly inflated from what they would be in the real world.

 

Trivedi K, Schuur JD, Cone DC. Can paramedics read ST-segment elevation myocardial infarction on prehospital 12-lead electrocardiograms? Prehosp Emerg Care. 2009 Apr-Jun;13(2):207-14. doi: 10.1080/10903120802706153. [PubMed]

103 Connecticut paramedics were given five scenarios that tested their ability to recognize the three ECG’s that showed true STEMI and two that did not warrant cath lab activation. Overall, the paramedics were 88.0% sensitive (83.8–91.3) and 88.3% specific (83.0–92.2)  in activating the cath lab with an 8.1% (5.4–12.0) false positive rate.

  • These paramedics performed well identifying a very limited number of obvious STEMI’s. Because they were computer-generated ECG’s it’s reasonable to assume the computerized algorithm would have been 100% sensitive and specific in identifying these STEMI’s.

 

Feldman JA, Brinsfield K, Bernard S, White D, Maciejko T. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Am J Emerg Med. 2005 Jul;23(4):443-8. [PubMed]

151 prehospital 12-leads (25 of which were judged as showing STEMI by a reviewer using standard millimeter criteria) were examined by blinded emergency physician and a blinded cardiologist. Their interpretations were compared with the initial interpretations performed by the paramedics in the field. The paramedics showed a sensitivity for STEMI of 0.80 (95% CI, 0.64–0.96) and a specificity of 0.97 (95% CI, 0.94–1.00). The overall accuracy was similar for the paramedics, emergency physician, and cardiologist (0.94, 0.93, 0.95; respectively).

  • Paramedics performed well in this study but it must be noted that they constituted a “stable force of highly trained, motivated, and experienced ALS providers” an urban EMS system and would be expected to perform better than the national average. Also, it’s important to note that there was an inordinately high rate of STEMI in the population studied, as mentioned below…

01 - Feldman et al.

 

Le May MR, Dionne R, Maloney J, Trickett J, Watpool I, Ruest M, Stiell I, Ryan S, Davies RF. Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. CJEM. 2006 Nov;8(6):401-7. [PubMed]

Another Canadian study, this time examining Advanced Care Paramedics (ACP’s). According to the reviewers (two emergency physicians and one cardiologist), during the study period the ACP’s correctly identified 63 STEMI’s, missed 3 cases, and had 13 false-positives. Their sensitivity was 95% (86%-99%) with a specificity of 96% (94%-98%).

  • Canadian training is very different from the American system and that needs to be kept in mind. Also, with only 3 “missed” STEMI’s reported, I suspect there were a lot more not picked up by the reviewers…

 

Davis DP, Graydon C, Stein R, Wilson S, Buesch B, Berthiaume S, Lee DM, Rivas J, Vilke GM, Leahy DR. The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram. Prehosp Emerg Care. 2007 Oct-Dec;11(4):399-402. [PubMed]

This study was performed in two phases. In Phase I paramedics activated the cath lab on their own and in Phase II ECG’s were transmitted to emergency physicians who then activated the cath lab. 110 patients were enrolled (54 in Phase I, 56 in Phase II). In Phase I cardiologists confirmed STEMI on the prehospital ECG in 78% of cases (42/54), emergent PCI occurred in 70% (38/54), and culprit lesions were found (or the patient arrested) in 69% (41/54). In Phase II cardiologists confirmed STEMI in 96% of cases, emergent PCI occurred in 91% of cases, and culprit lesions were found or the patient arrested in in 89%.

  • Allowing the emergency physician to activate the cath lab via transmission significantly improved the accuracy of the decision.

 

Garvey JL, Monk L, Granger CB, Studnek JR, Roettig ML, Corbett CC, Jollis JG. Rates of cardiac catheterization cancelation for ST-segment elevation myocardial infarction after activation by emergency medical services or emergency physicians: results from the North Carolina Catheterization Laboratory Activation Registry. Circulation. 2012 Jan 17;125(2):308-13. doi: 10.1161/CIRCULATIONAHA.110.007039. Epub 2011 Dec 6. [PubMed]

14 primary PCI hospitals were examined over 12 months, during which time there were 3973 cath lab activations. 29% were performed by prehospital providers were 71% were called by emergency physicians. 596 cases were deemed “inappropriate” activations, with EMS responsible for 242 of them (40.6%) due to incorrect ECG interpretation while emergency physicians were only responsible for 183 cases (30.7%) despite activating the cath lab more times.

  • Yet again emergency physicians demonstrate their superiority in regards to correct activation of the cath lab.

 

Some Conclusions

After sorting through that huge pile of information, let’s start drawing some conclusions. Here’s the big three I’ve gathered from the above studies.

  • Computers are specific but not very sensitive when it comes to recognizing STEMI. When they say it’s a STEMI it usually is, but they also miss a lot of them. Their performance can be improved by ensuring good-quality tracings with mimimal artifact and no “Data quality precludes interpretation” message, but there is still a ceiling to their abilities.
  • Prehospital providers are more sensitive but often less specific than computerized algorithms. Also, their performance varies greatly from region to region.
  • Emergency physicians are at least as good as prehospital providers (at least in studies) and often significantly more accurate at ECG interpretation. They also initiate less false-positive and cancelled activations.

So, if you want optimal numbers, your system should be transmitting 100% of its ECG’s to an emergency physician base station for interpretation and activation. I hope that answers the question we set out to address, and true to our goal from the start, it’s certainly a sobering pill for me, your ECG-obsessed author.

 

 

…there are some other considerations to keep in mind though.

  • It is expensive to run that sort of setup unless you work in a large system with an academic center willing to handle the influx of ECG’s.
  • ECG’s cannot be transmitted from everywhere that there is radio contact, so there are times when a medic would be able to activate well before getting into transmission range.
  • There are systems with highly-trained, well-seasoned, eager medics capable of reading ECG’s as well as emergency physicians. In addition to saving money, it also encourages excellence amongst the providers because they know they are the ones who will be making important decisions and not just pressing a button for someone else to do the work.
  • The person in the field is also the person who can see the patient, and quite often that plays a big role in whether an ECG is concerning or not. It is much more difficult to perform a cold-read on an ECG than it can be with the patient in front of you.

There are certainly many more variables that go into deciding what setup will work best for a particular region, but that’s a start. Admittedly, though, those are all exceptions when the rule is that, taken in toto, emergency physicians are a better bet when it comes to accurate STEMI activation.

What I think is clear is that there are two major possibilities in play: physician interpretation and medic interpretation (with the computerized interpretation turned on please); along with combinations there-of. And what I think is clearly inferior to those options is a system where cath lab activation is based solely on the computer’s message of:

***ACUTE MI SUSPECTED***

It’s nice when it’s there, but like most folks who type in all caps, the computer can be oblivious to some things that are pretty obvious to the rest of us.

 

For more self-contradictory posts from the What If We’re Wrong a-Thon, check out this page.

Snapshot Case: What Happened?

Snapshot cases are tracings where we do not have good patient follow-up—or sometimes even clinical information—but still feel there are points worth discussing.

 

This is a patient who required emergent cardioversion for unstable rapid atrial fibrillation.

01 - Rob McDonald

What happened?

 

Tracing shared by Rob McDonald, and emergency department nurse in Queensland, Australia.

Proficiency vs Deficiency… The Art Of Electrocardiography Analysis

Understanding the different types of  assessments, assessment tools, and findings acquired from these assessments, are all part of proper patient care in both acute and chronic emergency medicine management, in every realm of the term “PATIENT CARE”. One of the most important tools, in both the prehospital setting and long term care, is the 12 lead ECG, which just like any other tool, requires attention to detail, probably even more so than other tools. We have to know when to use it, why to use it, and be able to recognize the information given to use through its use.

ECG INTERPRETATION IS MORE THAN A SKILL, IT’S AN ART!

It’s an art which requires never-ending practice and will never reach a limit.  We will never know it all, and we will never be able to say, “I have seen it all”. Over the years we have seen providers and clinicians, in every setting and level of care, both being proficient and completely lacking ECG interpretation skill. Often, many clinicians, from Paramedics to Physicians, rely on the computerized ECG interpretation for proper patient care and management.

But how do we truly define “PROPER“?

Let’s discuss some scenarios…

This 93 year old male has been brought to the Emergency Department by a family member after complaining of sudden dizziness spells. He is overall healthy considering the age, with minimal pertinent history and just takes daily vitamins, at least per the family. The following 12 lead ECG was obtainedScan_20150522There appears to be sinus bradycardia with 3rd degree AVB (Atrioventricular Block), IVCD (both RBBB and LBBB morphologies) with Leftward frontal axis at approximately -70 degrees (aVR is the most isoelectric lead perpendicular to aVL), aberrantly conducted impulses during the 2nd and 7th beats, with a QTc (using Bazett’s formula) of approximately 400 ms, not taking into consideration the slight afterdepolarizations which cause a false QT prolongation.

Because of the initial computerized ECG interpretation of “EXTREME TACHYCARDIA WITH WIDE COMPLEX”, lack of awareness (for professionalism’s sake) by the receiving physician, and chief complaint of dizziness, the patient was initially on the verge of receiving a full Amiodarone drip of 150 mg over 10 min, but thank goodness for compensatory hypertension. In this case, there were multiple things wrong with the computerized interpretation, and treatment to be followed.

  • There Heart Rate is not 283 beats/min, but in the 30′s
  • The QTc is not 1121 ms
  • There is AV dissociation, with variant blocks throughout ED visit, from 1st degree to 3rd degree AVB
  • Amiodarone is definitely not indicated in bradycardias or high degree AVBs

Click on the highlighted title for an Amiodarone breakdown, UNDERSTANDING AMIODARONE   One tool I use in these cases of bradycardia, is SPo2 monitoring. Remember, with every systole achieving arterial pressures, the Pulse Oximeter will provide a value and waveform. We are not focusing on oxygenation values right now, just the presence of an SPo2 pleth coinciding with each QRS on the cardiac monitor.

Conclusion to 1st case:

This patient was admitted to the cardiovascular unit,  awaiting pacemaker placement.

 

Another example of why we should not solely rely on the computerized ECG interpretation:

wrong interpt.There is a sinus rhythm with LVH, physiologic Leftward axis (aVF is the isoelectric lead perpendicular to Lead I) at approximately -10 degrees. No primary (ischemic) ST-T changes with normal R wave progression and QT prolongation.

The computerized ECG interpretation is “SINUS TACHYCARDIA WITH 2nd DEGREE AV BLOCK 2:1 AV CONDUCTION”

 Does this mean that we will give Atropine or stand by pacing for the 2nd degree AVB? If you answer is NO, then you’re on the right track…

 

Now, in most instances, the computerized interpretation is accurate and useful:

  EMS HUMOR!!!

 While other times, it may not be as specific, depending on variations, most commonly movement and poor lead placement leading to Artifact:

77yof-unresponsive-12L    Artifact is one of the most common causes of inaccurate Atrial Fibrillation and Atrial Flutter computerized interpretation

Other causes of inaccurate computerized interpretation include:

  • QRS width
  • Intrinsic rate and irregularity
  • ST segment and T wave morphology

This is taking into consideration that each system has an analysis algorithm, like the Physio-Control’s Lifepak 15, one of the most common cardiac monitors used prehospitally, which uses the Glascow Analysis Algorithm, which gives us the computerized interpretations based on calculations and measurements of the recorded waves from parameters set by the creators. 12-Lead ECG Analysis Algorithms_2_450

 Image obtained from Physio-Control

 

KEY POINTS:

 

1.We should not base our ECG interpretation and our patient’s care and treatments solely on the computerized interpretation provided.

2. The computerized interpretation gives us a second opinion on cardiac electrical system analysis, and is not a confirmed statement.