EKG Post CPR: Would you activate?

[thegenius]

71 yo man with unknown PMH BIBA undergoing CPR. He has a witnessed syncopal event in a parking lot. First rhythm was VFib and was defibrillated by first responders. He underwent about 30 mins of CPR, received numerous ACLS meds, and I was able to get a pulse. The EKG below was done about 2 minutes post-ROSC.

Do you think this is a STEMI? Would you activate? (note these are two different questions as it's possible to answer "no" and "yes")

I will later discuss what happened.

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[turkeyjerky]

Looks like a spiked helmet sign. Would probably activate though.

 

[Apollyon]

Concur. Would activate. Could just be shocked/post-arrest myocardium, but, more to lose by not activating.

 

[bravotwozero]

Agree with activation, too many indications of that here. As for STEMI, you got the classic tombstoning going on in the anterior and lateral/septal leads, but not really reciprocal changes, so that's a little questionable, but that's for cards to worry about. I'd activate this all day long.

 

[Groove]

1) Do I think it's a STEMI - No idea and it's almost impossible for anyone to say definitively in that kind of scenario post arrest.

2) Would I activate the Cath lab? Yes. You have electrocardiographic criteria for STEMI in a VFIB arrest patient which already raises your pre-test prob for ACS. I'd get an ABG with lactate. If PH >7.2 and lactate <7 then they would probably make a good candidate for diagnostic/interventional cath.

Do they have an AVF? Do we have a K level?

 

[RoyBasch]

I think V-fib arrest with ROSC alone is worth considering emergent cath regardless of the post ROSC EKG. So, in this case in particular with significantly abnormal ST segments with elevation, for sure. Although I agree it isn't necessarily a classic STEMI on EKG (does not have expected reciprocal changes for an anteroseptal STEMI). I wouldn't be completely shocked if the cath did not show a culprit lesion.

 

[Cinclus]

I would consider it a STEMI, and I would activate.

 

[Radetzky]

Yes and yes

 

[AlmostAnMD]

As a dissenting voice, I say no

That EKG shows global ischemia, consistent with an EKG taken from someone who was dead two minutes ago.

Would follow standard post-arrest care, hypothermia, ICU admit and cath when stable. Can start heparin, sure why not

 

[emergentmd]

Activate. If ur wrong they will stilll cath so no loss

 

[GeneralVeers]

If u activate, then u get an unstable ICU patient out of the ED as quickly as possible.

 

[southerndoc]

Either that's post epi, they have diffuse multi-vessel disease (and arrest/hypotension triggered further ischemia), or they have a wraparound LAD lesion (not common, but it gives you diffuse ST elevation like that). Myocarditis can present that like too. So can post-arrest HOCM, Takasobu or however you spell it, and repolarization from extreme blood pressure (i.e., after epi).

It's not fitting with an anatomical pattern except a wraparound LAD. I would discuss with cards, but would repeat in 10 minutes to see if it resolves.

 

[Lexdiamondz]

I would activate

Dude had a v fib arrest with equivocal signs of ischemia on ECG. you have more to lose by not activating

 

[Siggy]

Repeat EKG in 5 minutes or so and call on-call STEMI. If on-call STEMI doesn't answer their cell phone, then activate if no change.

I try to call the on-call STEMI cardiologist prior to activations to give them a chance to stop the activation (especially at night, I feel bad for the rest of the team who might get half way to the hospital, only to have it cancelled), but that's a curtesy. No answer? Activate.

 

[WheezyBaby]

Witnessed event consistent with arrhythmogenic arrest, substantiated by VFib on first rhythm check, with ST elevations post arrest... Just from a medicolegal standpoint I would activate. Even from a patient care standpoint, while I'm suspicious that EKG is not representive of true ACS, I'm not confident enough in that if it were my loved one coming in I would hold off on activating. Bare minimum doing as Siggy mentioned and talking directly to interventionalist. My crystal ball guess is ischemic CHF with CHF-related arrhythmia, activated and taken to cath, found to have nonintervenable triple vessel disease

 

[MechEDoc]

How about split the difference. Call the interventional cardiologist for a stat consult (even if by phone with texting the EKG) and punt the whole thing to cardiology. If it's not ICH or electrolytes, they're going to be managing it anyway...

 

[Kryptocoin]

Not sure I would call this a STEMI. EKG shows diffused STE with no discrete anatomic pattern, likely secondary to global ischemia from his cardiac arrest. I would activate the cath lab though since he meets the criteria for post-ROSC Vfib arrest.

 

[emergentmd]

If you work at a place where Cards will call back quickly, like 5 min, then Call Cards and let them decide. I do this all the time.

If you work at a place where Cards take forever, then call a Stemi.

Bottom line is if you incorrectly activate a STEMI, the cardiologist may be mad at you but so what happens all the time and they get paid for it.

Don't call and it ends up being a Stemi, not only did you provide poor care but then you get to justify why you missed an OBVIOUS STEMI to QA/MEC.

'

 

[GonnaBeADoc2222]

I'm surprised at the attendings stating that would not immediately activate. This is a slam dunk activation all day long.

Activate and let the interventionalist waive you off if need be. Who gives a **** about the team that has to drive in? This is literally what they're paid for.

No one in their right mind will fault you for activating this. Conversely, you potentially will face all sorts of pain if you don't.

 

[dadaddadaBATMAN]

Would request a vbg/abg while I activated for several reasons.

1. If the potassium is 8 I can always call them off after
2. This patient probably is better off at the mothership anyway, though that’s mostly for the sake of creating more veggies at 30 minutes
3. After activation they can always tell you F off. They still might here.
4. Punishment for false positive vs negative as above
5. You want this pt declined by cards before you call micu

 

[RustedFox]

Related:

Someone refresh my memory, but isn't "ROSC after V-fib arrest" (not that this is v-fib; it's not, but that's where my brain is at with this question - I can be wrong) an indication for cath? I remember ONE of my intensivists at ONE of my shops getting into a shouting match with cardiology over this.

 

[bravotwozero]

Related:

Someone refresh my memory, but isn't "ROSC after V-fib arrest" (not that this is v-fib; it's not, but that's where my brain is at with this question - I can be wrong) an indication for cath? I remember ONE of my intensivists at ONE of my shops getting into a shouting match with cardiology over this.

Correct. EM newsletter had an article on this a while back

 

[turkeyjerky]

Related:

Someone refresh my memory, but isn't "ROSC after V-fib arrest" (not that this is v-fib; it's not, but that's where my brain is at with this question - I can be wrong) an indication for cath? I remember ONE of my intensivists at ONE of my shops getting into a shouting match with cardiology over this.

Nah—that was so 5 years ago. (And based on observational data). RCT from 2019 showed no benefit to routine immediate angiography.

 

[Mount Asclepius]

I think it looks more like global ischemia than a STEMI from a culprit vessel. I wouldn’t activate. I would though immediately discuss with an interventionalist as can usually do that within 5 minutes at my facility. I’d let them make the decision on whether to cath immediately or not.

Does anyone know the history of ED cath lab activation? We don’t unilaterally activate the OR for an ex lap or IR for thrombectomy. Sure, everyone would agree with us activating the cath lab for a classic story of CP in someone with risk factors and ST elevation on EKG in an anatomical pattern with reciprocal changes, the OR for an isolated GSW to the belly that is FAST positive, or IR for a clear ischemic CVA presentation receiving tPA with proximal clot on CTA. There are plenty of other grey area cases where we defer to specialists even if we don’t agree as they are the ones performing the procedure or surgery.

Also, for those of you in rural locations further than 120 minutes from a cath lab, would you push TNKase based upon that story and EKG? Makes it a little more interesting if you have to provide the definitive treatment, rather than debating if you would activate the cath lab or immediately call Cardiology. Either way Cardiology will be involved with this case at larger facilities and be the ones deciding whether or not to emergently cath.

 

[southerndoc]

Nah—that was so 5 years ago. (And based on observational data). RCT from 2019 showed no benefit to routine immediate angiography.

For those curious, I think he's referring to the Lemkes study from NEJM.

Post-arrest with STEMI is a class I recommendation for immediate intervention. nSTEMI doesn't show any benefit. It's hard to say activate the cath lab on patients with only a 1/4-1/3 chance of having an acute lesion causing their arrest.

 

[aafisahar]

put it on interventionalist, imo, post ROSC cath is almost always helpful even if no culprit lesion.

conversely, if this patient has another ventricular arrhythmia or dies of pump failure 3 days later, medicolegal will be all over the ED physician.

 

[southerndoc]

put it on interventionalist, imo, post ROSC cath is almost always helpful even if no culprit lesion.

conversely, if this patient has another ventricular arrhythmia or dies of pump failure 3 days later, medicolegal will be all over the ED physician.

Most interventionalists are concerned about reporting their mortality numbers. If they take someone to cath, they have an anoxic brain injury, and the family later withdraws care, then it's a reported mortality even if no intervention was done. At least that's my understanding. I'm not an interventionalist so I'm not entirely up on the nuances of their mortality data.

 

[Pigg-O-Stat]

I don't know if it's a real STEMI, but I would definitely activate.

 

[turkeyjerky]

For those curious, I think he's referring to the Lemkes study from NEJM.

Post-arrest with STEMI is a class I recommendation for immediate intervention. nSTEMI doesn't show any benefit. It's hard to say activate the cath lab on patients with only a 1/4-1/3 chance of having an acute lesion causing their arrest.

View attachment 340355

Right. And I cant stand it when cardiology puts up a fuss about taking a post-ROSC STEMI (ie not this patient) to the cath lab.


put it on interventionalist, imo, post ROSC cath
almost always helpful even if no culprit lesion.

People say that, but the best evidence available does not support this notion.

 

[Apollyon]

Nah—that was so 5 years ago. (And based on observational data). RCT from 2019 showed no benefit to routine immediate angiography.

Right. And I cant stand it when cardiology puts up a fuss about taking a post-ROSC STEMI (ie not this patient) to the cath lab.


put it on interventionalist, imo, post ROSC cath
almost always helpful even if no culprit lesion.

People say that, but the best evidence available does not support this notion.

It sounds like you have an agenda, or, maybe you got burned in the past.

 

[thegenius]

1) Do I think it's a STEMI - No idea and it's almost impossible for anyone to say definitively in that kind of scenario post arrest.

2) Would I activate the Cath lab? Yes. You have electrocardiographic criteria for STEMI in a VFIB arrest patient which already raises your pre-test prob for ACS. I'd get an ABG with lactate. If PH >7.2 and lactate <7 then they would probably make a good candidate for diagnostic/interventional cath.

Do they have an AVF? Do we have a K level?

Where in the guidelines for PCI does it suggest that a low pH or low lactate are relative contraindications for going to cath post ROSC? I'm just curious.

 

[thegenius]

Well I'm happy at least that many of my esteemed ER docs on this forum don't all unilaterally agree. Makes me feel better.

I felt this was a STEMI. And if it's not a STEMI it's an OMI (occlusive myocardial infarction). I know there is no evidence surrounding OMI and ROSC that has never been studied. Anyway I thought it was a STEMI. So I activated. I spoke to the cards interventionalist and he was a little concerned that this guy wasn't going to live anyway...and asked me to get a lactate and an ABG.

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

 

[Radetzky]

The lemkes study is BS. They powered for a 15% mortality difference. This means that cath could save 10% mortality and it wouldn’t have been picked up by this study. The problem was the low incidence of IHD in the cohort they cathed, but history can help select the pts that are more likely to have IHD despite no STE. They also excluded any patients who were shocked (bp<90)

 

[WheezyBaby]

Well I'm happy at least that many of my esteemed ER docs on this forum don't all unilaterally agree. Makes me feel better.

I felt this was a STEMI. And if it's not a STEMI it's an OMI (occlusive myocardial infarction). I know there is no evidence surrounding OMI and ROSC that has never been studied. Anyway I thought it was a STEMI. So I activated. I spoke to the cards interventionalist and he was a little concerned that this guy wasn't going to live anyway...and asked me to get a lactate and an ABG.

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

All the balls to hard call it j point, none of them to hold off on cathing. Seems about right

 

[Groove]

Where in the guidelines for PCI does it suggest that a low pH or low lactate are relative contraindications for going to cath post ROSC? I'm just curious.

Severe metabolic acidosis after out-of-hospital cardiac arrest: risk factors and association with outcome

Metabolic acidosis is frequently observed as a consequence of global ischemia–reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assess the impact of metabolic acidosis on outcome after OHCA.We included ...

www.ncbi.nlm.nih.gov

Cards has kind of latched onto this in the past few years and although it's not a hard and fast rule, they typically like to have the ABG results prior to making a decision. I've had them delay or cancel any "Hail Mary" PCI attempts for any OHCA pt's with severe acidosis or lactatemias.

I still think you made the right decision and someone having the balls to tell you that it "wasn't a STEMI" after they just confirmed and diagnosed a 100% "OCCLUDED CORONARY VESSEL" is the definition of asinine.

 

[southerndoc]

Where in the guidelines for PCI does it suggest that a low pH or low lactate are relative contraindications for going to cath post ROSC? I'm just curious.

I'll see if I can dig up the reference later. There is some evidence to support pH <7.2 or lactate >4 (maybe it was 7, it's been a while since I reviewed) being highly suggestive of anoxic brain injury and poor neuro outcome.

 

[southerndoc]

Severe metabolic acidosis after out-of-hospital cardiac arrest: risk factors and association with outcome

Metabolic acidosis is frequently observed as a consequence of global ischemia–reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assess the impact of metabolic acidosis on outcome after OHCA.We included ...

www.ncbi.nlm.nih.gov

Cards has kind of latched onto this in the past few years and although it's not a hard and fast rule, they typically like to have the ABG results prior to making a decision. I've had them delay or cancel any "Hail Mary" PCI attempts for any OHCA pt's with severe acidosis or lactatemias.

There's another one out there as well.

 

[southerndoc]

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

Was it a wraparound LAD lesion? Would be interested if they stented or if he had collaterals. Regardless of activating or not, it is certainly deserving of sending the EKG to the interventionalist.

 

[Siggy]

I'm surprised at the attendings stating that would not immediately activate. This is a slam dunk activation all day long.

Activate and let the interventionalist waive you off if need be. Who gives a **** about the team that has to drive in? This is literally what they're paid for.

No one in their right mind will fault you for activating this. Conversely, you potentially will face all sorts of pain if you don't.

...because it will take me less than 2 minutes to call on call cards and I don't subscribe to the toxic thought process of "if I'm up, everyone is up." People gotta sleep. Now I agree, I'm not going to go through a call center and wait 20 minutes for a call back before making a decision. Either on-call answers their cell or the lab gets activated. You're going to have to talk with cards before they get into their car anyways, so you're not even delaying the case to begin with.

 

[emergentmd]

If you didn't call it, and guy was cathed the next day with 100%, you would have been crucified by the Cardiologist who would clearly stated it was an obvious STEMI.

 

[e30ftw]

I would activate 100% of the time in that situation with the foreknowledge that emergent cath is unlikely to benefit this elderly patient with a 30m downtime who is likely neurologically compromised, and would be fine if cards did not want to take pt to cath lab (to pad their mortality numbers..) however the conversation is going in the chart that I am advising cardiology of a patient post ROSC w acute MI in need of emergent cath.

Cardiology knows it's a STEMI but also that it's likely to die on the table or afterwards, so asks for lactate/abg so meanwhile guy codes again in ED and pronounced.. I'm just sayin.. I wouldn't really care either way if they took him as long as I spoke to someone and put their name on the chart.

 

[GassYous]

J point elevation lmao your hospital needs to fire those jokers and get some real doctors

 

[Zebra Hunter]

All the balls to hard call it j point, none of them to hold off on cathing. Seems about right

Stating "This is just J point elevation" is indicative of someone that has no clue what they are talking about, as that statement makes absolutely no sense. It's always terrifying when cardiologists have a poor understanding of interpreting ECGs, especially ischemic ECGs. Every STEMI has "J point elevation". I'm assuming they meant benign early repolarization which is absolute nonsense in a 70 year old. Sounds like someone that was upset about being woken up and wanted to throw out a jab at the person that woke him up prior to doing what he is paid to do.

No ER doc in the world (including Steve Smith or Amal Mattu) should hold off activating the cath lab on this ECG s/p v-fib arrest. Reasonable to get a VBG to look at the ionized calcium (not worried about potassium in this case as this is clearly not hyperkalemia), but I'm activating before that and can call off if there is presence of severe hypercalcemia. 70 yos don't have benign early repol. This patient has terminal QRS distortions in V2 and V3, presence of Q-waves, contiguous ST elevations, and is s/p v-fib arrest. 30% of Anterior STEMIs have no reciprocal changes (a fact I have to explain to my cardiologists all the time). This does look like a Type III LAD lesion given the slight elevation in inferior leads too, but who knows immediately s/p arrest.

Sounds like OP did a great job.

 

[Zebra Hunter]

I think it looks more like global ischemia than a STEMI from a culprit vessel. I wouldn’t activate. I would though immediately discuss with an interventionalist as can usually do that within 5 minutes at my facility. I’d let them make the decision on whether to cath immediately or not.

Does anyone know the history of ED cath lab activation? We don’t unilaterally activate the OR for an ex lap or IR for thrombectomy. Sure, everyone would agree with us activating the cath lab for a classic story of CP in someone with risk factors and ST elevation on EKG in an anatomical pattern with reciprocal changes, the OR for an isolated GSW to the belly that is FAST positive, or IR for a clear ischemic CVA presentation receiving tPA with proximal clot on CTA. There are plenty of other grey area cases where we defer to specialists even if we don’t agree as they are the ones performing the procedure or surgery.

Also, for those of you in rural locations further than 120 minutes from a cath lab, would you push TNKase based upon that story and EKG? Makes it a little more interesting if you have to provide the definitive treatment, rather than debating if you would activate the cath lab or immediately call Cardiology. Either way Cardiology will be involved with this case at larger facilities and be the ones deciding whether or not to emergently cath.

Yes, if I was in my rural ER, I would absolutely push lytics prior to transfer for PCI. This is a slam dunk STEMI.

 

[dadaddadaBATMAN]

Stating "This is just J point elevation" is indicative of someone that has no clue what they are talking about, as that statement makes absolutely no sense. It's always terrifying when cardiologists have a poor understanding of interpreting ECGs, especially ischemic ECGs. Every STEMI has "J point elevation". I'm assuming they meant benign early repolarization which is absolute nonsense in a 70 year old. Sounds like someone that was upset about being woken up and wanted to throw out a jab at the person that woke him up prior to doing what he is paid to do.

No ER doc in the world (including Steve Smith or Amal Mattu) should hold off activating the cath lab on this ECG s/p v-fib arrest. Reasonable to get a VBG to look at the ionized calcium (not worried about potassium in this case as this is clearly not hyperkalemia), but I'm activating before that and can call off if there is presence of severe hypercalcemia. 70 yos don't have benign early repol. This patient has terminal QRS distortions in V2 and V3, presence of Q-waves, contiguous ST elevations, and is s/p v-fib arrest. 30% of Anterior STEMIs have no reciprocal changes (a fact I have to explain to my cardiologists all the time). This does look like a Type III LAD lesion given the slight elevation in inferior leads too, but who knows immediately s/p arrest.

Sounds like OP did a great job.

I am curious what makes you say this is “clearly not hyperkalemia” beyond the fact that they are no longer dead with no treatment documented, which could easily be an omission of “we gave bicarb and calcium and got a pulse.” I routinely give calcium, glucose +/- narcan for unknown cardiac arrest, +\- bicarbonate which many docs do.

There’s not much in the way of p waves which may have flattened, qrs is wide, and the ekg is generally odd looking. I’ve seen a number of cases where that translated to a k of 7+.

Beyond that, I find hyperkalemia on the ekg is often like pe from the history, in that about 15% of the cases I find feel completely unfair (no way to have known, just some slow bizarre thing).

I agree with the remainder of your statement.

 

[Zebra Hunter]

I am curious what makes you say this is “clearly not hyperkalemia” beyond the fact that they are no longer dead with no treatment documented, which could easily be an omission of “we gave bicarb and calcium and got a pulse.” I routinely give calcium, glucose +/- narcan for unknown cardiac arrest, +\- bicarbonate which many docs do.

There’s not much in the way of p waves which may have flattened, qrs is wide, and the ekg is generally odd looking. I’ve seen a number of cases where that translated to a k of 7+.

Beyond that, I find hyperkalemia on the ekg is often like pe from the history, in that about 15% of the cases I find feel completely unfair (no way to have known, just some slow bizarre thing).

I agree with the remainder of your statement.

S/p arrest hyperkalemia cases almost never have an ECG that lacks all evidence of hyperkalemia unless it is multifactorial. Lack of terminal R-wave in aVR and V1, lack of right axis deviation, lack of bradycardia, lack of sinusoidal pattern, lack of peaked T-waves, lack of QRS prolongation. If your post arrest patient is lacking all of that, you can rest assured that they probably didn't arrest from severe hyperkalemia.

 

[lucid_leprechaun]

Well I'm happy at least that many of my esteemed ER docs on this forum don't all unilaterally agree. Makes me feel better.

I felt this was a STEMI. And if it's not a STEMI it's an OMI (occlusive myocardial infarction). I know there is no evidence surrounding OMI and ROSC that has never been studied. Anyway I thought it was a STEMI. So I activated. I spoke to the cards interventionalist and he was a little concerned that this guy wasn't going to live anyway...and asked me to get a lactate and an ABG.

I was a little peeved when the cardiology RN who often comes to the STEMI activations looked at the EKG and said "this isn't a STEMI. This is j-point elevation." I was most pissed about that.

Anyway...he was taken to cath within about 30 minutes and he had a 100% occluded mLAD and multivessel disease. I spoke briefly to the cardiologist during the cath and he said "this isn't a STEMI, it is j-point elevation and there is no reciprocal depression." I like this cardiologist and work well with him, so I nodded and left. I don't agree...but that is OK. Anyway I believe the patient was stented. He's been in the hospital for 5-7 days with severe anoxic brain injury and I think they are going to make him comfort care.

Good call. Sounds like they didn’t know what they were talking about re EKG, LAD occlusion a often don’t have reciprocal changes. It seems like there is so much variability in when a cardiologist will take post ROSC patients, it varies so much depending who is on. Some I can show an ECHO/EKG and they will take them regardless of recurrent Vfib, others won’t take if numbers look bad. We have some cardiologists here who will take to lab, put in bilateral impellas and cath while in Vfib/tach.

 

[Jabbed]

Counter-points:

1. EKG shows an accelerated idioventricular rhythm with RBBB morphology and diffuse STE without reciprocal depression. I would argue that is only diagnostic of reperfusion arrhythmia. If I were going on ECG criteria alone I would repeat one every 5-10 minutes until I got something diagnostic.

2. Several people have made points that the pre-test probability of OMI is so high that they should go to cath lab anyway. This, I think, is the key to getting your patient into the cath lab. If you start dissecting gray-zone EKG criteria with your interventionalist you seldom get them to agree with you. Slam-dunk non-ECG criteria for cathing unstable patients in my neck of the woods include: VT storm, young patient with VT/VF arrest, paced patients with hx of ACS.

3. (Not in reference to this case) I would argue that emergently taking every post-code to the cath lab is bad practice. Post-cardiac arrest care is incredibly delicate. Sending your patient to the cath lab is essentially putting all your eggs in the ACS basket and delaying any meaningful level of critical care by at least 45 minutes.

 

[thegenius]

Was it a wraparound LAD lesion? Would be interested if they stented or if he had collaterals. Regardless of activating or not, it is certainly deserving of sending the EKG to the interventionalist.

A summary of the coronary anatomy: left main disease free, gives rise to a type 2 LAD which is 100% occluded at the mid-level. There are 2 lesions upstream that are 90% which are hazy and were reduced by balloon angioplasty. The LAD was 100% occluded reduced to 15% post balloon angioplasty. Circumflex was nondominant has 50%-60% stenosis. RCA dominant, long tubular stenosis of 90-95%, 70% distal RCA stenosis.

So he was ballooned angioplastied, but not stented. Sorry I was incorrect at first

 

[Zebra Hunter]

Counter-points:

1. EKG shows an accelerated idioventricular rhythm with RBBB morphology and diffuse STE without reciprocal depression. I would argue that is only diagnostic of reperfusion arrhythmia. If I were going on ECG criteria alone I would repeat one every 5-10 minutes until I got something diagnostic.

2. Several people have made points that the pre-test probability of OMI is so high that they should go to cath lab anyway. This, I think, is the key to getting your patient into the cath lab. If you start dissecting gray-zone EKG criteria with your interventionalist you seldom get them to agree with you. Slam-dunk non-ECG criteria for cathing unstable patients in my neck of the woods include: VT storm, young patient with VT/VF arrest, paced patients with hx of ACS.

3. (Not in reference to this case) I would argue that emergently taking every post-code to the cath lab is bad practice. Post-cardiac arrest care is incredibly delicate. Sending your patient to the cath lab is essentially putting all your eggs in the ACS basket and delaying any meaningful level of critical care by at least 45 minutes.

Counter-counter point regarding point 1: (I know you would have activated this case, so this debate is purely academic) Reperfusion arrhythmia implies there is evidence of reperfusion or at least an absence of active ischemia, which I see no evidence of. To imply reperfusion means there is a lack of ST elevations along w/ AIVR (which I am not 100% convinced of given some irregularity in the rhythm) and/or evidence of classic reperfusion T-waves (biphasic or inverted T-waves) along w/ a lack of ST elevation. If you are implying this ECG represents partial reperfusion, then you must also accept that ST elevations are still present which means there is still active transmural ischemia and is a clear indication for cath lab activation. Also, don't rely on reciprocal changes in anterior MIs, you will get burned.

If you have a patient presenting even with a decent history for ACS (not talking SOB or weakness, although I would probably activate even in those cases with this ECG), you need to activate this ECG. ST elevations with terminal QRS distortion in V2 and V3 is essentially pathognomonic for STEMI. When this is present, don't bother repeating ECGs, just activate. We as lowly ER doctors should not be burdening ourselves with the liability of caring for someone with this ECG alone. It's okay to be wrong every once and a while. Our job isn't to have a hit rate of 100% on cath lab activations. That shouldn't excuse being over aggressive with activation with cases that are clearly not ACS, or post arrest cases w/o STEMI, but we shouldn't be afraid to be wrong.