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12 leads: where do you feel weak?


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I try to perform a 12-lead on all cardiac, respiratory, "weak/dizzy," and abdominal complaints, depending on the patient. I can pick out a STEMI without the computer, and am aware that BBBs and LVH are common imitators. I know that if the infarct is inferior, I should perform a V4R. I even learned how to check posterior not too long ago.

That's pretty much the limit of my knowledge, and puts me above roughly 80-85% of providers at the same level of licensure in my state.

I continually seek to learn more whenever possible, it just doesn't always take long enough to use it in the field and reinforce it. My call volumes at the two jobs I actually can do 12-leads at is pretty low.

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More importantly though, be careful with those nitrates.

Sorry, should have specified. I was focusing more on what I actually knew about 12-leads as opposed to what I know to do about the results. ;)

And yes, I knew about caution with nitrates too- even before I learned how to do V4R, ironically. I knew "Inferior STEMI- nitrates bad!," as opposed to "If Inferior STEMI plus positive V4R- nitrates dangerous without caution, IV access, and pre-dose fluid bolus!"

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Thanks for your honesty guys. I wasn't sure whether I was going to get replies like I did, or replies like "oh I check all those AND (insert extremely obscure syndrome here)." In the same spirit I have to say that I am guilty of many of the same things. Someone said that they sometimes look at the "cool stuff" before looking at rate and rhythm. I freakin' ALWAYS do that and I keep promising myself to change but it's been hard going.

All of the 12 lead big wigs and books say that in order to do this well we ought to develop a systematic way of interpreting and do it every single time.

That interpretation in my opinion should always include (in addition to the basics):

Axis, because it can help with identification of the tough rhythms (VT versus SVT with abbarrancy!)

Hypertrophy, because this is a big confounder with STEMI. LVH produces ST elevations and we don't want false STEMI calls. Also tells us about health condition, output, and potential issues.

Other STEMI mimickers like left bundles (remembering Sgarbossa), Benign Early Repolarization, Pericarditis, etc.

A quick check for syndromes as mentioned above. I feel this is important because many of them change the treatment plan or are otherwise remarkable.

Would you agree that those 4 things would more or less sum up the "extracurricular" stuff that we don't often do, but maybe should? Would you attend a class that focused on those things and a systematic interpretation? Anything else?

Btw here's the wikipedia on Wellen's: http://en.wikipedia.org/wiki/Wellens%27_syndrome

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The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

I'm thinking about doing an "advanced 12 lead" class at my service, and I was hoping I could get some information from you all to get me started.

How in depth do you get when you read a 12 lead? Do you look at just the STEMI signs, or do you go as far as axis, rotation, hypertrophy, and the syndromes? How about electrolyte disorders, pulmonary complications and strain patterns?

Please be honest: how deep is your 12 lead knowledge, how often do you use it on routine patients, and how comfortable do you feel with your understanding? What would you like to know more about, or get more practice with?

Thanks guys! :D

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The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

I have to disagree. Unfortunately, it is not as simple as saying, "yep, it's a STEMI." Many conditions can masquerade as STEMI. LVH, Brugada syndrome, Pericarditis & BBB among many others. In addition, identification of other conduction defects can help us plan and provide appropriate interventions. For example, what would you expect somebody's LV ejection fraction to be if they had a rather significant BBB? What problems could you anticipate with significant axis deviation and say a bifascicular block? What could occur if we loose the other fascicle? We also need to identify drug and electrolyte effects and anticipate interventions or even use the findings to narrow our list of differential field diagnoses. I could continue to ramble; however, I would hope you get the point?

Additionally, MONA is not a catch all phrase and it is certainly not how we should treat every patient experiencing an ACS.

Take care,

chbare.

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Okay I'll be more specific:

1. Do you routinely determine the mean QRS Axis and can you apply that information practically?

2. Are you aware of the Sgarbossa Criteria and have you used it before?

3. Do you routinely check for Cor (or P) Pulmonale?

4. Do you look for LVH, BER, and BBB on every STEMI?

5. Do you systematically interpret every 12 lead you read in the same order every time?

6. How familiar are you with syndromes like Brugada, Pericarditis, Wellen's, WPW, hyper/hypo K, and long QT?

Others....?

1. No; I don't know how.

2. No.

3. No

4. LVH, yes. I have difficulites with BBB at times.

5. Yes

6. Pericarditis, WPW, Hyper K+ and long QT I am familiar with.

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The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

I hope never to aspire to be so lazy as to only know the minimum. Sorry I disagree and darn it I'm just a student and I already do much more than that. Plus I already have more in my Cardiac protocols as an intermediate than MONA.

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Fiz, this is a great idea. When you get this educational piece put together any chance to get a copy in the hands of those in the EMTCity land? That would be a wonderful educational tool that we could all use, basic or advanced.

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1. No; I don't know how.

2. No.

3. No

4. LVH, yes. I have difficulites with BBB at times.

5. Yes

6. Pericarditis, WPW, Hyper K+ and long QT I am familiar with.

The cheaters way to look at QRS axis:

If you look at the top of your XII lead, you should note a line that reads something like: "P-QRS-T Axes." This should be followed by a set of numbers such as: "55-37-17." The entire line will look like this: "P-QRS-T Axes: 55-37-17." The number in the middle is the calculated mean QRS Axis. In this case, the mean QRS Axis is 37 degrees.

Then, just write the Axes down in your notebook or guide for safe keeping:

Normal: 0-90

Physio LAD: 0 to -30

Patho LAD: -30 to -180

Physio RAD: 90-120

Patho RAD: 120-180

Right Shoulder: -90 to -180

Another easy method is the three lead QRS picture method.

Bundle branch blocks for dummies:

Identify the presence of a BBB then look at the QRS complex in V1. Draw a line through the complex and perform the "turn signal criteria." Google should give you pictures that easily show you down and dirty BBB differentiation.

Take care,

chbare.

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