WE ARE STEMI HUNTERS LearningObjectives I have no relevant

WE ARE STEMI HUNTERS
Jennifer Carlquist PA-C, ER CAQ
Salinas Valley Memorial, ER
Central Coast Cardiology, Specializing in EP
LearningObjectives
 How to use pattern recognition to detect ischemia
 Triage approach to EKG’s
 EKG patterns that are not STEMI’s but should be
I have no relevant disclosures
treated like one
 Myth busting: The EKG software is not always
right
Myth:
 If something is abnormal, the machine will catch
it.
 If there is really something wrong, they will have a
complaint.
 Just because it says NSR – don’t stop looking
1
REALLY?
How I approachan EKG
• Fast/ Slow
• Arrhythmia
• MI
Intervene
Intervene
Intervene
SecondTierTriage
Subtle MI
Last but not least:
Stemi
Mimic
C/C based
2
C/P/ dyspnea algorithm
Things that you should come to mind.
Arrhythmia
Ischemia
Big stuff first.
Then, things like PVC’s.
s1q3t3
Electrolyte status
MI
LV strain
CNS events
Size matters.
NormalTWave
Positive, Asymmetric
The T wave is the diva of the show – people always want to look at it!
Problem T Waves
Tall, Peaked
Reasons aT wave may be upside down
 Normal finding in children
Wide, Broad
 Myocardial ischaemia and infarction
 Bundle branch block
 Ventricular hypertrophy (‘strain’ patterns)
 Pulmonary embolism
 Hypertrophic cardiomyopathy
 Raised intracranial pressure
3
Criteria
 1 mm ST segment elevation in two contiguous
leads
 > 1 mm in v4-v6
 >2 mm elevation in v1-v3
 New Left Bundle
Acute Myocardial Infarction
Two up, two down
Atypical Presentations Common
 3 high risk patients: Diabetics, females and elderly
 20 % with proven mi have only upper abd pain
 40% pain radiates to right side
 Character: 1/3 pressure, but others sharp stab
aching or indigestion
only 1/3 with exertion
JAMA. 2005 Nov 23;294(20):2623-9
StagesofMI
ECG Findings
 First: T wave flips in early
ischemia.
 Then: ST elevation either
flat or tombstoning
 Finally: We see Q waves.
Which would you
rather have as your
“wine glass”?
4
Q waves to worry about
63 y/o male:Chestpain– EMS responds…
“I really don’t feel so well…”
The EKG is asnapshot.
“ My pain is getting worse…”
50 year old male
 P – minimal exertion
 Q – “I have asthma”
 R – Left arm, but its unrelated
 S – “My wife made me come”
 T – 5 days, worse over last 2
“No. I won’t go to the ER….can’t you just do
something here?”
5
Clinic EKG
ER Visit
ST depression in V1, V2
T Wave Inversion
Biphasic T Waves
ST elevation in AVR
CoolClues
Post hospital clinic visit
 T wave inversion can be seen as the sole ECG
change in 10% of AMI.
6
58 year old female with chest pain
Her cath report
Lesion on mid LAD
99% stenosis
Sneaky MI’s
Youcan’tfind it if you don’tlookfor it.
High index of suspicion
50 y/o male with “indigestion”
Posterior MI
7
42 year old maleC/P –clinic EKG
Case
 42 y/o male presented with intermittent chest
pain.
 HX: HTN, smoking, hyperlipidemia severe,
possible ehlers danlos. High stress lifestyle.
Worked as a mechanic.Thin framed.
PMD note
 “Has chest tightness after dinner, worse laying
down, sometimes when sitting. Connection to
activity, but not consistently so. Eases with doing
less. No lightheadedness, dizziness, sweats.”
POSTOP
Wellens
 A Can’t Miss EKG Finding
What happened?
5 vessel bypass.
EF of 40%.
8
87 y/o BIBA for possible STEMI







0400 sudden onset c/p
P – unprovoked
Q – pressure/discomfort
R – bilateral arms
S – 5/10
T – ½ hr
2010 EKG was normal
“EKG done yesterday was normal.” - ERMD
EMS





No nitro – he was hypotensive
Was noted to be diaphoretic
“Noted dyspnea” by medics
BG chem normal at 80
Took ASA before EMS arrived
SH: occ etoh use
Meds: Plavix, ASA, Simvistatin
Door time ER EKG
Labs
 BNP: 10644
 Trop: 8.696
 Initiated a norepi drip
 Not a candidate for nitrates, BB secondary to VS
 XRAY: Large cardiac silhouette “suggestion of
pulmonary edema”
9
Consult note
Asystole. CPR.Cath.
“An attempt will be made to save
his life.” – cardiologist
Cardiology diagnostics
 Triple vessel bypass
 Echo: EF 20% LV normal with global hypokinesis
 Valves normal, wall thickness normal
Could this have been prevented???
 Syncope 10 d ago, dizziness
 C/P center of chest rad to right arm, 20-30 ¾
 No allev factors, pain improves with antacids
 BP in ICU: 89/34, 112 bpm, intubated
 HX: HTN
 “EKG today showed NSR, but there was ST
 “responds to verbal stimuli….seems confused…”
depression in inferior leads, suggestive of
ischemia..”
10
AVR
AVR
“The Eleven Lead EKG?”
“The Rodney Lead”
Ischemia in
other leads +
AVR STE =
BADNESS
Ominous finding!
78 year old male with shoulder pain when I
work out
 Elevation of more than 1mm in aVR in the setting of
Acute Coronary syndrome is associated with left
main disease
 Not a stemi, but should be treated like one
 PCI
 Associated with an increase in mortality
His stress test
Resources to use in Clinic
11
Electronic Resources
 EKG Wave Maven
 12 Lead EKG Challenge App (by: Limmer)
 ECG Guide App (by: QxMD)
 Cardiology Draw MD
 Life in the Fast Lane
Books I Recommend
 Advanced Field Cardiology – Mike Taigman
 Introduction to 12-Lead ECG (The Art of
Interpretation) – Tomas Garcia
 ECG’s for the Emergency Physician – Amal Mattu
 Clinical Cardiology Made Simple – MichaelChizner
[email protected]
12

Download Report