Medics were criticized for not activating the cath lab

 This is the prehospital ECG from an 81 year old man with acute chest pain.

You will need to click on it to enlarge it in order to see it well enough

What do you think?

The medics did NOT activate the cath lab.  

But the paramedic got "told off" by ER staff saying they should have called the Cath lab saying it’s an inferior MI". 

 ECG:

There is what appears to be STE in inferior leads with reciprocal STD in aVL.  But if this is STE, the QT interval is far too short.  

This inferior "ST Elevation" is obviously not due to OMI.  But what is it?

Remember you should always assess the rhythm first.   Look for P-waves.  P-waves are best seen in leads V1 and II.  Look at V1.  There are 2 atrial "bumps" for every QRS.  One is hidden in the QRS, so not so easy to see.

Here I put arrows:

Arrows shows slow atrial flutter waves.  These mimic ST Elevation.  But there is no STE.

Of course the Queen knows it is not OMI:

Click here to sign up for Queen of Hearts Access

Here are other cases of the same:

A 50 year old man with sudden altered mental status and inferior STE. Would you give lytics? Yes, but not because of the ECG!

Arrhythmia? Ischemia? Both? Electricity, drugs, lytics, cath lab? You decide.

Tachycardia and ST Elevation.

===================================

MY Comment, by KEN GRAUER, MD (7/16/2024):

===================================

Among the most rewarding type of case for me during my days working in the ED — would be seeing a patient who presented with acute CP (Chest Pain) — who I would be able to “cure” simply by recognizing and treating their arrhythmia. Today’s case recalled that scenario for me, in that it features recognition of an arrhythmia that fooled ED staff into thinking the ECG was showing an acute infarction.

• For clarity in Figure-1 — I’ve reproduced, reformatted and labeled the initial ECG in today’s case.

Be Systematic:

As per Dr. Smith — When interpreting ECGs, the BEST way to avoid overlooking important findings is to regularly employ a Systematic Approach.

• Today’s case illustrates the importance of always starting with the rhythm before looking at the rest of the 12-lead ECG. The ED staff failed to do this — and as a result, they completely overlooked the arrhythmia.

I favor the Ps, Qs, 3R Approach — as a simple acronym to facilitate recall of the 5 KEY Parameters for rhythm interpretation (See My Comment in the October 25, 2022 post in Dr. Smith’s ECG Blog).

• The rhythm in Figure-1 is Regular, at a Rate of ~100/minute.
• The QRS complex is narrow in all leads — therefore confirming that the rhythm is supraventricular.
• P waves are present! (RED arrows in lead II).

PEARL #1: The temptation is to call the rhythm sinus — and move on.

• The problem is, that the PR interval of the upright deflection in lead II (under the RED arrows) is relatively long (clearly more than 1 large box in duration) — and if anything, the PR interval should shorten when there is tachycardia. 
• The PEARL is that recognition of a longer-than-expected P wave in a supraventricular tachycardia should bring to mind the “Bix Rule” (See My Comment at the bottom of the page in the August 3, 2018 post in Dr. Smith's ECG Blog).
• Named after the famous Viennese cardiologist — the Bix Rule states that if, with an SVT of uncertain etiology, you see a P wave occur near the middle of the R-R interval — then there probably is another P wave hidden within the QRS complex! While fully acknowledging that the RED arrow P wave in Figure-1 is not quite in the middle of the R-R interval — the PEARL is to recognize the longer-than-expected PR interval in this tachycardia — and to appreciate that this recognition at least merits a closer look.
• Calipers facilitate (and greatly expedite) your search. My "Go To" Leads when I find myself searching for atrial activity are leads II, III, aVF — lead aVR — and lead V1. Sinus P waves are defined as an upright P wave in lead II — and lead V1 is 2nd-best for identifying sinus P waves — but I've found the other 3 leads ( = leads III, aVR, aVF) may at times be invaluable for picking up flutter waves or ectopic P waves.
• To Emphasize: It took me no more than seconds to find that extra P wave that is partially hidden because of its proximity to the preceding QRS. The colored lines in lead III illustrate the process I use = The YELLOW lines that I've placed precisely midway between the RED lines fall directly over a 2nd hump that confirms 2:1 atrial activity.
• 
  
• PEARL #2: The "beauty" of lead V1 for arrhythmia detection — is that extra atrial activity so often appears as a pseudo-r' deflection (within the dotten RED oval in this V1 lead). And once again — the YELLOW lines that I've placed precisely midway between the RED lines in lead V1 confirm 2:1 atrial activity.

BOTTOM Line: The rhythm in today's case is a regular SVT in which there is 2:1 AV conduction, with an atrial rate of 200/minute and a ventricular rate of 100/minute.

• An atrial rate of 200/minute would be slow for untreated AFlutter — but this could represent an atypical AFlutter (given the lack of a "sawtooth" pattern) — IF this 81-year old man was on some rate-slowing medication. OR, this could be ATach with 2:1 conduction — with distinction between these 2 entities not significantly altering initial emergency management.
• As per Dr. Smith — the important clinical point in today's case, is that the initial concern of the ED staff that the patient's CP was the result of acute inferior MI was clearly erroneous, as the pseudo-elevated ST segment will doubtlessly disappear as soon as the rhythm is converted to sinus.
• And — it may be that this 81-year old man's "chest pain" may also disappear as soon as normal sinus rhythm is reestablished.

Figure-1: I’ve labeled and reformatted the initial ECG in today's case.