WE ARE STEMI HUNTERS. LearningObjectives. I have no relevant disclosures. Myth: Jennifer Carlquist PA-C, ER CAQ

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WE ARE STEMI HUNTERS Jennifer Carlquist PA-C, ER CAQ

Specializing in EP LearningObjectives How to use

approach to EKG s EKG patterns that are not STEMI s

software is not always right I have no relevant

1 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 treated like one Myth busting: The EKG software is not always right I have no relevant disclosures 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

2 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. Big stuff first.

Arrhythmia Ischemia s1q3t3 Electrolyte status MI LV strain CNS events Size matters.

look at Problem T Waves Tall, Peaked Wide, Broad Reasons at wave may be upside down Normal

3 C/P/ dyspnea algorithm Things that you should come to mind. Big stuff first. Then, things like PVC s. Arrhythmia Ischemia 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 Problem T Waves Tall, Peaked Wide, Broad Reasons at wave may be upside down Normal finding in children 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

Myocardial Infarction Two up, two down Atypical Presentations

% with proven mi have only upper abd pain 40% pain radiates to

aching or indigestion only 1/3 with exertion JAMA.

4 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 Nov 23;294(20): 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 ratherhaveas your wine glass? 4

5 Q waves to worry about The EKG is asnapshot. 63 y/o male:chestpain EMS responds My pain is getting worse I really don t feel so well 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

6 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

7 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

HX: HTN, smoking, hyperlipidemia severe, possible ehlers

8 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

- ERMD EMS No nitro he was hypotensive Was noted to be diaphoretic Noted dyspnea by

ASA, Simvistatin Door time ER EKG Labs BNP: 10644 Trop: 8.

9 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: Trop: 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.

hypokinesis Valves normal, wall thickness normal Could this have been prevented?

factors, pain improves with antacids BP in ICU: 89/34, 112 bpm, intubated HX: HTN EKG today

10 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, 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

I work out Elevation of more than 1mm in

11 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

Taigman Introduction to 12-Lead ECG (The Art of Interpretation) Tomas Garcia ECG s for the

12 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 Jennifercarlquist@yahoo.com 12

Addressing the Needs. patient. My pain is getting worse. 63 y/o male : Chest pain EMS responds

Addressing the Needs. patient. My pain is getting worse. 63 y/o male : Chest pain EMS responds Addressing the Needs of the ACS patient Jen Carlquist PA C, ER CAQ Central Coast Cardiology SVMH ER 63 y/o male : Chest pain EMS responds My pain is getting worse I really don t feel so well 56 year old