Comments on: “Funky Troubling Looking” — Right Bundle Branch Block and MI

By: Mark

Mark — Tue, 29 Sep 2009 06:32:42 +0000

I say good on all of you for fine tuning your 12lead skills but let us not forget to treat the patient first and the EKG second. If it walks and talks like a duck…guess what…it's get'n cath'd. Read your patient…not the ECG!

By: Tom B

Tom B — Mon, 22 Dec 2008 15:19:00 +0000

Sgarbossa's criteria wasn't designed for LVH, but you are correct in that concordant ST segment depression in the right precordial leads would be a grossly abnormal finding with LVH, and probably suggestive of AMI.You have to be careful with the > 5 mm discordant ST segment elevation criterion, especially with LVH, since we know the deeper the S wave, the higher the ST segment elevation. So that criterion isn't very specific when deep QRS complexes are present. You may be better off thinking in terms of % of QRS complex.The GE-Marquette 12SL interpretive algorithm gets a bad rap. It's not very good at rhythm analysis, but when it's a chest pain patient, and the data quality is good (no artifact), it has a very high specificity when it gives the *** ACUTE MI SUSPECTED *** message, particularly when the patient is not tachycardic.It's a tool, like any other. In other words, it needs to be well understood. I'm not aware of anyone who has suggested the patient be "diagnosed" based on the interpretive statement. Remember that ED physicians don't diagnose chest pain, they risk stratify chest pain. Risk stratification includes ST segment elevation or depression on the 12 lead ECG.The key issue is triage of suspected STEMI patients. I know many of you feel strongly that relying on computerized interpretive statements is a step backward for EMS. Certainly there are areas where the paramedics can make the call with a high degree of accuracy (Boston, Ottawa, Seattle) but even there, there will be fall-outs. That's life.The goal is to develop a program that works, and I personally don't believe there is a "one size fits all" solution for every EMS system, based on the heterogeneity of EMS systems and the accompanying financial and political realities. I personally think a combination of methods is optimal.The deeper issue is EMS education and training. Does it need to be improved? You bet. But there's not wide agreement on that point. There are also many areas that are BLS only, so obviously those areas would be confined to computerized interpretation or transmitting the ECG, if the 12 lead ECG is to affect transport destination.Take it away, TOTWTYTR! Key word: brumbe

By: Walt Trachim

Walt Trachim — Mon, 22 Dec 2008 15:01:00 +0000

Wow – funky looking 12-leads, indeed. Great call, though. Definitely enough going on to make anyone err on the side of caution, I think.I agree with Cayce about Tim Phelan and the Sgarbossa criteria. We got this training when I was in medic school, in fact. Made for a nice foundation in 12-lead interpretation.

By: Anonymous

Anonymous — Mon, 22 Dec 2008 05:22:00 +0000

I would have done the same thing you did, let them know I’m concerned, but not activate the cath lab. BTW, since the subject of letting the ECG diagnose came up, an old joke around here goes “do you know what they call the person who diagnoses based on what the ECG says (i.e. ACUTE MI SUSPECTED)?The defendant.

By: Cayce

Cayce — Mon, 22 Dec 2008 00:54:00 +0000

We use the Sgarbossa criteria in my county. It really helps with identifying a STEMI in BBB and LVH. We will call a STEMI alert based on +Sgarbossa without the presence of ST elevation, although I’m curious as to the stats of how many patients were taken to the cath lab afterwards. I think it would be nice to formalize a “Possible STEMI alert” to make the transport decision more cut and dry. We have a LARGE hospital network that really hates repatriation when we take their patients to other hospitals. BTW, if you ever get a chance to take a Tim Phalan 12 lead class do it. He teaches the Sgarbossa criteria as part of the imposter rule out. My company had him do some classes for the medics in county and it was really beneficial. It resulted in more interpretation by medics and less of the LP-12 telling us which hospital to go to.