Chronic S-T segment elevation???

[firefighter523]

So, I was on an interesting call today, a 78 yof, caox3, complaining of SOB for the past 24 hours. She was diagnosed with an upper resp infection a day ago. Upon arrival I listened to her lungs, she had a nice mixture of rhonchi, rales, and some experatory wheezes. She does have a cardiac history, wasn't noted in her chart, but her meds indicated that she had one, (nitro, cartizem, coreg.....) We do a baseline 3 lead, to find a sinus rhythm with some s-t elevation in leads 2 and 3. We did a 12 lead, and found s-t elevation in 2,3,AVF, and V1 through V5 (various mm's, 2 and 3 for the most part). She didn't have chest pain, nausea, vomiting. Her skin was a little pale, and she was warm and dry. This patient got albuterol (two treatments) in route to the hosp for her wheezing. I was told that the EKG was suspicious, but not definative, and that they think her elevation is chronic. I didn't want to give her the treatments because of the increased oxygen demand on the myocardium. Her pulse ox was 95 on 2lpm 02 via NC in the nursing home, so she was getting properly oxygenated. Was I wrong to think that albuterol would make this possibly worse? and if we can't trust our 12 leads, why do we use them? How can someone say that it is a chronic thing?? Just wondering!

[vs-eh?]

Few things...

1) 3 lead interpretation will not give a good indication of the ST segment.

2) The pattern of ST elevation that you note to me would be inconsistant with any type of specific injury. That pattern I guess could be seen in a "global MI" or perhaps more likely pericarditis.

3) Various conditions such as BBB, repolarization issues, pericarditis, etc...will influence the ST segment and make it unreliable in any kind of diagnostic evaluation.

4) I'm indifferent at this point with the salbutamol without more patient hx and pmhx.

[nsmedic393]

You have to remember that a single piece of equipment or information does not a diagnosis make.

[AZCEP]

When you have elevations in leads that look at that many different parts of the heart, particularly with the little bit of a history you provided, it is either endo, or pericarditis.

Did you listen to the heart? Did the patient have a fever? The "chronic" ST elevation sounds a bit fishy. The fact that the patient is an elderly female should make anyone nervous about the possibility of a cardiac event. Did you consider some NTG? Might have helped the lung sounds a bit. Any treatment option can make things worse, so yes you were right to carefully think about what you were doing.

As long as you can learn from the experience it was a good call.

[Dustdevil]

I didn't want to give her the treatments because of the increased oxygen demand on the myocardium.

Valid concern. Unfortunately, the lack of vital signs, as well as the patient's absence of full mental orientation, makes it very difficult to comment intelligently on this specific case.

Her pulse ox was 95 on 2lpm 02 via NC in the nursing home, so she was getting properly oxygenated.

Don't you mean obviously NOT? 95 on supplemental oxygen sucks. And with the sound of her chest, I'm not surprised.

Was I wrong to think that albuterol would make this possibly worse?

Possibly. But there are multiple situations where a patient's cardiac history has to be weighed against other factors, and non-cardiac respiratory distress is one of them. If, given the info you have from your H&P, you believe that the respiratory distress is critical, then you have to go with the salbutamol but keep a very, very close eye on the patient's for signs of intolerance. This is a clear example of why all that boring stuff in paramedic school is truly important. Because cookbook protocols simply cannot make these kids of decisions for you. It takes a clear understanding of your patient and the pathophysiology of his conditions, as well as the pharmacology of the agents you chose to administer. If you lack any of those understandings, then no, you certainly shouldn't be administering any treatments at all. If you do, and your patient is in serious need, and you're more than five mins from the ER, then sometimes you have to take a chance. But as AZCEP alluded to, all that wheezes is not asthma. If the lungs were that wet, I would have been looking more towards fluid relief than bronchodilation. A little NTG and Lasix sounds more reasonable than salbutamol, given the information you have provided.

and if we can't trust our 12 leads, why do we use them?

I hope you don't actually believe that a 12 lead in and of itself is a definitive diagnostic tool. I hope that is not what is being taught in schools today. It is not. I don't see any problems with trusting our 12 leads. But I see a HUGE problem with a lot of the medics out there attempting to interpret them with inadequate education and understanding of the concept. And any doc will tell you that an EKG alone is not enough to definitively diagnose an AMI, so banish that thought from your mind.

How can someone say that it is a chronic thing?? Just wondering!

That has been pretty well covered above. Again, don't get hung up on EKG's alone, and the cookbook protocols used to treat them. Always refer back to rule number one of cardiology which is...

• But to answer your question, yes. You were quite correct to be sceptical about using beta agonists in this patient. I would venture a guess that medical control simply got so tunnel visioned by the respiratory symptoms that he wasn't seeing the same concerns that you were. But, as I said in the beginning, it's really hard to say with only the info we have here.

[firefighter523]

I guess, since I heard rales, rhonchi, and experatory wheezes, and her age, and her not be febrile, and the fact that she had elevations in several leads, I wouldve gone with the nitro. (Her pressure was 134/68, HR 82, R 20.) I think the wheezes were from cardiac asthma. After the two treatments, she felt worn out, and she still had the same amount of audible wheezes. I know that the monitor itself is not a diagnostic absolute, but women feel MI's different then men, especially diabetic women. Not that she was a diabetic, but.. That is why I was so hesitant about the EKG. The medics were not too worried though.

The medic's checked back on her condition, and she was in failure BTW.

[Ridryder 911]

As above posts describe, she might have some cariomegally, causing the the elevation as well with a hx. of CHF. Also wondering about axis deviation. She might have had some associated ischemia.

I am glad that you are recognizing the need and concern of not giving "carte blanche" treatment, and as other suggestions as posted. You will encounter many other scenarios that don't follow the outline or has many other factors.

R/R 911

[Dustdevil]

The medic's checked back on her condition, and she was in failure BTW.

Heart failure? Respiratory failure? Both? :dontknow:

[firefighter523]

She was in heart failure. Also she had a left axis deviation, with a left anterior fasicular block. Also it is showing that she has left ventricular hypertrophy. Hope this helps, my concern was the elevation. I wish I could get the strip on the forum. I am not that computer literate...

[Dustdevil]

She was in heart failure. Also she had a left axis deviation, with a left anterior fasicular block. Also it is showing that she has left ventricular hypertrophy. Hope this helps, my concern was the elevation.

Sweet. Sounds like you are vindicated. Your clinical judgment was on the money, even if you weren't absolutely sure why. Nice job! This is the kind of case review that reinforces your knowledge and gives you confidence in your assessment skills. Again, the key point here is all that wheezes is not asthma, or even COPD, and you called that one.