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ECG Case Series ECG case series for paramedics: October 2024 Charles Bloe, Coronary Care Unit, NHS Highland, Inverness, UK. Email: charles.bloe@nhs.scot A32-year-old lady presents with palpitations. She normally keeps fit and well and regularly cycles long distances. This morning, while having a shower, she felt her heart racing and thumping hard within her chest. This caused her to panic. She called for her husband and by now was quite distressed. After several minutes, the symptoms stopped abruptly and she immediately felt better. She called her GP and was seen that afternoon. Her vital signs were as follows: l Blood pressure: 148/92 mmHg l Pulse: 72 beats per minute l Respiratory rate: 14 breaths per minute l Temperature: 36.9oC l SpO2 on air: 98%. The 12-lead ECG in Figure 1 was recorded and she was subsequently referred to the cardiology outpatients unit. Figure 1. ECG of a 32-year-old woman who experienced palpitations while in the shower Interpretation of the ECG rhythm l The heart rhythm is regular l The heart rate is approximately 75 beats per minute. There are however are a number of abnormalities with this 12-lead ECG: l The P-R interval is < 120 milliseconds. i.e. it is short. l The QRS complexes are >110 milliseconds, which is wider than normal l There is a slurring of the upstroke of the R waves, particularly in leads I, aVL, V4, V5 and V6. This is called a delta wave. These features are consistent with Wolff– Parkinson White (WPW) syndrome. In a normal heart, electrical impulses from the atria pass through the atrioventricular (AV) node. This structure is located near the coronary sinus. Electrical impulses from the atria are momentarily paused in the AV node before passing to the ventricles to permit ventricular filling. WPW is a congenital disease where an additional accessory pathway called the bundle of Kent exists between the atria and ventricles. Electrical conduction through this accessory pathway is faster than through the AV node, resulting in a shortened PR interval. There is early activation of the ventricle as impulses bypass the AV node. This pre-excitation of the ventricle results in a delta wave at the beginning of the QRS complex. Patients with WPW are at risk of developing supraventricular tachycardias. Electrical impulses may be conducted through the normal AV node and then up the accessory pathway from the ventricles to the atria, causing a re-entry circus movement. Dangerously rapid ventricular rates may occur in the presence of atrial fibrillation or atrial flutter. Because the accessory pathway does not delay conduction as the AV node does, the rapid atrial impulses may be conducted to the ventricles, resulting in dangerous tachycardias. JPP Follow the Journal of Paramedic Practice on Facebook /journalofparamedicpractice CPD lthcare Ltd Hea MA 2024 © 402 https://doi.org/10.12968/jpar.2024.0083 Vol 16 No 10 • Journal of Paramedic Practice
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Spotlight on Research SpSp tlight on Research Managing women’s emergencies as a man – what do we actually know? Paramedics and other emergency medical services (EMS) professionals routinely manage patients from hugely diverse backgrounds with wide-ranging conditions. Normally, the gender of the attending health professional is of little relevance, but where a female patient is experiencing a condition that may be both private and intimate, barriers may exist that impact the care of the patient and the experience of the professional. This paper from Iran focuses on the lived experiences of male emergency medical technicians (EMTs) when managing what the authors refer to as ‘women’s emergencies’. The authors did not specify exactly what was meant by ‘women’s emergencies’, but it is inferred that this relates to conditions only ever experienced by women, such as obstetric and gynaecological emergencies. The qualitative study used in-depth, semi-structured interviews to explore the experience of EMS technicians facing female or women’s emergencies in Iran. The study included 15 participants with a mean age of 35 years and a mean work experience of 10.54 years. The authors then undertook thematic analysis and identified the following themes: cultural-social factors, organisational factors, human resources factors and administrative-legal factors. Although carried out in Iran, some of the issues may be familiar to those working in the UK. Some examples include verbal communication issues due to language or dialect issues; patients’ suspicion of health professionals; religious prejudices; ethnic traditions; distress of the health professional, patient and companions; lack of medicines and related equipment; and insufficient theoretical training. A number of quotes are given in the article to support the themes developed and they make for interesting reading. The study findings have some synergy with the UK but the main reason for selecting the paper was to highlight how little research we currently have of the lived experiences of women and EMS staff in the UK. We could, and should, do better! Marzaleh MA, Peyravi M, Ahmadi E, Mahmoodi H, Shakibkhah I, Armin H. Lived experiences of Iranian prehospital emergency technicians in facing women’s emergencies: a phenomenological study. BMC Emerg Med. 2024;24(1):98. https://doi.org/10.1186/s12873-024-01019-5 How accurate is our estimate of time when delivering emergency care? Endotracheal intubation has fallen out of favour in most areas of UK paramedic practice, so it may seem strange to include a paper on this topic within this section. However, this paper is about more than endotracheal intubation; it is about situational awareness and time distortion in emergency procedures. This gives it utility as we need to understand whether or not our perception of how long an emergency procedure takes is comparable with reality. This American study included patients >18 years old who underwent endotracheal intubation by paramedics using video laryngoscopy. Total laryngoscopy time (TLT) was defined as time elapsed from the laryngoscope blade entering the mouth until the endotracheal tube balloon passed the vocal cords. The researchers used the video recording of the intubation to calculate the TLT and were then able to compare this with the estimated TLT provided by the paramedic on an airway form that was routinely completed following the intubation attempt. The primary outcome was the difference between actual and perceived total laryngoscopy time. The primary measure showed that the mean actual TLT was 50.0 seconds (s) (95% confidence interval [CI] 43.7–56.3) compared with the mean perceived TLT of 27.8 s (95% CI 24.7–31.0). The median difference between actual and perceived time was 18 s (interquartile range 6–30). The clinical implications of this underestimation of time could be catastrophic for the patient, and the authors suggest that the current focus on first-time pass-rates as the measure of success should be amended to one that emphasises overall time awareness with a low threshold for recognising and aborting a prolonged intubation attempt. Is this the same for other time-critical interventions? We do not have these answers yet but, at the very least, this should encourage us to question our own perceptions of how long emergency interventions truly take. Shou D, Levy M, Troncoso R, Scharf B, Margolis A, Garfinkel E. Perceived versus actual time of prehospital intubation by paramedics. West J Emerg Med. 2024;25(4): 645–650. https://doi.org/10.5811/westjem.18400 lthcare Ltd Hea MA 2024 © Call for Papers Email your ideas to the Editor at jpp@markallengroup.com CPD Journal of Paramedic Practice • Vol 16 No 10 https://doi.org/10.12968/jpar.2024.0075 403

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ECG Case Series

ECG case series for paramedics: October 2024

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

A32-year-old lady presents with palpitations. She normally keeps fit and well and regularly cycles long distances. This morning, while having a shower, she felt her heart racing and thumping hard within her chest. This caused her to panic. She called for her husband and by now was quite distressed. After several minutes, the symptoms stopped abruptly and she immediately felt better. She called her GP and was seen that afternoon.

Her vital signs were as follows: l Blood pressure: 148/92 mmHg l Pulse: 72 beats per minute l Respiratory rate: 14 breaths per minute l Temperature: 36.9oC l SpO2 on air: 98%.

The 12-lead ECG in Figure 1 was recorded and she was subsequently referred to the cardiology outpatients unit.

Figure 1. ECG of a 32-year-old woman who experienced palpitations while in the shower

Interpretation of the ECG rhythm l The heart rhythm is regular l The heart rate is approximately 75 beats per minute.

There are however are a number of abnormalities with this 12-lead ECG: l The P-R interval is < 120 milliseconds. i.e. it is short. l The QRS complexes are >110 milliseconds,

which is wider than normal l There is a slurring of the upstroke of the

R waves, particularly in leads I, aVL, V4, V5 and V6. This is called a delta wave. These features are consistent with Wolff– Parkinson White (WPW) syndrome.

In a normal heart, electrical impulses from the atria pass through the atrioventricular (AV) node. This structure is located near the coronary sinus. Electrical impulses from the atria are momentarily paused in the AV node before passing to the ventricles to permit ventricular filling. WPW is a congenital disease where an additional accessory pathway called the bundle of Kent exists between the atria and ventricles. Electrical conduction through this accessory pathway is faster than through the AV node, resulting in a shortened PR interval. There is early activation of the ventricle as impulses bypass the AV node. This pre-excitation of the ventricle results in a delta wave at the beginning of the QRS complex.

Patients with WPW are at risk of developing supraventricular tachycardias. Electrical impulses may be conducted through the normal AV node and then up the accessory pathway from the ventricles to the atria, causing a re-entry circus movement.

Dangerously rapid ventricular rates may occur in the presence of atrial fibrillation or atrial flutter. Because the accessory pathway does not delay conduction as the AV node does, the rapid atrial impulses may be conducted to the ventricles, resulting in dangerous tachycardias. JPP

Follow the Journal of Paramedic Practice on Facebook /journalofparamedicpractice

CPD

lthcare Ltd

Hea

MA

2024

©

402 https://doi.org/10.12968/jpar.2024.0083

Vol 16 No 10 • Journal of Paramedic Practice

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