Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Who Needs a 12 Lead ECG?

ResearchBlogging.org
 

Do we do too many 12 lead ECGs on patients who do not have chest pain?

This is something that some people worry about.

Save the electrodes!

Those poor little electrodes are being abused!

Are electrodes being abused?
 

Women and the elderly with STEMI are particularly likely to present with atypical chief complaints such as dyspnea and weakness. Such patients experience significant delays in door-to-ECG time and treatment and have increased morbidity and mortality compared with patients who present with chest pain.5,9-12 [1]

 

Tiredness/weakness is the second best predictor of STEMI (ST segment Elevation Myocardial Infarction).

After chest pain (pressure, tightness, heaviness, squeezing, et cetera), the best predictor of STEMI is dyspnea in akll age ranges, but dyspnea indicates 20% of STEMIs in patients over 80 years old.

Are we helping anyone by avoiding 12 lead ECG (ElectroCardioGram) assessment?
 

Presenting chief complaints among 6,464 patients with STEMI. Chest pain decreased in frequency with age, whereas a chief complaint of dyspnea, weakness, syncope, or altered mental status all increased in frequency with age.[1]

 


Click on images to make them larger.
 


 

The advantage of a logarithmic chart is that there is greater distinction among the smaller numbers (such as the other complaints that make up less than 5% in the image above). The disadvantage is that large changes are flattened. I modified the dyspnea line to show how it would look on a linear scale (from 5% to 20%). As you can see, the ability to predict STEMI increases dramatically with age – more dramatically than the logarithmic scale suggests.
 


 

How should we remember all of this?

The authors came up with a nice simple flow chart (below).

This is for the ED, but is there a good reason for EMS to ignore these STEMIs?
 


 

Even in the 18-49 year old patients, dyspnea is about as likely to predict a STEMI as weakness is likely to predict a STEMI in an 80+ year old patient.

Chest pain still indicates about 50% of STEMI patients over 80, but we will miss half of STEMIs in this population if we only do 12 leads on chest pain patients.

Can an 80+ year old patient have a good quality of life after a STEMI?

Absolutely.

Also see When should you get an ECG? at Mill Hill Ave Command.

Footnotes:

[1] Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction.
Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, Glickman LT.
Am Heart J. 2012 Mar;163(3):372-82. doi: 10.1016/j.ahj.2011.10.021.
PMID: 22424007 [PubMed – indexed for MEDLINE]

Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, Granger CB, Cairns CB, & Glickman LT (2012). Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. American heart journal, 163 (3), 372-82 PMID: 22424007

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Comments

  1. I love this. I received very thorough 12-lead and STEMI recognition training in Medic school, which was and is still not the norm. And I have always been aggressive with cardiac monitoring and 12-lead acquisition. My philosophy is three-fold-

    When in situations where you are not necessarily inclined to think cardiac:
    1- Always think cardiac
    2- Why talk yourself out of doing the right thing?
    3- How does more information hurt?

    It pains me seeing Medic after Medic bring patients in to the ER who should have received 12-leads based on their symptoms, but had the misfortune of not having chest pain.

    • JDA,

      It pains me seeing Medic after Medic bring patients in to the ER who should have received 12-leads based on their symptoms, but had the misfortune of not having chest pain.

      Some people believe that we don’t get paid to think.

      They seem to justify it with, We don’t diagnose, but ignorance is ignorance.

      Once we start using words like diagnosis, accountability, and research, it is just a slippery slope to better patient care.

      .

  2. “He didn’t have chest pain, he just had pain in his upper abdomen…”

    “He had chest pain, but he said it was like her GERD…”

    “She doesn’t speak English, all I got from her was dolor…”

    • Brooks,

      “It isn’t weakness, it is just tiredness.”

      There is always the problem of too stupid to recognize the patient actually selected one of the multiple choices we provided.

      Maybe multiple choice tests do not really prepare us for this kind of work.

      😉

      • “If you felt the need to run a 12-lead, then it is automatically an ALS call and the Medic has to attend it!”

        When this is the feedback one recieves from the Training dept. or supervisors auditing tickets, (and is also the opinion of some of the line Paramedics as well), I can see why some people are not running 12-leads without the magic complaint words being spoken…

        • The Medics that say this need to be uprooted from their positions like weeds. If you don’t want to run ALS calls all day, then don’t become a Medic. The world always needs more ditch-diggers. This is one of the reasons why I’m grateful that my service doesn’t allow EMT’s to Tech calls that come through the 911 center (only NET calls and totes). Trying to frame a call as BLS (that needs an ALS assessment) is completely taken off the table.

          • On behalf of all the EMTs: thanks!

          • JDA,

            This is one of the reasons why I’m grateful that my service doesn’t allow EMT’s to Tech calls that come through the 911 center (only NET calls and totes). Trying to frame a call as BLS (that needs an ALS assessment) is completely taken off the table.

            This is one of my pet peeves.

            Why does the misbehavior of a few cause a rule to be made to prohibit thinking?

            Is this good oversight?

            The medical director should be addressing the problem of inappropriate release to BLS, not by prohibiting all release to BLS, but by providing actual oversight.

            Prohibitions as alternatives to using judgment are bad and are examples of bad judgment.

            When we prohibit thinking, do we expect thinking to improve?

            .

            • I don’t want to take an argumentative position, because it isn’t productive. Rather, I would ask whether there are services that have successfully excised the Medic that doesn’t actually want to think from its system? I share your umbrage at the lack of accountability, remediation, discipline, and high expectations that exist within training departmnts. There seems to be what I would describe as outright fear to actually dare to aggressively agitate lack of movivation, laziness, and lack of thought out of a system. But what is the cost of not drawing a line in the sand? Even in proposing this, I’m not married to any one position. I am just frustrated with seeing the same stereotype in each service I’ve had the pleasure to serve continuously avoid key words and questions in order to steer a patient to a BLS transport rather than do his or her job.

              Now, with all that said, I’m aware that by simply forcing these medics to be the responsibe provider does not automatially mean they will be a responsible provider. So I concede the logic falls back on itself.

              • JDA,

                There is nothing wrong with drawing a line in the sand.

                The line should be drawn to discourage incompetence, not to make it less likely that we notice the incompetence that is there.

                A line in the sand should not be placed there to avoid confronting real problems.

                I am not defending laziness. It is not lazy to have a basic EMT transport a BLS patient. It is lazy for medical directors/management to make rules that prohibit thinking.

                We need to stop being lazy and aggressively protect our patients from incompetent people. Why would anyone want to be treated by a medic who is not allowed to think?

                This rule states – You don’t get paid to think!

                .

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