Chest pain in a patient with previous inferior STEMI. Scrutinize both the ECG and the history!

I was looking through a stack of ECGs (I can't help myself) and saw this one, which caught my eye:
What do you think?  Computerized QRS duration is 120 ms.

My thought was that it looked like there was likely very subtle anterior injury.  In spite of the slightly prolonged conduction, I applied the anterior STEMI calculator (see sidebar excel applet, or "subtleSTEMI" iphone app), using:

1. ST elevation at 60 ms after the J-point in lead V3: 2 mm (it is probably really 2.5 mm, but I wanted to be conservative)
2. computerized QTc = 413 ms
3. R-wave amplitude in V4 = 9 mm

Result = 23.83 (greater than 23.4 and thus indicating likely LAD occlusion)

Here is his previous ECG:
Note the inferior ST elevation that was present even after opening the infarct artery causing the inferior STMEI.  But also look at V1 and V2.  The ST segments and T-waves are different from the ED ECG.  Thus there is new ST elevation, suggesting anteroseptal STEMI and greatly increasing the suspicion for LAD occlusion.

So I went to look at the chart:

He was a male in his 60s who complained of chest pain.  He had h/o inferior STEMI which was stented.

As I suspected, these ST and T-wave changes were not seen.  Most physicians do not see such abnormalities, even if they are changes, as in this case.  They are extremely subtle.  That is why I recommend scrutinizing them, comparing carefully with the previous ECG, and using the formula to see if your suspicions are worth pursuing.

A positive result with such scrutiny does NOT mandate cath lab activation, but does require further intense scrutiny.

One area of further scrutiny is to look at the previous cath findings:  was there LAD or left main disease?  Is LAD ischemia a real possibility?  If they had looked, they would have found that the left main had a 50% lesion and the LAD had a 90% distal stenosis.  The distal stenosis does not fit with this ECG which looks like septal STEMI, but the left main does.

This patient was treated for unstable angina medically.  His initial troponin was negative.

However, he did not get evaluated for possible acute LAD occlusion.


Later, his next troponin 3 hours later was 1.3 ng/mL.  At this time, he underwent another ECG, five hours after the first:
The ST elevation is resolved.  This again strongly supports that the first one had acute ischemia causing ST elevation

The next day he went for an angiogram and was found to have severe 3 vessel disease involving the left main and the LAD.  The LAD had a new, open, 80% ostial lesion.  The left main had a new 60-70% stenosis.  I am not sure which (or both?) was the culprit, but either could have resulted in death.

It is all but certain that one of them was occluded, or nearly so, when the patient was having chest pain and ST elevation.

Fortunately for all involved, this LAD (or left main) reperfused spontaneously, with the aid of aspirin, plavix, and heparin.  Had it not done so, it could have been disastrous for the patient.

He went for CABG.


Scrutinize the ECG
Scrutinize the History

These findings are discoverable: I found them by just glancing at the ECG in a random stack, without any other information.  They are there on the ECG.  You just have to get good at looking for them, use the formula, compare with the previous, and look at the previous angiogram results.  If suspicion persists, pursue even further scrutiny.

FASH US exam for HIV/TB with Hein Lemprecht. Ebook free for a few more days. #foamed.


We swore we’d bring it to you, and here it is.

Yes, it’s not basic like we’ve been doing recently, but we just can’t help ourselves.  This is too cool not to bring to you now.  If you work in a setting where there is a high prevalence of HIV/TB or you ever plan on working there, then you NEED to listen to this and learn this.
Also, you already know the Introduction to Bedside Ultrasound is free on right now.  Well it’s also free in iTunes right now.  So it’s completely FREE everywhere for a few more days.  Make sure all the medical students that you know download it.  It’s available for their ipad or mac (iTunes) or their iphone, PC, or Android via Inkling.  Don’t miss out on this #FOAMED. (Links are below.)
Lastly, we’ll be streaming Castlefest to you this year if you weren’t able to register to come learn with us.  Right now we have an early bird special going for the streaming version.  It’s available for the very reasonable price of $0.  However, we’re going to double that price in about a week and then probably double it again day of, so you want to reserve your virtual spot now!  We’ll put more info on the website soon as to when and where the stream will be.
Check back here and follow us on twitter for the latest breaking news. @ultrasoundpod
Follow us:  @ultrasoundpod
Get on the wait list (sorry sold out):
iTunes versions if you prefer the iBooks Textbook format:

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Article: Hypotonic maintenance IV fluids in pediatrics

IVbags2 copyA 6-month-old male presents to the emergency department with diarrhea and vomiting. Despite antiemetic therapy, the the child is unable to tolerate oral intake in the ED and so you opt to admit him to the hospital for IV fluids.  The pediatric hospitalist requests that you write maintenance fluids prior to admission to the floor. Utilizing the 4-2-1 rule you calculate maintenance needs and choose D5 ½NS as your fluid. This is what you had been taught to utilize in children. It seems appropriate… but is it?


Holliday and Segar published their seminal work on the maintenance caloric and fluid needs of children in Pediatrics in 1957 [1]. As the paper utilized hypotonic solution to match presumed solute needs, subsequent generations of emergency physicians and pediatricians have relied upon hypotonic solutions to serve as the primary vehicle for which to deliver caloric and electrolyte needs. The original calculations recommended 0.2% saline however this has largely been supplanted by 0.45% saline with dextrose as a primary intravenous maintenance fluid. Though D5 0.45% saline is chemically hypertonic, in vivo it is an effective hypotonic solution due to the rapid uptake and metabolism of dextrose. 

Recently there have been a few trials (reviewed in the systematic review we are discussing) that question the wisdom of using hypotonic solutions as maintenance fluid. It is theorized that hospitalized and critically ill children may have a non-osmotic stimulus for anti-diuretic hormone secretion potentially leading to hyponatremia and/or cerebral edema.    

Article Citation

Foster BA, Tom D, Hill V. Hypotonic versus Isotonic Fluids in Hospitalized Children: A Systematic Review and Meta-Analysis. J Pediatr. 2014 Feb 27. PMID:  24582105


  • Systematic review of all studies comparing isotonic to hypotonic maintenance fluids in chilren assessing for hyponatremia

Study Methods 

  • Cochrane style systematic review in which a total of 10 studies met inclusion criteria and were included in the final analysis
  • 5 ICU studies, 4 ward studies, 1 mixed study
  • Patients had variety of illness (many were very sick) 
    • Large representation of PICU and post-operative patients 
  • Multiple different hypotonic fluids included across studies including 0.18%, 0.3%, and 0.45% saline
  • Primary outcome: hyponatremia (Na <135 mmol/L)
  • Secondary outcomes: 
    • Change in serum sodium from baseline
      • Moderate (<130 mml/L)
      • Severe (< 125 mmol/L)
    • Adverse events of hypernatremia (> 145 mmol/L)
    • Mortality


  • 11 RCTs included
  • Primary outcome
    • Relative risk for hyponatremia = 2.37 (1.72-3.26)
    • Assuming an estimated control event rate (CER) for hyponatremia of 5%, the Number Needed to Harm (NNH) = 15 (9-28)
    • Assuming an estimated CER for hyponatremia of 20%, the NNH = 4 (3-7)
      • The calculations of these NNHs are based upon the varying CER found in the various studies.
        • The control event rate describes how often an event in study occurs within the control group
        • To determine the NNH (as the NNT) we utilize the control event rate and the experimental event rate (EER—how often the event in study occurs in the treatment group).
          • NNH= 1/(EER-CER)
      • The authors utilized both the high and low end of the CER to give a range of NNH (4-15) with corresponding confidence intervals (3-28) depending upon the CER 
  • Secondary outcome
    • Change in serum sodium (5/11 studies described this statistic) = -2.46 (-3.11 to -1.81)
    • Mortality: none identified
    • Relative risk for hypernatremia (8/11 studies described this statistic) = 0.81 (0.32-2.04)
      • Reported about 0-6% incidence of hypernatremia using isotonic fluids
      • NNH not calculated due to nonsignificant findings 


The studied population, that which the systematic review included, was heterogeneous and included disparate disease states lumping together floor patients admitted for various reasons with post-operative patients admitted to the PICU setting.  Though the underlying question of hyponatremia in the entire cohort may be equivalent (the I2 statistic did not demonstrate significant statistical heterogeneity) it may also be the case that sicker and post-operative patients have altered physiology from increased disease burden and represent the primary population in which ADH excess is triggered by non-osmotic stimuli (the actual at risk cohort).   

Due to the few studies included with routine pediatric EM admissions (e.g. dehydrated gastroenteritis) it is difficult to secondarily generalize these findings into the ED setting. It is also worth noting that there were no disease oriented outcomes delineated in either group from shifts in serum sodium concentrations. Though hyponatremia may predict subsequent neurological deterioration and cerebral edema, this systematic review did not find deleterious patient responses either because they do not occur or they are rare enough to not be found in the final analysis.  

Future Directions

This article forces us to reassess conventional wisdom in the light of new experimental evidence. Hypotonic maintenance fluids were originally established using a now 60 year old study on the basis of presumed rather than clinically confirmed patient physiology. While this particular systematic review failed to find patient oriented harm associated with hypotonic maintenance fluids it did show an absolute alterations in serum sodium potentially predictive of poor patient outcomes.

The next step will be to verify the study results and make it more applicable to our ED patient population. A prospective study of pediatric ED patients admitted for disease entities requiring maintenance fluids could be undertaken comparing the two intravenous fluid tonicities, using laboratory and clinically relevant outcome measures.  


  1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957 May;19(5):823-32. PMID: 13431307.

Author information

William Paolo, MD
William Paolo, MD
Residency Program Director
Assistant Professor of Emergency Medicine
SUNY-Upstate Medical Center

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The LITFL Review 132

The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.

Welcome to the 132nd edition, brought to you by:

The Most Fair Dinkum Ripper Beaut of the Week

Ripper this week is taken out by  the ongoing debate on do C-spine collars still have a role? Scancrit explains why EMS in Bergen, Norway has made the move to get rid of cervical collars for trauma patients. Minh Le Cong at the PHARM also has some strong words about cervical collars this week. [TRD,MG]

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

The Best of #FOAMPed Paediatrics

  • Cliff Reid on Resus.Me discusses the optimum number of team members to be around for a  paediatric resus – the balance between overload and support. [TRD]
  • Sean Fox covers patellar dislocations for this week’s PED EM morsel. [TRD]
  • Swimming pools, baths, and even buckets can all be potential drowning traps for kids. How do we manage near-drowning? Ben Lawton on Don’t Forget the Bubbles. [TRD]

#FOAMTox Toxicology

  • It looks like Intralipid is going to be my Tox word of the year but what about Intralipid AND HIET (high dose insulin euglycaemic therapy)? Probably not. Leon Gussow of the Poison Review looks at a reported case series where both HIET and intralipid were used but it’s not all it’s cracked up to be [JAR]
  • Do people on anti-coagulants and/or antiplatelets bleed more after snakebite? Complex question but Justin Hensley of EMGoneWild gives his thoughts (via on a recent paper investigating bleeding following rattlesnake envenomation in patients on antiplatelet and anticoagulant drugs [JAR]
  • In another post, Leon Gussow looks at the recent report from the CDC regarding e-cigarettes. This new trend known as ‘vape’ has lead to more and more calls relating to exposure in the US. Check it out…

#MedEd Education and Social Media (including #smaccGOLD)

News from the Fast Lane

  •  Our shiny new author Mat Goebel kicks of with a brilliant ECG case in Winter is Coming… [KG]

LITFL Review EM/CC Educational Social Media Round Up

Emergency Medicine and Critical Care Blogroll — Emergency Medicine and Critical Care Podcasts — — Academic Life in Emergency Medicine — A Life at Risk — Bedside Ultrasound - Boring EM — Broome Docs — CCM-L — Critical Care Perspectives in EM — Dave on Airways — Dont Forget the Bubbles — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week — ED ECMO — ED Exam — ED-Nurse — EDTCC — EKG Videos — EM Basic — EMCrit — EM CapeTown — EMCases — EMDocs — EMDutch — Emergency Medical Abstracts — EM Journey — EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News — Emergency Medicine Ireland — Emergency Medicine Tutorials — Emergency Medicine Updates — EM on the Edge — Emergucate  — EM Journey —  EM IM Doc — EM Literature of Note — — EMpills — Emergency Physicians Monthly — EM Lyceum —EM nerd— EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — EXPENSIVECARE — Free Emergency Medicine Talks — Gmergency! — Got Resuscitation— Greater Sydney Area HEMS — — Impactednurse —Injectable Orange  — Intensive Care Network — iTeachEM — IVLine — KeeWeeDoc — KI Docs— ER Mentor — MDaware — MD+ CALC — MedEDMasters — Medical Education Videos — Medical Evidence Blog — MedEmIt — Micrognome — Movin’ Meat — Paediatric Emergency Medicine — Pediatric EM Morsels — PEM ED — PEMLit — PEM Cincinnati — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — — Radiology Signs — Radiopaedia — REBEL EM - — Resus.ME — Resus Review — RESUS Room — Resus Room Management — Richard Winters’ Physician Leadership — ruralflyingdoc — SCANCRIT — SCCM Blogs — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SOCMOB — SonoSpot — StEmylns — Takeokun — thebluntdissection — The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The Flipped EM Classroom — thenursepath — The NNT — The Poison Review — The Sharp End — The Short Coat — The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog —  — ToxTalk — tjdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls —Ultrasound Podcast

LITFL Review

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What Happens When You Work With Warring Tribes?


My first reaction when asked to write a piece for Injectable Orange was almost embarrassment that someone felt I had something to contribute to this up swell of amazing nursing and medical blogs that have changed the way I think about reflective learning over the last 3 years.  This was quickly followed by an overwhelming feeling of terror – what the hell am I going to say?

After a few weeks of contemplation I decided to take some inspiration from the opening address at the recent SMACCGOLD conference. The incredible Victoria Brazil spoke about the concept of various teams in a hospital being like tribes: the ED tribe, the ICU tribe, the Cardiology tribe, and the various nursing, medical, and allied health tribes. During this presentation a case was laid out detailing perhaps not the best way to navigate through the various tribes of the hospital with their respective cultures and languages to achieve primary coronary angioplasty for a patient presenting with an acute myocardial infarction.

As the laughs and head shaking continued in the audience whilst this case unfolded, in my mind on loop playback was ‘welcome to my daily practice as an ICU Outreach nurse’. I am often asked, ‘what exactly does an ICU Outreach nurse do?’ My response is usually a mixed bag, there is something relating to assessment of the deteriorating patient. I am part of the medical emergency team and to a large degree I am an educator. The one thing I am always sure to explain is that I act as a pivot to ensure the right clinicians are involved in a deteriorating patient’s care to intervene and hopefully change this patient’s clinical course. Another question I am frequently asked in my line of work is ‘how did you manage to get “them” to listen to you when it comes to escalating the care of deteriorating patients?’ This is something I have struggled to answer, but thanks to Victoria’s presentation and a little book called Tribal Leadership, by David Logan, I have come to a better understanding of how I achieve this task. A function which can be so difficult at times. More importantly I have reflected on how I can continue to improve on the vital skill of communicating.


David Logan describes organisations and subsets within these organisations as a tribe. A tribe as a group of 20 to 150 people who know one another well enough that if they saw each other walking down the street, they would stop and say ‘hello’. I thought about this from a ward perspective It’s the nurses, doctors and allied health teams you work with every day, not the ‘tribe’ that works 2 floors down with a different specialty to your own. It’s the nursing staff, whom see their role completely separate to that of the medical staff.

This book then goes on to describe what makes an effective tribe, culture. This culture is a product of the language people use and the behaviours that accompany those words. The nursing staff don’t suggest interventions, the resident dutifully scribes the notes on rounds but lives by the adage ‘been seen and not heard’, the graduate nurse who is worried about her patient’s respiratory rate of 30 but has been told before that is fine on this ward. So what happens when we need something from another tribe? My medical patient needs a surgical review. The in-charge nurse is justifying a 1:1 nurse ratio for an unwell patient and needs medical documentation, but the medical team don’t agree?  In most cases, it is what I like to call war; different tribes, with different cultures and language at the end of a bed. How do you strive for the common goal, when you are from a different culture and speaking a different language? David Logan describes the five stages of tribal cultures that evolve from individual focused behaviours and language. Tribes who strive to be the best against the competition give way eventually to the tribes that can work with almost anyone to achieve the common goal and compete only with what is possible. Sounding like a hospital near you yet?

These five stages of tribalism gave me the insight to understand that I was able to have effective conversations and escalate care because, before having the conversation, I take the time to think about where the other individual was coming from. I pause to consider whether they are an intern that had been sent by the registrar with orders to ‘sort it out’, but whatever you do don’t bring the patient back to ‘my ward’. Are they the ward charge nurse, that has just been pushed to take three patients from the emergency department under the threat of the 4hr Rule and I was asking her to make a bed for the fourth sick patient. I have taken the time during those rare quiet shifts to get to know the tribal chiefs and understand their cultures.

In my role as an ICU Outreach nurse, I realised I had been striving to be a Tribal leader. David Logan describes this as a very personal journey and to get there you must do the “prep work” on yourself first, including:

  • Learn the language and customs of all five cultural stages.
  • Listen for which tribal members speak which language – in essence, who is at what stage?
  • Move yourself forward, start talking a different language and shifting the structure of relationships around you.
  • Take these actions as you upgrade the tribe around you.

There is so much to this concept that lends itself to the way we work as healthcare professionals, the next time you feel like you are going to war, I challenge you to consider the language and culture of the other team, changing yours may just get you to the common goal.

What happens when you work with warring tribes?

I guess I am lucky enough to be bilingual.


ECG of the Week – 7th April 2014 – Interpretation

This week's ECG is from a 14yr old female who presents following an episode of palpitations and associated dizziness.
Check out the comments on our original post here.

Click to enlarge
  • 110-115 bpm
  • Regular
  • Sinus rhythm
  • Normal
  • PR - Short (80ms)
  • QRS - Prolonged (120ms)
  • QT - 340ms (QTc Bazette 460 ms)
  • ST Elevation leads aVR, V1-2
  • ST Depression leads I, II, III, aVF, V4-6
  • Delta waves best seen inferolaterally
  • T wave inversion leads I, II, III, aVF, V3-6
  • 'Pseudo' left ventriclar hypertrophy
    • Prominent R waves leads I, II, III, aVF, V4-6
    • Deep S waves leads aVR, aVL, V1-2
  • Wolff-Parkinson-White
    • Right anteroseptal pathway - using Arruda algorithm
    • Voltage & ST/T changes secondary to pre-excitation
    • Patient requires referral for an EP study.
The right anteroseptal pathway can be difficult to ablate due to the close proximity of the AV node and risk of AV nodal injury during ablation. Cryothermal ablation and careful mapping may be required rather than RF ablation. A more detailed review of septal accessory pathways and ablation techniques can be found here:
  • Macedo PG, Patel SM, Bisco SE,Asirvatham SJ. Septal Accessory Pathway: Anatomy, Causes for Difficulty, and an Approach to Ablation. Indian Pacing Electrophysiol. J. 2010;10(7):292-309. Full text here (html). Full text here (pdf).

There are two commonly used algorithms to identify accessory pathway location from the surface ECG, the Arruda algorithm and Milstein algorithm. Pictorial representations of both can be found here. You can also download a free app called EP Mobile which incorporates both algorithm's in addition to lots of other useful EP formulas (iTunes or Google play) [I have no affilitation with the app or it's developers]

References / Further Reading
Life in the Fast Lane
  • Wolff-Parkinson-White here
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.