EKG CASE STUDY #3: A Case for Serial 12-Leads

HISTORY

Your crew is dispatched to a lights and sirens response to a retirement community for an early 70s female complaining of possible food poisoning. The patient is seated on the edge of her bed actively vomiting when you find her. She tells you that she went out to eat about 1700 this evening, came back to her apartment, and became violently ill with profuse nausea, vomiting, and diarrhea. It is now around 2230, and the patient states that her illness is becoming worse. She denies any complaint of pain or shortness of breath. No evidence of any recent trauma is noted.

ASSESSMENT

  • Skin is flush, warm, and profusely diaphoretic
  • Bounding, regular radial pulses noted
  • Respirations are rapid, unlabored
    • Lung sounds are clear/= throughout
  • Patient a GCS of 15 with no visible neuro deficits noted

VITAL SIGNS

  • BP: 176/100
  • HR: 72/regular
  • RR: 24
  • SpO2: 95% on R/A
  • BGL: 176mg/dl

MEDICATIONS

  • Omeprazole
  • Furosemide
  • Lisinopril
  • Atenolol
  • Aspirin

ALLERGIES

  • NKDA

INITIAL TREATMENT

  • Oxygen @4lpm via NC
  • 12-lead
  • IV start
  • 4mg IV Zofran

INITIAL 12-LEADS

70YOF EKG1

  • Crew obtains a second 12-lead due to artifact from continued vomiting; no gross changes noted.

70YOF EKG2

  • While patient is being transferred to the stretcher and crew is heading out to truck, patient begins to complain of some mild dyspnea despite oxygen via NC; no changes in SpO2%.
  • Crew places patient on NRB @15lpm
  • Vomiting has resolved
  • Crew obtains third 12-lead due to new onset of dyspnea

70YOF EKG3

  • Crew initiates transport to hospital of patient choice, which consequently also happens to be a PCI center.
  • Patient starts to complain of epigastric and left shoulder pain approximately tens minutes away from hospital.
  • 324mg PO Aspirin given
  • 0.4mg SL Nitroglycerin given
  • Fourth 12-lead obtained

70YOF EKG4

  • Patient remains hypertensive around 180/110
  • No gross changes in other vital signs or mentation
  • Note the ST segment changes in ALMOST EVERY lead
  • Crew continues nitro therapy to a total of three rounds of SL nitro
  • Contacts receiving facility due to change in 12-lead; 12-lead transmitted
  • Fifth 12-lead acquired while pulling into ambulance bay

70YOF EKG5

Bottom line, this crew found MASSIVE 12-lead changes over the course of 19 MINUTES. We understand that some departments lack finances and frown upon use of unnecessary EKG paper, as well as having constraints on how many 12-leads you can bill…That being said, do what’s right for your patient. If something feels wrong, it probably is. We don’t endorse the use of serial 12-leads on every patient, but would suggest it in the presence of significant cardiac symptoms, as well as whenever nitroglycerin therapy is at play. Good catch to those involved!

 

 

 

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