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ECG Case Series ECG case series for paramedics: September 2024 Charles Bloe, Coronary Care Unit, NHS Highland, Inverness, UK. Email: charles.bloe@nhs.scot This 94-year-old man lives in a care home. He has had multiple hospital admissions over the last 2 years for general frailty and urinary tract problems. He is known to have prostate cancer that is being medically managed and has a permanent urinary catheter in situ. He had recently been in hospital for treatment of a urinary tract infection (UTI). This morning, he complained of being short of breath at rest. He is normally mobile using a walking frame but today, he is unable to walk. His oxygen saturation was 89% on air. His pulse was also noted to be irregular. The last time this was checked, he had a normal, regular pulse. The staff in the care home decided to call for an ambulance. His vital signs were as follows: l Blood pressure: 98/58 mmHg l Pulse: 86 beats per minute, with a very irregular pulse noted l Respiratory rate: 20 breaths per minute l He was apyrexial l SpO2 on air: 89%. Figure 1. ECG of a 94-year-old man who found himself short of breath at rest. The 12-lead electrocardiogram (ECG) in Figure 1 was recorded: Interpretation of the ECG rhythm l The heart rhythm is regular l The heart rate is approximately 75 beats per minute l The rhythm is very irregular l The heart rate is approximately 80 beats per minute l There are no identifiable P waves l V1 in particular shows sawtooth flutter waves (hint: if you are struggling to see P waves on an ECG, have a look at V1 and V2 where atrial activity is often easier to see) l The QRS complexes are >0.10 seconds in duration, i.e. wide l There is a left bundle branch block (LBBB) configuration (RSR complexes in lead I, aVL, V5 and V6) l The cardiac axis is normal (positive QRS complexes in leads I and aVF). This ECG shows the patient to be in atrial flutter with a variable ventricular response and left bundle branch block configuration. His high sensitivity troponin was moderately elevated. A final diagnosis of new onset atrial flutter and LBBB with subsequent heart failure was made. LBBB causes an abnormal depolarisation. This also results in abnormal repolarisation, which causes a secondary ST/T wave abnormality. A primary ST/T wave abnormality would be caused by myocardial infarction. LBBB results in secondary ST/T wave abnormalities that can mimic ST segment elevation myocardial infarction (STEMI). In this case, there is appropriate ST segment and T wave discordance, i.e. in those leads with a positive QRS complex, the ST segment and T wave are deflected in the opposite direction and vice versa. This is an appropriate finding in LBBB and is a secondary ST/T wave abnormality, i.e. not ischaemia/infarction. JPP Follow the Journal of Paramedic Practice on Facebook /journalofparamedicpractice CPD lthcare Ltd Hea MA 2024 © 358 https://doi.org/10.12968/jpar.2024.0071 Vol 16 No 9 • Journal of Paramedic Practice
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Book Reviews ECGs on the Go: a clinical comfort blanket Vincent Romano, Consultant Paramedic – Education, North West Ambulance Service NHS Trust, Cumbria, UK. Email for correspondence: Vincent.Romano@nwas.nhs.uk While not a book, another valuable resource for paramedics from Class Professional Publishing will be the subject of this quarter’s Book Review. Within this pack, you will find 21 colour-coordinated cards. The colours separate the cards into five different categories related to electrocardiogram (ECG) interpretation:  ST-Segment change  Bundle Branch Blocks  AV Blocks  SVT rhythms  Ventricular rhythms. All the topics covered are ones you would expect to find on a paramedic degree course and that have relevance in the prehospital setting. The cards are described as ‘pocket-sized’, which is accurate if you are talking about the leg pockets in a standard ambulance service uniform. The cards are doublesided. One side illustrates the rhythm with some supporting text to describe certain elements such as where you would find significant changes to identify the rhythm in question. The flip side provides sub-headings and details associated with each specific rhythm. The same format is followed on each card, providing information on each of the following: Poulton S. ECGs on the Go. Class Professional Publishing; 2024.  Description  Recognition  Leads  Signs and symptoms  Significance. The cards are promoted as a quick-reference learning tool or as a knowledge refresh while on the move. This is an accurate description. The detail provided on the card is brief but succinct, and would rely on some previous knowledge of ECGs. The cards are clear in their description of the rhythm and, although the wider information does not go into great depth, it is concise, making it a usable quick-reference guide. I do recall having a homemade set of laminated ECG cards, which I carried around with me for those occasions where an ECG had me baffled—a kind of clinical comfort blanket should it be needed. These are just that. If you are just about to start learning ECG recognition these are ideal. They would however need to accompany wider learning as they do not provide the depth of knowledge to understand the theories of ECG interpretation. They are nonetheless a great quick prompt or refresher. They would serve as an excellent revision aid for any upcoming ECG exams, but I could also see them tattered and torn having been shoved in a trouser pocket and used on the road at the patient’s side. The main test, which I have not yet performed is—would these cards survive a hot wash when you inevitably forget to take them out of your uniform at the end of shift? I am proud to say that my homemade laminated sheets have made it through several wash cycles! JPP lthcare Ltd Hea MA 2024 © Three Key Takeaways  The ECG detail is clear and succinct, making the cards a quick and easy point of reference  Wider ECG knowledge is required; however, the cards will help to build and maintain ECG knowledge  The illustrations of the rhythms are neatly presented with helpful prompts provided to highlight identifying elements unique to that rhythm Journal of Paramedic Practice • Vol 16 No 9 https://doi.org/jpar.2024.0070 359

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ECG Case Series

ECG case series for paramedics: September 2024

Charles Bloe, Coronary Care Unit, NHS Highland, Inverness, UK. Email: charles.bloe@nhs.scot

This 94-year-old man lives in a care home. He has had multiple hospital admissions over the last 2 years for general frailty and urinary tract problems. He is known to have prostate cancer that is being medically managed and has a permanent urinary catheter in situ. He had recently been in hospital for treatment of a urinary tract infection (UTI).

This morning, he complained of being short of breath at rest. He is normally mobile using a walking frame but today, he is unable to walk. His oxygen saturation was 89% on air. His pulse was also noted to be irregular. The last time this was checked, he had a normal, regular pulse. The staff in the care home decided to call for an ambulance.

His vital signs were as follows: l Blood pressure: 98/58 mmHg l Pulse: 86 beats per minute, with a very irregular pulse noted l Respiratory rate: 20 breaths per minute l He was apyrexial l SpO2 on air: 89%.

Figure 1. ECG of a 94-year-old man who found himself short of breath at rest.

The 12-lead electrocardiogram (ECG) in Figure 1 was recorded:

Interpretation of the ECG rhythm l The heart rhythm is regular l The heart rate is approximately 75 beats per minute l The rhythm is very irregular l The heart rate is approximately 80 beats per minute l There are no identifiable P waves l V1 in particular shows sawtooth flutter waves

(hint: if you are struggling to see P waves on an ECG, have a look at V1 and V2 where atrial activity is often easier to see) l The QRS complexes are >0.10 seconds in duration, i.e. wide l There is a left bundle branch block (LBBB)

configuration (RSR complexes in lead I, aVL, V5 and V6) l The cardiac axis is normal (positive QRS

complexes in leads I and aVF). This ECG shows the patient to be in atrial flutter with a variable ventricular response and left bundle branch block configuration. His high sensitivity troponin was moderately elevated.

A final diagnosis of new onset atrial flutter and LBBB with subsequent heart failure was made.

LBBB causes an abnormal depolarisation. This also results in abnormal repolarisation, which causes a secondary ST/T wave abnormality. A primary ST/T wave abnormality would be caused by myocardial infarction. LBBB results in secondary ST/T wave abnormalities that can mimic ST segment elevation myocardial infarction (STEMI). In this case, there is appropriate ST segment and T wave discordance, i.e. in those leads with a positive QRS complex, the ST segment and T wave are deflected in the opposite direction and vice versa. This is an appropriate finding in LBBB and is a secondary ST/T wave abnormality, i.e. not ischaemia/infarction. JPP

Follow the Journal of Paramedic Practice on Facebook /journalofparamedicpractice

CPD

lthcare Ltd

Hea

MA

2024

©

358 https://doi.org/10.12968/jpar.2024.0071

Vol 16 No 9 • Journal of Paramedic Practice

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