Yes, I admit: I am an EKG nerd. There’s nothing more “fun” to me than poring over a weird strip trying to figure out what exactly is going on with the particular patient. Maybe it’s just and exercise in academia, but i have found it to be useful. I just stick that little nugget of electrical conductance deep into my brain and ever so often it will pop out with an, “A-ha!” moment. What I love more though is putting the pieces together into the whole clinical picture.
So tonight I figured I would let y’all into my archive of nerdiness. Or at least show off the most recent additions.
1. Ride the Lighting.
No, not the Metallica song, (although I’m listening to it just to set the mood…), but an elective cardioversion. Just suppose a patient presents to the ED feeling, “weak.” According to the Cardiology resident, they’re in sinus tachycardia. But if you look closely, you can see the wonderful F-waves that are the hallmark of atrial flutter. The attending Cardiologist realizes this is new-onset, so a cardioversion can be done. Anticoagulation is prescribed as are beta-blockers. In the morning they do a TEE and see nothing to worry about. Then comes the fun. Nothing sounds as much fun as DC electricity coursing across your chest. So, here’s the first shock.
Starting out in atrial flutter (see those nice F-waves…) a shock of 150 joules is applied, reseting them to atrial fibrillation. That’s still no good, we’re looking for a fix. Hit ’em again!
200 joules later and a beautiful sinus rhythm is restored. Ain’t modern medicine (and a little electricity) great?
2. Why Door-to-Balloon time is actually important.
Suppose you were out ambling along in your back 40 when you start to feel this vague feeling of pressure come creeping over your chest. It soon transforms into badass substernal chest pain. Full-blown, elephant on the chest, clutching your left pec chest pain. Now think and remember that your father, bless his soul, died of a massive heart attack when he was 50. You’re over 50. Don’t panic, head for home. Get home, tell the wife and head down the road to the fire department. They see it and go, “OK, let’s head to town.” Along the way they tell you they are going to take you to Hospital V. Before they get there they hook you up to a 12-lead EKG. After reading it, the paramedic tells his partner, “Head to whatever’s closest and don’t spare the lights and sirens.” You arrive at the ED, they fuss all over you, drawing blood, hooking you up to a cardiac monitor, starting IVs, the full-monty. They shoot another 12-lead and get this:
You also over hear them talking about how your troponin is only 0.05, but nonetheless you’re whisked off into the cath lab to inflate a balloon in our heart, therefore reperfusing your heart and saving your life.
Now of course, this is hypothetical. It would also be hypothetical to say that post-intervention, your troponin level was 180.6. Yes, 180.6. That is high. In fact, I’ve never seen it that high. Looking at the EKG, besides the computer diagnostic screaming ‘ACUTE MI’ at you, what do you see?
OK. See those T waves in V1-V4, they look kind of funny right? Really wide and peaked. Not narrow and peaked like hyperkalemia, but wide and peaked. Look closer, see the J-point? Right, it’s kind of off the baseline isn’t it? Hmmm…what do we have?
Right then. You’re looking at an antero-septal MI in the hyperacute phase. By looking at the J-point, you can see that ST segment elevations are beginning to start, but no other signs. Rarely do we get to see this, so seeing one is a great learning opportunity. I admit, I had to look it up to see exactly what was going on. The hypothetical patient had a 90-95% occlusion of his proximal LAD and got stented for it. The really cool thing was the timing. Joint Commission goals are a door-to-balloon time of under 90 minutes. This particular hypothetical patient had a pain onset-to-balloon time of just under 2 hours. 45 minutes to the ED and about 65 minutes to the cath lab. But check out those troponin levels, pretty spectacular. Sometimes knowing when to come in and not wait makes all the difference in the world. Oh, the hypothetical patient? Hypothetically, they had no loss of LVEF or other signs of myocardial damage.
Hope this was as fun for you as it is for me…