Interesting ACS Case: Persistent ST Elevation s/p PCI?

[fiznat]

Dispatched for heart problems to a local SNF/Quasi Hospital. O/A found 69 y/o male in no apparent distress in bed, surrounded by nurses holding the 12 lead ECG they recently obtained. Charge nurse states that this patient just had emergent PCI 10 days ago at a local hospital and is at the SNF for rehab. On a routine follow-up lab draw the patient's Troponin was found to be 7.65 and they are now noticing ECG changes.

The patient presents AOx2 (hx Dementia and is at his baseline mental status) with NO complaint. No chest pain, no shortness of breath, no weakness, n/v, whatever else you can think of).

HX: AMI c Angio + 2 Stents, HTN, Dementia, High Lipid, Parkinson's

RX: ASA, Metaprolol, a few others that you'd expect...

All: NKDA

Vitals:

BP: 122/76

HR: 78

RR: 20

Here is the ECG:

I look at this and basically say oh, shit. Significant ST elevations in V2-V4 with QS waves probably from his previous MI. No reciprocal changes, QRS of normal width, no evidence of hypertrophy or other confounder... The patient is without complaint but at the same time he is demented and confused. He does look a little pale.

I get an IV, give some NTG and ASA (without change afterward), and transport emergently to the hospital.

At the hospital they shrug me off. Usually we get a "medical alert" for things like this, but for some reason the triage nurse seems extremely apathetic about this patient. We go through the entire normal registration procedure (which takes 5-6 minutes of us just standing there), and we are eventually sent to a normal ED bed, NOT in the critical area. I am a little pissed off and at the same time wondering if they see something that I dont.

I find a nurse and explain the patient who has the same attitude, so I find the doc next and talk with him about it. He raises his eyebrows when he sees the ECG but pulls up the patient's old ECGs (from the date of his discharge after the PCI) and they look almost exactly the same. The doc points to them and says "see, this is just residual ST elevations from his cardiac surgery 10 days ago. You didn't do anything wrong, but this isn't acute." Same goes for the Troponin, he said.

What?? I'd never heard of anything like "residual ST elevations." I remember specifically from class and various books that ST elevations MEANS something is acute. Q waves or ST depressions can sometimes be old, but when that ST segment goes up then we are talking about right now. Apparently not? I looked up residual ST elevations and a few other keywords in research on the net but am having a hard time finding a real explanation. It seems that there are cases where patients still have ST elevations a few hours after surgery, but ten days??

Anyone ever heard of this? ...Or maybe one of our docs can offer an explanation?

[emt322632]

I'd never heard of this either, and probably would have reacted the same way you did.

However after Googling (which I shouldn't do at work, someone may walk in) the topic of persistent ST elevation, I found the following article:

http://www.incirculation.net/NewsItem/Pers...to-myocard.aspx

Apparently some Italian fellas have found a correlation between persistent ST elevation post PCI and microvascular damage. This gentleman may have sustained some of that damage, and the end result is the persistent ST elevation.

As for the elevated troponin...not sure on that one.

[zzyzx]

Great topic, guys. I learn something new every time I log into this forum.

I can see why the doc wasn't worried, but what's up with the nurses? I remember once I brought in a patient with ST elevation and I showed his ECG to the charge nurse and another nurse and they did nothing about it. I showed the strip to a third nurse, who then gave it to the doc. As soon as he saw it, he immediately made the patient a STEMI alert.

I think that some nurses don't pay much attention to an ECG unless they see the computer's "Acute MI alert" message.

[Connie31079]

I would have acted the same way you did, fiznat. I was always under the impression that ST elevations meant something acute was happening with the patient.

My question is: How are we, as pre-hospital care providers, supposed to be able to tell the difference between an acute MI and residual ST elevations in a cardiac patient? We don't have old 12-leads to compare to when we arrive on-scene.

[spenac]

My question is: How are we, as pre-hospital care providers, supposed to be able to tell the difference between an acute MI and residual ST elevations in a cardiac patient? We don't have old 12-leads to compare to when we arrive on-scene.

In this case unless I missed something you have only nurses expressing concern, but a patient with no symptoms. While it was advisable to continue to monitor patient for changes enroute to hospital all treatment should be based on patient not on that funny little box that makes up down lines. Was fiznat wrong to follow cardiac protocol? No, a supposed higher level of care said it was a cardiac call. But their statement may have clouded thinking processes. The question I have for fiznat is would you have treated same way if you had been only person with medical education to evaluate this patient, no input from others? If yes then you did what you thought was best for patient.

Thanks for interesting case. And other poster thanks for link with info on this abnormality.

[triemal04]

I would have acted the same way you did, fiznat. I was always under the impression that ST elevations meant something acute was happening with the patient.

My question is: How are we, as pre-hospital care providers, supposed to be able to tell the difference between an acute MI and residual ST elevations in a cardiac patient? We don't have old 12-leads to compare to when we arrive on-scene.

After reading this thread, it is something to think about if you get someone who just had an MI a week ago. Go through your full assessment. Question the pt about any pn, SOB, N/V, recent illness, etc etc. Look for any abnormal vitals, ekg changes. Then go with what your assessment tells you is going on. Gotta say I'd treat it like the real thing, even without a complaint from the pt.

Looking at the 12lead, there's no reciprocal depression, but there is plenty of elevation and an elevated troponin level. For me, treat it like an MI, I'd definitely try and contact the ER doc ASAP to give him a heads up and get some advice, but barring them pulling the records there and losing interest...that's an MI.

[Scaramedic]

One thing you can do is verify a rhythm like that with the MD. Then go back to your unit and make a copy, right the rhythm on it and sign and date it. Then give the copy to the patient and ask her to keep it and give it to the next crew that responds to her. You would be amazed at how great patients are at keeping thing like that and giving them to crews. That way the next crew can have an old EKG as a baseline.

[fiznat]

The question I have for fiznat is would you have treated same way if you had been only person with medical education to evaluate this patient, no input from others?

I think I would still have had to. The patient was demented and really was not answering questions at all. Altered as he was, I didn't feel like absence of chest pain complaints was really of any diagnostic significance since he was not communicating anything very well at all. True, this goes against the "treat the patient, not the monitor" mantra, but that is really tough to do when the patient is baseline GCS 12,13,14.

[spenac]

I think I would still have had to. The patient was demented and really was not answering questions at all. Altered as he was, I didn't feel like absence of chest pain complaints was really of any diagnostic significance since he was not communicating anything very well at all. True, this goes against the "treat the patient, not the monitor" mantra, but that is really tough to do when the patient is baseline GCS 12,13,14.

Then you did right. My bad I must need new glasses missed the mental status. In his case all we can do is treat what we have in front of us. I think based on what you have brought out I would have ran him under cardiac protocol to. My old job I basically worked as a paramedic even though only an EMT-I. This case will make some interesting study as I am in my Paramedic course.

[CBEMT]

I had a nearly identical call (baseline dementia patient, vague info from the nurses) about 18 months ago.

Can't find the printout at the moment, but to say the least it showed a significant inferior/posterior STEMI. At the ER, they dig up his records and discover he had an MI 12 weeks prior.

Which the SNF nurse AND the patient's daughter apparently decided I didn't need to know about any of that, because "clearly" he was having a GI bleed. :?

Poor guy. NPO, no veins and a BP of 70. I couldn't do anything for him except O2 and a suggestion to my partner that he make our transport a quick one. Not that he went to the lab anyway as it turned out, but I didn't have to feel as useless for as long.