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ECG Case Series ECG case series for paramedics: February 2024 Charles Bloe, Lead Nurse for Cardiology, Coronary Care Unit, Raigmore Hospital, Inverness, UK. Email: charles.bloe@nhs.scot This 32-year-man presents with severe central chest pain. He has a long history of significant mental health issues and he smokes in excess of 60 cigarettes a day. He has been experiencing intermittent chest pain for 2 days. However, this morning, it has become more severe. He describes it as being aching in nature and located across the front of his chest. He rates it as 9 out of 10 in intensity. His arms feel heavy. He is also pale and sweaty. There is significant family history with both his father and older brother diagnosed with coronary heart disease at a young age. l The heart rate is approximately 105 beats per minute. Interpretation of the 12-lead ECG l The most striking abnormality is ST segment depression in leads V1–V4. This man was triaged to the catheterisation laboratory (cath lab) for emergency primary percutaneous coronary intervention (PCI) with a likely diagnosis of acute posterior myocardial infarction (MI). He was found to have an occluded proximal circumflex coronary artery. A single drug-eluting stent was inserted. An echocardiogram was recorded 48 hours later. It demonstrated akinesis of the posterior wall of the left ventricle. The ejection fraction was estimated at 45% (normal 50–60%) Figure 1. ECG of a 32-year-old man presenting with severe central chest pain What does the ECG show? Interpretation of the ECG rhythm l The heart rhythm is regular and in sinus tachycardia Posterior myocardial Infarction Around one in four patients with an acutely occluded coronary artery do not present with ST elevation. These acute ‘occlusive MI’ (OMI) patients do not meet the standard ST elevation criteria (mm) for primary PCI or coronary thrombolysis, however still need it. A number of ECG patterns should be recognised as indicative of OMI: l De Winters ECG l Posterior MI l Hyperacute T waves l Aslanger’s ECG. Posterior MI is the most common ECG pattern of (OMI) without ST elevation, caused by circumflex or right coronary artery occlusion. It is often associated with inferolateral ST/T changes on the ECG. ST depression can be as low as 0.5 mm in V1–V3 and ST depression does not worsen towards V4–V6. JPP Call for CPD Papers The Journal of Paramedic Practice is seeking articles in various topic areas across the four pillars of paramedic practice for its Continuing and Professional Development platform. Contact the editor to contribute articles in paramedic research, clinical practice, education and leadership management. jpp@markallengroup.com. CPD lthcare Ltd Hea MA 2024 © 50 Vol 16 No 2 • Journal of Paramedic Practice
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Spotlight on Research SpSp tlight on Research lthcare Ltd Hea MA 2024 © Unused peripheral intravenous catheters— is it all in ‘vein’? Peripheral intravenous catheters (PIVCs) are invasive devices that are widely used by paramedics for the administration of intravenous (IV) therapy; however, adverse events including PIVC-associated bloodstream infection and increased on-scene times have been well documented. This study sought to investigate the incidence of paramedic-inserted PIVCs, unused PIVCs, and factors that influenced practice. The study team conducted a retrospective review of electronic patient care records (ePCRs) of all patients attended to by St John Western Australia between 1 January and 31 December 2020. In this ambulance service, the decision to insert a PIVC is guided by the service’s clinical practice guidelines, however, is largely an autonomous decision by the paramedic. All emergency calls and paramedic interhospital transfers were included but nonurgent patients were not. Data on 11 variables were extracted from the ePCRs and categorised into patient, environmental, and paramedic characteristics. Details of the variables are within the article. The team used binomial logistical regression models to evaluate the combined impact of the variables for PIVC insertion and unused PIVCs. Of 187 585 patients, 20.3% had a PIVC inserted. The unused PIVC rate was 44% (n=16 792), with the rates being higher in males (53.2%), and in patients aged 65–84 (50.8%) and 85+ years (50.3%). The highest unused rates proportionally per complaint were in respiratory (74%), cardiac (65%), and neurological conditions (59.8%). Catheters inserted by more recently qualified staff were most likely to be unused (49%, n=3801 and 49.3%, n=2744, respectively) compared to the lowest frequency in those with 10+ years of experience (44.3%, n=6907). Multiple variables were identified for the unnecessary insertion of PIVCs, many of which could be addressed through better education and mentoring of paramedics supported by clearer clinical guidelines. The study is Australian so may be different to the UK; however, the findings should encourage reflection on practice by UK paramedics. Golling E, Barr N, van de Mortel T, Zimmerman PA . Paramedic insertion of peripheral intravenous catheters, unused catheter rates, and influencing factors: a retrospective review. Am J Infect Control. 2023;51(12):1411–1416. https://doi.org/10.1016/j. ajic.2023.05.007 Does the JRCALC age-per-page make paediatric drug calculations child’s play? The potential for drug errors in the prehospital environment is high due to the uncontrolled environment, urgency of intervention and changing status of the patient. When dealing with children, the risk increases because of the need to ensure the correct dose by body weight. JRCALC helpfully provides an age-per-page drug dose reference; however, evidence from America suggests that this is not enough to eradicate dosage errors. Prior to this study, work in Michigan found an overall medication error rate relating to paediatric drug administration by emergency medical services (EMS) to be 34.7%. To reduce these errors, the state of Michigan implemented a paediatric dosing reference that had been developed to address known issues related to weight-based medication dose calculations. The need for mathematical calculations was eliminated as the drug dose was provided in milligrams (mg), along with the volume to be administered in millilitres (ml). Additionally, the reference was colour-coded to match the Broselow-Luten Paediatric Emergency Medicine Tape. To establish the effect of this dosing reference, the authors conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤12 years of age treated by 16 EMS agencies. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the paediatric dosing reference. During the study period, there were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3–48.4]). Notably, 17 drugs were given via the wrong route, including a case of 1:1000 epinephrine administered IV. This study shows that on its own, a drugs dosing reference is not enough. The authors concluded that four key areas were likely contributory factors to medication dosing errors in this population: lack of sufficient paediatric education, limited paediatric encounters, limited medication administrations in the paediatric population, and weight-based dosing. Kazi R, Hoyle JD Jr, Huffman C et al. An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference. Prehosp Emerg Care. 2024;28(1):43–49. https:// doi.org/10.1080/10903127.2022.2162648 Pete Gregory, Associate Dean and Head of the School of Allied Health and Midwifery, University of Wolverhampton, UK. Follow the Journal of Paramedic Practice on Facebook /journalofparamedicpractice CPD Journal of Paramedic Practice • Vol 16 No 2 51

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ECG Case Series

ECG case series for paramedics: February 2024

Charles Bloe, Lead Nurse for Cardiology, Coronary Care Unit, Raigmore Hospital, Inverness, UK. Email: charles.bloe@nhs.scot

This 32-year-man presents with severe central chest pain. He has a long history of significant mental health issues and he smokes in excess of 60 cigarettes a day.

He has been experiencing intermittent chest pain for 2 days. However, this morning, it has become more severe. He describes it as being aching in nature and located across the front of his chest. He rates it as 9 out of 10 in intensity. His arms feel heavy. He is also pale and sweaty.

There is significant family history with both his father and older brother diagnosed with coronary heart disease at a young age.

l The heart rate is approximately 105 beats per minute.

Interpretation of the 12-lead ECG l The most striking abnormality is ST segment depression in leads V1–V4. This man was triaged to the catheterisation laboratory (cath lab) for emergency primary percutaneous coronary intervention (PCI) with a likely diagnosis of acute posterior myocardial infarction (MI). He was found to have an occluded proximal circumflex coronary artery. A single drug-eluting stent was inserted.

An echocardiogram was recorded 48 hours later. It demonstrated akinesis of the posterior wall of the left ventricle. The ejection fraction was estimated at 45% (normal 50–60%)

Figure 1. ECG of a 32-year-old man presenting with severe central chest pain

What does the ECG show? Interpretation of the ECG rhythm l The heart rhythm is regular and in sinus tachycardia

Posterior myocardial Infarction Around one in four patients with an acutely occluded coronary artery do not present with ST elevation. These acute ‘occlusive MI’ (OMI) patients do not meet the standard ST elevation criteria (mm) for primary PCI or coronary thrombolysis, however still need it.

A number of ECG patterns should be recognised as indicative of OMI: l De Winters ECG l Posterior MI l Hyperacute T waves l Aslanger’s ECG.

Posterior MI is the most common ECG pattern of (OMI) without ST elevation, caused by circumflex or right coronary artery occlusion. It is often associated with inferolateral ST/T changes on the ECG. ST depression can be as low as 0.5 mm in V1–V3 and ST depression does not worsen towards V4–V6. JPP

Call for CPD Papers

The Journal of Paramedic Practice is seeking articles in various topic areas across the four pillars of paramedic practice for its Continuing and Professional Development platform. Contact the editor to contribute articles in paramedic research, clinical practice, education and leadership management. jpp@markallengroup.com.

CPD

lthcare Ltd

Hea

MA

2024

©

50

Vol 16 No 2 • Journal of Paramedic Practice

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