12 Lead EKG is it necessary for EMS

[BURNSEMS]

I was wondering what if anything the 12 Lead EKG adds to EMS care, we currently dont have it, but other services do and I cant see where it adds any thing stupendous to the Paramedic arsenal, we still treat PVCs and Cardiac Patients the Same, and the ones I have seen end up in the Trash at the ER, and the Hospital Runs another with their machine,if you use it does it help.

[benson911]

We start 12 leads on all suspected heart attack patients or ones with heart history - time allowing. This 12-lead doesn't change OUR treatment, but it helps the hospital by using our 12 lead or comparing ours to theirs for changes. We thought it was a waste of time and effort, but it's been pretty easy to do once you're used to it.

[Boothby]

The primary benefit of 12 lead is a reduction in door to drug time for thrombolytic theropy in the ED. To be truly diagnostic for AMI it is best to have two 12 leads. If we can get one in the field and transmit it to the ED they can pull old records and make comparisons prior to our arrival, or they can do the second 12 lead soon after our arrival. The other option is that they can look at your 12 lead and have the team standing by for your arrival. This can cut a considerable amount of time between when the patient hits the ED, and when thrombolytic/cath-lab treatment is started. 12-lead in the field may not change the way you treat the patient, but it can have a great impact on patient quality of life after they leave the hospital. This is true wether you are 5 min from the hospital or 45 min from the hospital.

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Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[benson911]

Boothby hit it right on the head - That's exactly why we started 12-leads in the field. So far, the ER staff and the hospital love it. I don't know if it has made a clinical difference for the patient, but I'm sure they'll have some results soon.

[Romania]

We don't have a 12-lead monitor at my curent department, mostly due to cost and short transport times. However, when I worked rurally, I commonly used my LP10 (which may be used to do a 12lead if you know how http://www.firehouse.com/interactive/boards/smile.gif) to do 12-leads on nay patient with CP, or dyspnea that indicates it may be cardiac in orgin. IT took the local (a.k.a. rural/set-in-their ways) hospital a little while to get used to it and actually looking at my strip, but once they did it worked as it is suposed to. Reduce the door to drug time... and more importantly event to drug time.

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[smoke1713]

we just recently started a 12-lead program. it was spearheaded by local er doc dr. vernon stanley, has published a book about it, it greatly reduces door to drug time for tPa . if a pt has probable cardiac problem, treat the pt per proper protocol, do 12-lead and transmit it by cell phone and modem to recieving er, do thrombolytic screen and when you get there that is far less actions that the staff has to do before busting the clot, remember time is muscle. this program is the beginnings of getting thrombolytics in the prehospital setting. it is not that far away. but it is gonna depend on medics furthering their education, and being competent so medical directors will trust our abilities, knowledge , and training to let us loose with this lifesaving yet potentially dangerous therapy.

[Boothby]

Alan talked about the cost and short transport times. Cost is definatly an issue. Our LP-12's were purchased by a local hospital under a grant that they recieved. The part about short transport times though is a very common misconception about 12 lead ECG. The actual transport may only be 5 minutes, but how much time is spent on scene? My unit is 5 min or less from no less than 5 different hospitals, but if you slap the 12 lead on right after you hit the scene the actual time between 12 lead and ED door can be closer to 20 minutes. Thats all time saved on the other end. Especially if you transmitt prior to transport. With the LP-12 if you don't have a cell phone you can jack it into the phone line in the house and send it to the FAX machine at the ED. I can understand the cost keeping a department from going to 12 lead, but don't let the argument about close hospitals stop you from making the jump.

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Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[Romania]

The other side to this, locally, is that we are an offline agency. Inother words we rarly patch. It would take some getting used to to start hooking or monitor into a phone. (i am not saying that this is a good reason). I want a 12 lead, and I want 'lytics. But, I am fighting another front right now...RSI http://www.firehouse.com/interactive/boards/smile.gif.

My solution (temporary) for my current situation is short onscene times.

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Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[Ed]

We have been performing and sending 12 leads via cell phone for 6 years and many interesting cases have happened. In a recent class we discussed and saw evidence with serial 12 leads that showed a patient having ST elevation with severe chest pain. I believe the monitor found an acute anterolateral MI. The person had no history. The squad initiated standard cardiac care and administered 325mg ASA. During transport the patients pain subsided and when the second 12 lead was taken in the E.D. Normal sinus rhythm was seen and the patient was pain free. You would have never seen that with a three lead. I am a believer in 12 leads and look foreward to future advancements in this area of Prehospital care.
Without the trained Medics you might as well take a cab.

[G]

Well said. I reiterate:

Acquiring a 12 Lead (once proficient) takes only about 2 min. more on scene

Transmitting a 12 Lead showing AMI to the ED can save lots of prep.time for thrombolytics or emergent angioplasty

The key is getting the hospital to buy into the plan-like early alerting to Trauma teams at EMS request. Ideally,they have to act before you arrive. Even if you cannot fax it in, it's easy to recognize most AMIs & mention it during the med patch. They can still get ready before you arrive.

Completing the prescreen checklist info (inclusion/exclusion criteria)not only saves time it can decide which therapy- 'lytics or angioplasty-is appropriate. For us that is a huge factor, since we have no cath lab to perform the angioplasty. Instead we could prearrange helicopter transport to meet us at the commmunity hospital if thrombolytics are contraindicated but our patient is actively infarcting. Thus saving a
huge amount of time vs. waiting until the hospital evaluates and then ships him out stat.

Also-we are part of a national study TIMI-19 right now in which we actually give Retavase (3rd generation rTPA thrombolytic given as bolus-no nfusion,repeat bolus in 30 minutes) prehospitally. So far we've only given it once (The 3rd service nationally in the study, 20th patient) with excellent results. We have transport times usually 5-12 minutes. No more than 30 min. on occassion. For the study, we don't change our routine at all-no additional scene/transport delays.
What we have already learned is that after the study is over we may eventually carry Retavase but will likely seldom ever use it prehospitally! (without adding additional scene time) BUT-we can (already) easily significantly reduce the door to drug time in the hospital ED by performing 12 leads, prescreen checklist, and early alert & FAX to ED. It works!

More importantly we may catch subtle silent AMI's prevelant in women, diabetics, and elderly who often present quite atypical and go unnoticed for considerable periods before being diagnosed in the ED's.

Admittedly, we sampled/piloted 12 leads here at several services several years ago, and like others concluded it was a waste of time and just another hassle. Thank God we finally woke up!! Please learn from our ignorance in taking this long to figure it out!

G



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These are my own thoughts/opinions; not necessarily those of my affiliations-YES,I THINK!

[fyrmedik]

In my opinion....12-leads can greatly improve the patient's survivability rate. In our system, we use LP-12s, and find that taking 2 minutes to run a strip at the scene, can greatly reduce the time from the initial incident, to the time the patient receives thrombolytics. This is especially true in areas with long transport times, and areas where medics can initiate thrombolitic therapy. We operate in an urban/rural setting, with transports from 1 min. to 1 hr.

[jfrzr]

This is my first venture into the Firehouse forum and if this is indicative of the forum I look forward to active participation. We implemented 12-lead about 2 years ago, after receipt of a grant to fund the LP12s. The field personnel expressed concerns about the "real" value of 12-lead. Our hospital ER physicians assured us that this would indeed help with the all important episode to treatment time. Anecdotally we believe this is the case. However, as our Quality Manager rightly says, "show me the data." I am unaware of a wealth of scientifically valid studies that conclusively show that pre-hospital 12-leads reduce episode to treatment time. If anyone is aware of these studies I would appreciate the references. EMS must grow beyond the I "think" we are doing good stage to we "are" doing good and this is the data that shows it.

[pompanofd]

I HAVE BEEN DOING 12 LEADS FOR THE LAST 6 YEARS. YEAH IT'S A PAIN IN THE BUTT SOME TIMES , ESPECIALLY IF THE PT. IS VERY FAT OR HAIRY. ANYWAY , THEY DO WORK ! PLUS IT GETS THE BALL ROLLING AT THE ER. ONCE YOU PUT THEM ON NOTICE THAT YOU HAVE A HOT MI (CARDIAC ALERT ) ST ELEVATION , CHANGES ETC.
THEY ARE UNDER OBLIGATION TO BE READY , ER DOC'S TAKE OUR 12 LEADS SERIOUS. IT PUTS ALL LIABILITY ON THEM IF THEY JERK AROUND AND DON'T JUMP ON A PT. THAT IS CRITICLE. WE HAVE CELL PHONE CAPABILITY TO TRANSMITT STRIPS , BUT WE DON'T BOTHER , ER DOC'S TAKE OUR WORD WHEN WE GIVE PRESENTATION & ECG INTERP. GOOD LUCK.....MIKE G.

[chief4102]

Our situation is much like pompanofd's. We use them to gain a few minutes in the E.D. It takes f couple of minutes more at the scene to set up but, if it's the real thing, the E.D. has a heads-up and seem to get things going quicker. Does it change the treatment in the ambulance pre-hospital....no. We still treat the patient - NOT the monitor.

Be Safe
Dan

[desoto]

Let me fist say that I am encouraged by what I read in these posts. I think we have come a long way in the use of the pre-hospital 12-lead, and I look forward to seeing that trend continue.
In response to a couple of the posts; jfrzr, the "data" you are looking for is out there. For starters I would try the AHA ACLS book, (1997-99) pg. 9-39, references 92-95. I would also check out the references for some of the JEMS articles on the subject. ( there are many in back issues ) Most of the studies I have read about seemed to indicate anywhere from 12-56 minute improvement in "door to treatment" time. Let me know what you find.
In response to chief4102, I have to agree completely with your assertion to treat the patient and not the monitor. I submit to you however that the prehospital 12-lead does in fact change our treatment in some cases, and that when treating the patient, you treat the patient based on the best, most complete information you can get. You wouldn't treat a patient for dyspnea based solely on his or her oxygen saturation, you'd listen to their lung sounds. The 12-lead in the field can give us very useful information when treating a patient that is in cardiogenic shock. It's not always as cut and dried as 'dry lungs=right vent., wet lungs=left'. Knowing the location of a possible infarct in these cases, in my humble opinion, is paramount to successfully treating the patient. Also keep in mind that these possible changes should NOT be diagnosed using the monitor function of the LP12. Only when the 12-lead is run will you get the necessary bandwidth and anterior/lateral leads to accurately read changes.
Keep up the good work y'all!

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Todd Gritter
Firefighter/Paramedic
Engine/Medic-10
Columbus Division of Fire
Columbus, Ohio

[rlkaale]

In response to "jfrzr"'s question about prehospital 12-lead studies, below is a small sample of articles from peer-reviewed medical journals. From your location, consider going up to the USF School of Medicine Library in Tampa for copies of the articles (not likely to be in local libraries):

1. Zalenski RJ. Shamsa FH. Diagnostic testing of the emergency department patient with chest pain. Current Opinion in Cardiology. 13(4):248-53, 1998 Jul.
2. Myers RB. Prehospital management of acute myocardial infarction: Electrocardiogram acquisition and interpretation, and thrombolysis by prehospital care providers. Canadian Journal of Cardiology. 14(10):1231-40, 1998 Oct.
3. Kudenchuk PJ et al. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the Myocardial Infarction Triage and Intervention (MITI) Project. Journal of the American College of Cardiology. 32(1):17-27, 1998 Jul.
4. Brown JL Jr. An eight-month evaluation of prehospital 12-lead electrocardiogram monitoring in Baltimore County. Maryland Medical Journal. Suppl:64-6, 1997.
5. Seaman KG. Emergency medical service system evaluation and planning strategies for prehospital chest pain in Howard County, Maryland. Maryland Medical Journal. Suppl:80-7, 1997.
6. Millar-Craig MW et al. Reduction in treatment delay by paramedic ECG diagnosis of myocardial infarction with direct CCU admission. Heart. 78(5):456-61, 1997 Nov.
7. Joyce SM. Prehospital 12-lead ECG. Annals of Emergency Medicine. 30(3):352-3, 1997 Sep.
8. Collins D. The prehospital 12-lead EKG: starting outside the emergency department. Journal of Emergency Nursing. 23(1):48-50, 1997 Feb.
9. Canto JG et al. The prehospital electrocardiogram in acute myocardial infarction: is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators. Journal of the American College of Cardiology. 29(3):498-505, 1997 Mar 1.


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Rob Kaale
Med Student - UTMB
Licensed EMT-P (Tx)

[Trauma_Dog]

Boothe is dead about the reduction of door to drug time, however i can also be usefull in the Dx of AMI's that cannot be seen on the normal 3-lead ekg eq..Posterior wall MI.. However always remember treat the pt not the monitor..by the way thanks to all who submitted some really stong input.

[lt/medic]

We have been doing 12 leads now for over 4 years. We also have a local hospital with short transport times. Our suspected AMI/Chest Pain protocol includes: IV (twincath), if time permits 2nd line. ASA. NTG sl and gtt. blood draw x4, MS (standing order up to 4 mg)and 12 lead.

We have found no changes in our average scene times by doing 12 leads. To achieve that you are busy, but we have good teamwork with ALS Ambulance and ALS Engines. Have noticed a significant decrease in door to drug times.

12 leads have become part of our basic assesment. It even helped me pick up a silent inferior MI in an elderly male, s/p 1 car MVA -- caused by syncope.

Our local ED Doc's do rely on our 12 leads and our assesment. They have gotten TPA into patients as fast as 9 minutes post arrival.

[Chris Stabile]

We have been performing 12 lead ECGs in the field for several years. Our protocol is to perform a 12 lead on any patient with chest pain, difficulty breathing, syncope, chest trauma, heart rate <60 or >150, and CHF patients. We follow the standard oxygen, IV monitor NTG sub lingual, NTG paste, and aspirin. We also perform the pre-hospital inclusion/exclusion questionaire. If we see elevation in two or more contiguous leads, or the chest pain is completely or partially relieved with the SL NTG, then we can initiate IV nitro. We carry infusion pumps on all of our ALS units. We can also request orders from the ED physician for a 5000 unit heparin bolus, after we draw a blue top tube. As many other respondents have stated, the pre-hospital 12 lead gets the ball rolling. We have had many cases where the ED saw our 12 lead, prior to our arrival, and the patient received thrombolytics within 5 minutes of arriving at the ED.

[rock34150]

While everyone and their brother is (or has) climbed on the 12-lead bandwagon, there are no published studies that show that doing a 12-lead in the field improves patient outcome.
The savings on door-to-drug time that is always cited as a reason to do field 12-lead has 2 problems:
1) studies have shown that the same amount of time can be saved, in most cases, by improving efforts in the ED (and this doesn't cost an arm and a leg for new equipment for the prehospital).
2) studies have also shown that the vast majority of patients do not call 911 until more that 2 hours after the onset of symptoms. These patients have a much reduced benefit from thyrombolytics. (take the money you would spend on 12-lead machines and spend it on PSAs teaching folks to call at the onset of symptoms.)

As an aside, the only research I'm aware of on prehospital thrombolytics (King's County, WA and Tucson, AZ) showed a patient benefit to field thrombolytics only when transport times exceed 45 minutes.

[FF162718]

In my opinion, for any new procedure, we need to ask ourselves "does it benefit our patient?”. That is "what really matters"!

Do prehospital 12 Lead ECG's help our patients? Yes! But, if you're not a believer, look at the pros & cons.

Pro - Gives Paramedics a better assessment of their patient.

Pro - Gives Paramedics a more credible call-in to the hospital.

Pro - In a system with multiple hospitals (some with cath labs, & some without cath labs), if you have a 12 lead confirmed AMI, you may have protocols to transport to the nearest ED with a cath lab, cutting the amount of time the patient would otherwise need to be transferred later. ("Time Is Muscle!")

Pro - In some systems, if an AMI is confirmed with a prehospital 12 lead ECG, the patient will go straight to the Cath Lab, bypassing the ED all together. This can drastically decrease the total amount of MI time. ("Time Is Muscle!")

Pro - If your unsure if a patient's chest pain is cardiac in nature, 12 leads can help you make that determination. Not all chest pain is cardiac related.

Pro - If a patient with chest pain wishes to refuse transport, 12 lead ECG's may help you emphasize your case to the patient that they might die!

Pro - If a patient with chest pain wishes to refuse transport, 12 lead ECG's may help you feel better about getting the refusal. I personally, never feel comfortable getting a refusal from a patient with chest pain, but 12 lead ECG's help me feel better about it.

Pro/Con - In the event of a law suit, 12 lead ECG's will further document your patient's actual condition @ the time of treatment. (This is a pro if you paid attention when taught how to read 12 leads, a con if you didn't pay attention!)

Pro/Con - It requires additional knowledge/ training if you haven't been taught already. Some like the idea of learning more, however, most do not.

So, do you think it helps our patients? I say YES! I say it helps not only our patients, but also our Paramedics! We have used 12 Lead ECG technology for almost three years now, and it greatly helps our Paramedics do a better job serving their patients!

[OARMedic]

Our hospital is #1 in the US for door to intervention and one of the top 100 cardiology hospitals in the country. We have pre-hospital 12 lead throughout our area, both with career and vol. agencies. They are transmitted to the ED and our EMT-Is and medics are taught to interpet them. We seldom give thrombolitics any more. You go to the cath lab within minutes of getting to the ED. When a unit calls in with a report of an MI and what the 12 lead shows, we don't wait for the 12 lead to be transmitted. We notify the cath lab and get everything rolling. Considering we are a community hosptial system (Level II center, regional cardiology and ortho center) and not a large teaching hospital, we are very proud of our system. We have even had some of the large teaching hospital come here to see how we pull this off. As for studies, this is being written up for publication and should be out in the not too distant future.

[kghemtp]

How's this for resuscitating an old topic?!? I wonder where some of our original posters here are with prehospital 12-leads. I agree that anything done enroute that speeds the definitive treatment is a valuable addition to our regimen. We DO have to make choices out there based on 12-leads quite often, and this procedure isn't hard to do along with our traditional care. My question would be why delay proper care of AMI by going to a facility that isn't ready to handle it completely? I am sure this happens to this day, simply bringing someone to the closest facility instead of where he/she COULD or SHOULD go. And of course, if we erred on the side of caution with every chest pain that didn't have the luxury of 12-lead, we'd be clogging our cardiac centers with acid reflux & abdominal pain. I am all for the technology & training that allows us to provide more thorough care.

[OARMedic]

We have a number of pts each year that come from other hospital EDs in the region. If it is an evolving MI, we will fly them in and go directly to the cath lab. If the weather is bad or our chopper is tied up and we can't get another helicopter service, we go get them by ground. If it has been an extended time, we may ground transport them to our CCU or Progressive Cardiac Unit for further evaluation. Sometimes the sending facility will use their own transport or a local ambulance services. These are usually wowfully inadaqate for these pts. Some EMS agencies take these pts to those hospitals because of regional protocols, it is the nearest hospital (even if it is closer by only a few miles), or "we always go there!"

[ABMedic]

I am a strong advocate of prehospital 12 lead acquisition, in my system (urban - 700,000 population base) we utilize 12 leads for a number of years. We were the leading site for prehospital fibrinolysis in the ASSENT 3+ trial - which demonstrated a saving of approximately 40 minutes for drug to patient time compared with ER administration. Currently we are part of the WEST pilot trial comparing prehospital lytic therapy versus PCI where the patient is taken directly to cath lab from the street and bypassing the ER.

The benefits of prehospital 12 leads - is multifaced; specifically, it increases the identification of ACS in the atypical presenting patient. The time on scene - (without lytic therapy) should not be statistically increased - average time to obtain 12 lead approximates 2 to 3 minutes after experience is obtained (no different then the ER time for 12 lead acquisition).

Furthermore, it allows the identification of high risk patients if the 12 lead demonstrates resolution of ST elevation with nitrate therapy. Clearly, this does not occur often - but it does occur - as demonstrated by cases within the ASSENT 3+ study. This can impact clinical outcome for these individuals by stratifying treatment to early PCI.

Finally, it allows prehospital lytic therapy to be considered in EMS systems - adding a potential measurable outcome difference - something that is very limited in prehospital medicine.

As for issues of 911 delay - while attempts have been made to reduce the time of symptom onset to 911 call, it appears that the early success at reducing this time has reached a plateau - further efforts have been less than successful at reducing this benchmark. A delay of 2 hours is common, even more so for atypical presentations, thus the importance of identification of these individuals to enable lytic therapy within 6 hours is even more critical. Hence more PSA probably will not impact this benchmark - for denial is a human experience!

Improvements in hospital door to needle time - sadly is not uniformed, recent studies demonstrate a wide spectrum to this benchmark between hospitals across the country and internationally.


One should do a new lit search to find newer articles then quoted and requoted old literature that is found in some of the posts. One study rarely has the weight of evidence that multiple studies do!

ABMedic

[ABMedic]

In addition 12 leads provide information on the involvement of the right ventricle during an inferior infarction. Does this clinically matter? Yes - certainly identification of RV involvement in inferiors impacts the management of these nitrate sensitive patients - where preload must be maintained or supplement (fluid bolus) to prevent significant hypotension if nitrates are to be utilized.

ABMedic

[swrr88]

We use the Zoll M series and I have never felt the 12lead took any serious time on the scene. I usually get my partner or a FR to hook them up while I set up something else. Once you get used to them, anyone can place the leads without much effort. The M series is very accurate and has no problem doing 12 leads moving down a bumpy city road. I have done multiple 12 leads while doing other things enroute. I caught an MI expanding with additional damage beginning. It made a difference to the patient for sure.

As our medical director states on a regular basis...anyone who doesn't care about our pre hospital 12 leads once we are in the ER is an idiot. Hospitals keep copies of 12 leads in patients charts and they are referred to on return visits...there's no difference in ours. Plus for a new patient with no prior 12leads another one to look at could show an obvious change and speed up the right care.

[MedicFletch]

My quick two cents:

12 Lead EKG's can be a valuable tool as aforementioned by other posters. The amount of information available is phenomenal to those who have the knowledge to interpret them. For instance:

1. Dialysis/ Renal Failure pts : early indications of hyperkalemia are only present in V3-V4. IVCD presence with wide QRS - treat for hyperkalemia
2. Ischemia : indicated by the shape of the ST segments and symmetry of the T waves can be crucial in determining cardiac origin of chest pain. I can't count the number of times I have been told by Fire or other EMS personnel that there are no EKG changes (usual ST or q waves) and the pt is B.S. but I see these small changes and low and behold those supposed non-EKG changes are being rushed to the cath lab.
3. Dx of Anterior or Septal MI's: there are no leads other than posterior V7V8V9 that will show reciprocal changes for these infacts (with the exception of high lateral changes)
4. Dx of Posterior and RV infarcts.
etc.

Unfortunately here in Las Vegas we do not have the capabillity to transmit, as of yet. And with our lengthy hallway wait times and angry nurses taking are telemetries and not informing our docs, the ability to read an EKG literally saves pt's as you can show them what you see and get your pt into a bed.

[ff7134]

My department is the first ones in the county to have 12-lead capability. We worked a while with the local hospital's coronary care team to set up our protocal for this and the ER. The patient is now fast-tracked to the cath lab and tPa. We transmit our 12 lead to the ER, when we hit the door they run one more 12 lead and off they go to coronary care. We are still compiling the stats but it is a great program...since we started about 6 months ago a neighboring dept went to 12-lead and now have the same protocol as we do. I'm all for whats best for the patient...and the faster they get to the definitive care in the coronary unit the better. It is doing the patient no good setting in the ER waiting to get these test done before treatment.

[RoryEl]

lead II was what we used because it was the only thing we had, but not any more. A 12 lead adds so much to your intrepretation and management. Lead II leaves you blind to many different problems that you can see with a 12 lead or 18 lead if they have an inferior MI evolving. Do you wanna give NTG to someone with ST elevation in lead II? How about leads III or AVF? Is that abberent conduction or ventricular in origin? A 12 lead readily reveals that info. Cardiac injury, ischemia, transmural infaction, bundle branch blocks, hemiblocks are readily revealed. Wanna know which pt's are high risk due to high grade blocks, do a 12 lead. If your seeing ST changes with reciprical changes and comunicate that to the hospital, they will move faster since door to drug time is an important TRACKED standard.

All that said, if your not going to invest in adequate training for 12 lead interpretation it's just another expensive fancy gizmo.
I believe a 12 lead has obtained a standard of care status.... As with so many things in medicine, It can be diagnostic of an AMI, but it can not rule out an AMI.

[jam755]

This reminds me of a call I had shortly after we placed 12 Leads on our units. 40 year old female with a chief complaint of "not feeling right." She had mild dizziness and nausea. She told us this feeling awakened her. Because of the unusual complaint we placed her on the 12 lead and she was having a lateral/septal MI. On arrival at the hospital the Cardiologist was waiting and she went straight to the cath lab. This happened about 7 years ago and she is healthy and happy today. Without the 12 lead I would not have known she was having an MI and my treatment would have been different due to the presentation. Also, how long she would have waited in the ER we have no way of knowing but in this case, as many others I have seen, there was definatly a reduction in time to definative treatment.

As others have stated this has to be a joint effort. Without proper training a 12 lead will not do you that much good. Also, if you do not have the support of the local medical community it will not reduce treatment times. If everyone is willing to work together 12 leads can be an invaluable tool in our toolbox.

Just my 2 cents.

[ALS142]

Is a 12 Lead ECG necessary?

Nice to have, yes. Necessary, no. A patient with chest pain and with a "normal" ECG will still get the same treatment as a patient with ECG changes revealed by a 12-Lead.

But if you have a 12-Lead capability, you're a fool for not using it. Knowledge is power and the more knowledgeable you are about your patient, your power to make better informed decisions about your patient will increase.

I came into EMS when we had the LP-5 which could only read in Lead II. If you wanted another presentation, you had to physically change the lead positions. Since then I've have always advocated the use of technology to assist us. What I'm hoping to see soon for EMS is the routine use of thrombolytics in the field when ECG changes are noted. That is when 12-Lead ECG will become the true standard-of-practice.

[DaSharkie]

As of November 1, 2003 all Paramedic units in the Commonwealth of Massachusetts need to have 12-lead capability. A good move as far as I am concerned.

Like ALS said, if you have it use. A few extra seconds before you put the truck in drive is great. You have a baseline to move from in your course of treatment. Even if you don't want to do the full 12 - lead, if you put the four limb leads on the patient (using a LP-12) you can do a "6-Lead." Gives you leads I, II, III, aVR, aVF, and aVL. If you see anything that may sway your you can then put on the other 6 leads and do the full 12-lead.

As of this time, it does not change our treatment but as it has been said before here, the doc in the box can take a look at what we had in teh field 5 or 10 minutes ago and see any progression to what the patient is presenting with now.

Sometimes when I get to the hospital before we pull the patient out of the rig, I'll do another 12-lead whil my partner is gloving up and walking to the back of the truck to see if there is any change. THis is especially true if I saw something initially.

[emstrainer]

I have read all of the posts and wanted to make a few comments.

If you want to develop a 12 lead Program that will have an impact on your customers you will need a few basic ingredients or time and money will be wasted.

#1 - You must train all personnel how to read and understand the 12 Lead ECG. To simply perform a 12 Lead and FAX it to the ED only causes a delay in patient care. The EMS Provider must be comfortable with interpreting the 12 Lead. Once an interpretation is made, the physician can be consulted in the ED via phone or radio. If you call a physician and tell him/her that you are inbound with an AMI they have a burden to be ready for you. Follow up with continuing education on a quarterly, semi-annual, or annual basis as needed.

#2 - Get buy in from the hospital community. If the strips are being placed in the trash on arrival then you have a problem. I can't imagine an entire medical community would be that ignorant. Contact the local cardiologist group and set up meetings to determine how the Pre-Hospital 12 Lead can best be utilized. I am confident that they will be interested in improving their "Door to Balloon" times.

#3 - Develop protocols that allow EMS providers to make treatment decisions based on the 12 Lead ECG. What do I mean you say ???

Acute Coronary Syndromes - Not all cardiac events cause Anginal Pain. We must be suspicious of any Anginal Equivelant such as Dyspnea, Diaphoresis, Weakness, Syncope, Near-Syncope, Abdominal Pain, Nausea/Vomitting. All of these may be the only sign of an ACS. If you have signs of ischemia on the 12 Lead (depressed ST, inverted T waves) you should be giving ASA and Nitro. I don't know how many times our EMS treatment resolved the 12 lead ECG Changes prior to arrival in the ED. These patients get admitted and often get a trip to the cath lab because of our early detection of the ACS.

RVI - to treat all AMI patients equally is not good medicine. We need to be cautious in those patients suffering from Right Ventricular Infarct. These folks have lost their RV function and therefore have no Preload. If we give nitro we may promote hypotension and shock. These patients typically need large amounts of fluid (1-2 liters in some cases).

Destination - To treat all hospitals as equal when it comes to cardiac care is a practice that should be abandoned. Study after study has shown that the most appropriate treatment for a patient suffering from STEMI is Acute Angioplasty. EMS must establish guidelines that direct AMI patients to Interventional Cardiac Facilities. This is taking place in some areas of the country, but others are very slow to accept the evidence. This is the same concept used to transport "Severely injured" Trauma patients to Trauma Centers. Thrombolytics are out and Cath Labs are in when it comes to the AMI patient. If you want to learn more do a Google Search for "Danami 2" and read the results. EMS is in the drivers seat - lets make a difference.

If your system does not want to tackle these issues I have presented I would recommend that you invest in some other equipment purchase. For a 12 lead program to be worth the money invested you have to at least have the basics in place. For those that feel it is a large obstacle to overcome I encourage you to continue the fight for your patients best interest. Be an advocate and get involved.

On a side note, our region has developed new protocols that allow us to make the decisions outlined above. All patients that have ST elevated AMI are transported to the Interventional Facility. If a paramedic calls ahead with a Cardiac Alert, the team is paged immediately. There are 5 hospitals participating, and over 80 EMS agencies in 6 counties. Initial data shows a 20 minute reduction in "Door to Balloon" time from 96 minutes - 76 minutes.

Good luck with the development of your programs, and I can share our information with anyone that is interested.

For those with current 12 Lead program, check out the 12 Lead ECG E-Mail discussion list on Yahoo Groups. It is very educational.

Jason Kinley, Lieutenant
Xenia Fire Division

[panther]

After reading all the replies it was nice to see someone finally bringing up the "I don't know how many times our EMS treatment resolved the 12 lead ECG Changes prior to arrival in the ED. (emstrainer)". Before and since the 12 our field treatment was the same. But think back to all those pts who we swore were having an MI only to get them to the hospital and be told the 12 Lead showed NSR without ectopy. So the ER sat on the pt until the labs came back only to find out that yes...in fact they were having an MI.

Most of us knew that treatment for AMI in the field could in fact significantly change the EKG. With the addition of the 12 its just much easier to prove. So rather than waiting for the "labs" to come back the pts care is expidited. If nothing else, that makes those extra two minutes very worth while.

[TraumaDog]

There is another use for the 12-lead ECG that has been over looked, The patient refusal of transport. Armed with a 12-lead ecg along with evidence of Acute Coronary Syndromes can be very powerful for the patient that is denial.

If you look in the front of the owners manual of most ECG monitor manufactors make a statement that the 3 lead ECG data if filtered and therefore not diagnostic quality and not to be used to interpret AMI(In this section of the manual there is also useful information about heart rates less than 20 and over 300 bpm). The 3 lead ecg should only be used to diagnose rate and rythym only.

We have all seem or heard of someone saying "well your heart looks fine Mr. Jones". When ever I hear this I say, "I don't care how it looks, I care about how its running". Without a 12-lead ecg I dont see how someone can make statement that give a patient the impression they are going to be alright when the truth is they have not even used a tool that is the hallmark of treating Acute Cornary Syndroms and the possibility of having a AMI is very real.

Anyway there has been some good talk on an old topic and it good to see folks that are using 12leads which in my opinion are now the standard of care rather than an option.

Have a nice day.

P.S. the information for the LP12 can be found on page 3-2 of users manual under the "ECG Monitor Warning" section.

[Medic818]

After reading through some of the other posts, I feel compelled to offer my advise (opinion). 12 leads in the prehospital setting is an invaluable tool, if in the hands of a well-versed and well trained Paramedic. Idealistically, every patient who is having "the big one" would present with chest pain and dyspnea.
Unfortunately, however, most MI patients present with "atypical" symptoms (i.e.: syncopy, profound exertional dyspnea, general malaise,etc). In fact, nothing against women, but about 80% of the female population that is expierencing an MI presents with one of these atypical symptoms. So, the next time you go to the elderly female patient with general malaise, bewary of her symptoms and the underlying cause...She could be having the Big one, and you'd never know it, without a 12 lead.
So, in summation, 12 leads in the prehospital setting are not only a terrific tool, but the standard of care.

[DrParasite]

Please allow this lowly EMT to post on such an advanced topic.

I can understand 12-leads are an invaluable tool for getting a better look about how the heart is looking/beating/etc. however in my experience, it is not used on every patient. very often it is just the basic 4 leads. with chest pains calls, usually the 12-lead is done (usually).

however, even if the 6 and 12 lead are normal, ALS will still treat the patient as though they are having a AMI (well, usually). this means a standard treatmnet of oxygen, nitro sub ling, sometimes nitro paste (but havn't seen it in a while), and a baby asprin.

i guess what I'm trying to say is, while they do allow for a more percise start treatment to ER picture of the heart, does it the 12-lead a) change your treatment protocals or b) change the way you assess a patient C/o chest pain?

[kghemtp]

Dan, you're very right about most treatments, but there are some other considerations. Many regions are using thrombolytics in the field that will need the 12 lead diagnosis of AMI before being used, and to wait for the hospital to do this while it can be done 10-20 minutes earlier can mean a considerable amount of saved muscle. I mentioned somewhere in the threads that a general assessment of chest pains could flood a cardiac center with non-cardiac situations. I will say that it's better to err on the side of caution, but when a particular diagnostic can help determine which facility this patient NEEDS to go to, then I am all for that tool. Assessments are getting SO much better for all levels of provider, so we can make better choices, but 12-leads are a tool that assessments aren't going to replace.

[jam755]

You also have to look at atypical presentations. As has been discussed in other posts all AMI's do not present with chest pain. Aspirin has been shown to improve outcomes and this is a treatment that would not generaly be done in the non chest pain patient unless you have a 12lead to show an AMI. The 12 lead may not significantly change the treatment on the typical chest pain call, but it may make a difference in treatment and transport priorities of the atypical presentation.

[Ohiovolffemtp]

Dan,
Good question. There are 2 basic answers:
1. As EMSTrainer explained very well, not all MI's are the same. What's going on depends on which part of the heart is affected. If the right side of the heart is having the MI, you need to be very careful that the vasodilators you give don't cause such a big drop in BP that the patient crashes. A 12 lead EKG, repeated with a right sided 12 lead by moving lead 4, will tell you that. If it is a right sided MI, you make sure you have a large bore IV in place and have bolused the patient with fluids (250-500cc's) before giving nitro.

2. There are a lot of MI's that don't present with chest pain. Women, the elderly, and diabetics often complain of vague general symptoms. A 12 lead will give you an indication that they're having an MI. Without that, you wouldn't do the aspirin & nitro treatment.

Hope this helps,
Paul

[canuckemt]

Though I am only a Paramedic student I feel that 12-leads are very important. We will use them on any patient with any cardiac history They are good at catching the silent M.I.s with a patient not experiencing chest pain.

[SPFDRum]

In St. Paul, a 12-lead EKG may change the patients hospital of choice. If there is any changes that may indicate an AMI, the pt will go to 1 of the 3 hospitals in the city that have cath labs. It also gives an almost immediate picture of what going on and a strip of that.

[DaSharkie]

I forgot that this thread was on here. I forgot to update that we have a new protocol for chest pains. If we have an MI, we are required to perform a 12-lead. After interpreting the 12-lead if the patient wants to go to a particular hospital (we are not allowed to divert to this particular hospital - doctor pissing matches will ensue) we can call the cardiology fellow direct, tell them what we have found and they will tell us whether he will meet us in the ED or to bring the patient right up to the cath lab and they'll have a room ready for us.

In the past 6 - 10 weeks it has worked out OK. We caught a couple of MIs and one had 54 minutes from time of symptom onset to being on the table in the cath lab. I realize that this is grossly abnormal but it worked out well.

[medicfire]

Many providers have stated that 12 leads are needed and becoming a standard of care. The question I raise is in my area and maybe yours does the cath labs have the capabilities to complete what they start. ie: open heart when they find the real bad blocks? Should this be a pre hospital problem and should we skip to the facility who can "do it all"?

[Weruj1]

why would you or your patient want to skip a facility that can "do it all" right there ? All of our local cath labs can take you right to bypass surgery if needed and I believe that they can also do some procedures right in the lab. So tell us why this isnt a good idea ?

[firenresq77]

Weruj, I think he was inquiring about a couple things.......

1.) Can cath labs fix the problem right there

2.) Should Pre-Hospital care providers worry about it

3.) Should we bypass a closer facility to go to a do-it-all one

______________________________ ______________________________ _____

1.) Around here, yes

2.)Of course you should. Do you take a trauma patient to the local clinic? Nope. They go to a trauma center

3.)See answer to #2

[DaSharkie]

The question I raise is in my area and maybe yours does the cath labs have the capabilities to complete what they start. ie: open heart when they find the real bad blocks?

I do believe that Duke University Medical Center has that capability. Just a hunch though. :p

Should this be a pre hospital problem and should we skip to the facility who can "do it all"?

Depends on the time frame we are looking at here. Is the pt. able to go right to the lab? Then if it is within a 20 - 30 minute time from transport, I say yes. Aggressive treatment by the Paramedic is necessary to treat.

Look at it this way: You get enroute to the ED, the nurse triages the patient, then tells the doc, gets a ECG tech to do a 12-lead and MAYBE compares it to yours. Then gets the drugs out of the Pyxis to thromobolyze. After teh thrombolitics are done they dink around getting a bed at a tertiary care center, arranging transport, get the patient loaded onto the stretcher. Then they get transported to the larger hospital, and goes through a lot of the same rigamoroll at the new hospital.

I say cut out the middleman, go directly to the cath lab. This is where good QA/QI is needed, good training, and education are required. PROPER utilization of the opportunity is warranted here.

Firenresq77 brings up a good point: why is this situation any different from a major trauma? Perhaps in some more rural and aggressive systems protocols will soon allow for calling a helicopter to get them there more rapidly. Outcomes from MIs will dramatically improve here.

Unfortunately, it will take a LONG time to change some people's ideas about it. The patient comes first and a good risk - benefit analysis is necessary.

[firenresq77]

I didn't read this whole thread, but in the county I dispatch for, we have a "STEMI" policy. STEMI = ST Elevation MI

These patients should automatically go to the closest hospital with a cath lab. We have 8 hospitals in the county and 5 of them have Cath labs........

[ffspo0k]

Originally posted by desoto
Let me fist say that I am encouraged by what I read in these posts. I think we have come a long way in the use of the pre-hospital 12-lead, and I look forward to seeing that trend continue.
In response to a couple of the posts; jfrzr, the "data" you are looking for is out there. For starters I would try the AHA ACLS book, (1997-99) pg. 9-39, references 92-95. I would also check out the references for some of the JEMS articles on the subject. ( there are many in back issues ) Most of the studies I have read about seemed to indicate anywhere from 12-56 minute improvement in "door to treatment" time. Let me know what you find.
In response to chief4102, I have to agree completely with your assertion to treat the patient and not the monitor. I submit to you however that the prehospital 12-lead does in fact change our treatment in some cases, and that when treating the patient, you treat the patient based on the best, most complete information you can get. You wouldn't treat a patient for dyspnea based solely on his or her oxygen saturation, you'd listen to their lung sounds. The 12-lead in the field can give us very useful information when treating a patient that is in cardiogenic shock. It's not always as cut and dried as 'dry lungs=right vent., wet lungs=left'. Knowing the location of a possible infarct in these cases, in my humble opinion, is paramount to successfully treating the patient. Also keep in mind that these possible changes should NOT be diagnosed using the monitor function of the LP12. Only when the 12-lead is run will you get the necessary bandwidth and anterior/lateral leads to accurately read changes.
Keep up the good work y'all!

------------------
Todd Gritter
Firefighter/Paramedic
Engine/Medic-10
Columbus Division of Fire
Columbus, Ohio


OMG A SMART COLUMBUS PARAMEDIC <falls over dead>

J/k brother, I work here in Whitehall and I also am friends with that red-headed turd who dropped his medic card (james).. Nice to see another local brother on the boards!

Either way, to answer the original post, yes yes yes yes yes yes yes.

I have a few major reasons for my belief in 12 leads, first you should be extremely cautious in giving nitrates to an inferior MI, and you should withhold nitrates to an inferior MI with right ventricular involvment (RVI). I won't get into the A&P for this, because I've posted it numerous times in the past, but either way, You cannot diagnose an inferior, much less an RVI without a 12-lead. In addition, prior to getting on the FD I worked at a local ER, one of the first to accept telemetry in the area. This hospital would have the patient in and out of the ER and up to the cath lab in about 5 mins when all things lined up, especially the prehospital 12-lead sent in to the hospital via telemetry.

[ffspo0k]

Originally posted by Weruj1
why would you or your patient want to skip a facility that can "do it all" right there ? All of our local cath labs can take you right to bypass surgery if needed and I believe that they can also do some procedures right in the lab. So tell us why this isnt a good idea ?


I can't speak for whoever you are replying to, but here in this area there were a few hospitals that could do thrombolytics in the ER but not emergency caths and no open heart surgery, requiring patients not appropriate for tPA/retaplase to be transferred downtown. Rather than doing a tpa checklist and risking missing something, I would personally rather take them downtown where they can change the oil and the tires and check the plugs all in the same place.


For me on my end of town this has changed, and the closest hospital is finally fully functional, which saves me the trouble of bypassing them to go downtown.

[Weruj1]

check out the last post on page 3 .................thats what I am saying ............

[firenresq77]

Many providers have stated that 12 leads are needed and becoming a standard of care. The question I raise is in my area and maybe yours does the cath labs have the capabilities to complete what they start. ie: open heart when they find the real bad blocks? Should this be a pre hospital problem and should we skip to the facility who can "do it all"? He's asking if you should skip TO the do-it-all, not skip it

[Weruj1]

AH HA !!!!! then yes you SHOULD go to the do it all facility......

[DaSharkie]

It's tough gettin' old ain't it brother?

[kghemtp]

Sharkie, it's not so much "old" as it is just crust forming over the eyes!

[medicfire]

Thanks to all who have replied, And sorry for the typo, I should have spell checked. but then again I am an EMS provider. The reason I ask the question about skipping facilities, is because around me there are many hospital who want to do the cath lab thing but are unable to complete the job when the .... hits the fan. The Emergent transport is called for and many risks are taken because of this fact. So I have gone past these hospitals that have only cath labs and right to the big boys who can finish the job, but this has gotten me in trouble and some feelings have been hurt. It put us providers in a tight position. To pass a hospital is a big risk, what if something goes wrong, what if that TPA or Cath was all they needed, then am I responsible for more damage because of the delay? Big questions to answer and I am not sure if any one person can. For now I go by who give me the right to practice medicine My Command. With a good working relationship, this person will stand by who allows to operate.

On a side note - there is a forum in my area called chesterfire.com and these providers are now talking about these issues. I have directed them hear, but I would also ask if anyone here would like to help me there. The feeling so far is if they have time 12 lead would be done... sometimes. Please help me talk to this group too.

Thanks and talk to everyone soon.

[Jdoane1]

Performing a 12-lead is only mildly disruptive to the crew's work and a patient's discomfort (lifting garments, poking the intercostal spaces, etc.). Once you start doing them, they take about as much time to run as a 3-lead. Where rhythm strips end up after a run is up to the receiving staff at the hospital, but usually ER's like them for comparison. If 12-leads are part of protocall, simply perform them. Lastly, if 12-leads don't change your treatment of the patient, perhaps they serve a psychological role in easing a patient's fears, etc.

[mittlesmertz]

Late to the thread, but from what I'm reading, people have to fax a 12 lead to the hospital? Or some type of telemetry?
Not bein a smartass, but aren't we supposed to interpret the EKG ourselves?
Our medics do a 12 lead, and based on the findings and exam we begin proper treatment and notify the closest facility with a cath lab of our ETA with a "CAth LAb MI". Our door to balloon times average in the 20 minute range. We usually don't even take the pt off our bed- just straight to the cath lab.
The ED Docs and Cardiologists trust our clinical judgements, but I kinda thought this was standard across the country.
Is this way different in other areas, or am I reading this wrong?

[kghemtp]

Mittle, yes many rigs running the newer devices (I'm sure of LP 12 & Zoll) have connections through the cell phone or a dedicated line. Works quite easily -- in a department where we have 4 choices of hospitals, all are programmed in as an option for transmitting to, so we select which one we want & the strip is sent.

[mittlesmertz]

Originally posted by kghemtp
Mittle, yes many rigs running the newer devices (I'm sure of LP 12 & Zoll) have connections through the cell phone or a dedicated line. Works quite easily -- in a department where we have 4 choices of hospitals, all are programmed in as an option for transmitting to, so we select which one we want & the strip is sent.
I think I've seen that option for LP's, but my point was why don't the crews just look at the 12 lead and make a determination based on that and the presentation? Are they under med control that won't allow them to interpret the 12 lead by themselves? Not being a smart ass, it's just that where I work we don't need to show the MD a12 lead prior to making decisions. Is telemetry common out there?