12-lead ECG protocols and policies

[lohof]

Greetings all,
In the near future our fire department would like to start doing 12-lead EKG's in the field. I would be very interested in any official protocols or policies your department has regarding 12-leads, when they are done, upon whom, how you transmit, etc. Also, a rough estimate on how many EMS calls you run on a year and how many 12-leads you perform. TIA!

[DCFyrMdc]

Lohof --

Prince William Co. has begun doing 12 leads in the field for the past few months. Basically, 12 lead candidates are anyone with:
* AMI or AMI like pain (jaw, left shoulder, etc.)or any cardiac event
* Respiratory distress or syncope (of unknown origin)
* CHF
* Post cardiac arrest resuscitation

We do not have to transmit them as it generally takes more time to get a phone line hook up than is appropriate. Our providers are going through a 2 day interpretation class but basically anybody who can identify ST elevation is set. We look for ST elevation in 2 contiguous leads and then go to notifying the receiving hospital of our suspicions and begin a thrombolytic eligibility checklist.

It's interesting to see the difference in patient care that occurs when you start letting your RNs know that you are coming with a patient with ST elevation in Leads x and y. Orders become much easier and the speed and deliberativeness of hospital based providers is much different than say 6 months ago when we weren't doing 12 leads.

I have done a dozen or so in the ten weeks I've had them.

[Rescue 21]

We have been doing pre-hospital 12 leads for about 4 years now. They are performed for any cardiac related complaint or or related symptoms. We can transmit them via land line or cellular phone. We are using the LifePak 11's currently. We average 5000-5500 EMS runs per year. I've probably done a couple hundred.
A lot of our providers think that it would take too much extra time to do them, but we have consistently proven that scene times are not greatly affected versus the benefit derived from an early 12 lead, especially if you catch an MI early.
Good luck with your program. If you need more info, I can put you in touch with our County EMS Coordinator via e-mail.

[lohof]

DCFyrMdc, have you had problems with transmitting ECG's? Land vs Cell times and connection aspects? Do the ED's have enough confidence in your reports to, say, activate a Heart Cath team prior to your arrival?

Rescue 21 I've heard the scene time complaint and I agree with your assessment. How long does it take to transmit? Do you have specific patients you run 12-leads on like DCFyrMed? Could you give me an example of you Chest Pain protocol?

[DCFyrMdc]

Regarding transmission, we have the capability but don't because of cel drop offs and the desire to not be hunting for a phone cord to connect to the LP12s while prepping the patient for transport.

Our two receiving hospitals will for the most part be "activated" based on our verbal reports while en route to the hospital. Again, we did a Tim Phalen-like 12 lead interpretation class and it's pretty hard to screw up seeing ST elevation in two contiguous leads. Some of our crews spend the time looking for conditions that would mimic these ST changes too -- like BER, hypertrophy, etc., but for the most part if you follow your ACLS MONA algorithm and let the hospital know you have ST elevation they are happy.

Regarding time, I haven't seen an increase in scene time...for a reason. Going into doing 12 leads, I had the mindset that 12 leads would not change scene time. I would say the biggest issue with time is finding your landmarks for placing the additional leads -- once you know where you are going it takes no time at all, because it becomes second nature like doing any other field skill.

I would recommend your department spend a good bit of time training fire and BLS crews so that they can place the leads also. Placing 12 leads should be like doing a BP or lung sounds, part of the everyday routine.

P.S. Don't let providers off the hook on 12 leads. While it seems daunting at first, this is not a complicated skill and certainly saves lives. Recently we were dispatched for a BLS overdose with a BLS ambulance.

Pt was 55 yom who had taken 2 of his stomach meds instead of 1 (don't remember what). Dispatch put us on it strictly as first responders b/c we were closer. When we got to the scene with this guy he was saying his pills were causing a sudden onset crushing stomach pain (There was a bit of a language barrier - so I won't blame dispatch this time). Smell something that isn't an OD? Well, hooked him up and sure enough he had ST elevation in V1 through V4 -- an anterior MI. Hospital was much different with him then than I expect they would have been if he had been transported BLS for taking twice his dose of a med that was still in therapeutic range.


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Christopher Suprun, FF/NREMT-P
Dale City VFD/Batt 4-13

[Trauma_Dog]

Everone has submitted some very good input on some things they have seen or delt with in the field, so I guess it is my turn to try to give some insight.

A study was done to see how well medics in the field dx AMI, the results were actully very low. This was contributed to the atypical MI. It was also found that atypical does not mean infrequent.You must maintain a high index of susp. in pt with mult. heath problems such as cva hx.,afib,diabetes, respiratory problems and so on. You may need to go out and hunt for the MI in these pts.



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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[Trauma_Dog]

Everone has submitted some very good input on some things they have seen or delt with in the field, so I guess it is my turn to try to give some insight.

A study was done to see how well medics in the field dx AMI, the results were actully very low. This was contributed to the atypical MI. It was also found that atypical does not mean infrequent.You must maintain a high index of susp. in pt with mult. heath problems such as cva hx.,afib,diabetes, respiratory problems and so on. You may need to go out and hunt for the MI in these pts.



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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[Medic 16]

I agree with everyone that has posted a reply and add that it sounds like most people have the same protocol for 12 lead criteria. I can tell you we have had 12 leads for about 2 years now. I work for all 3 ALS services in the County and only 1 transmits their 12 leads and that is due to them being the only service with almost 100% cell phone coverage for their district.

Our 12 lead protocol states that anyone over 18 years of age with non traumatic chest pain or shortness of breath gets one.

To give you my personnel opinion I think there are many patient's that DO NOT get them that should. As someone stated earlier there are many "missed" AMI's due to atypical presentation. I have seen some Medic's not due a 12 lead because "the patient didn't complain of chest pain".

In the rural setting where I work full time we do about 1800 calls per year and our closest facility is a small community hospital that is owned by a larger one. We find ourselves doing many transfers due to services not available at the smaller facility. Anyone who falls under ICU criteria gets transfered. Even though it is a small hospital we work very closely with all the staff. I can't tell you how many 12 leads I have done (less than 100 pre-hospital)but, to stay proficiant the hospital allows us to do 12 leads in the ER to stay atop lead placement. Since we work so close with them we have found that door to drug time has been decreased to about 15 minutes on average which is what the whole shootin' match is all about.