Would you get a 12 lead ekg on this pt?

[Arch Guillotti]

72 year old male for upper endoscopy.
Hx of CVA/TIA 3 years ago, no residual deficits, hx of htn as well.
The pt. states that he has an "irregular heartbeat" and that he has been advised multiple times to "get a pacemaker" but he refused to, because he didn't feel like it. He states that he had a cardiac catheterization "in my 30's" for an unknown reason. Functional capacity is good. Rhythm strip is attached (sorry for the quality). Do you get a 12 lead ekg?

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[ReefTiger]

Yes. Why wouldn't you?

 

[ssmallz]

Given the ease of getting a 12 lead and the low cost, I don't see why you wouldn't. The real question is why wouldn't you get an EKG on a pt w/this type of hx and a scary looking rythem strip

 

[Noyac]

Yes assuming he hasn't had one recently enough.

 

[mille125]

72 year old male for upper endoscopy.
Hx of CVA/TIA 3 years ago, no residual deficits, hx of htn as well.
The pt. states that he has an "irregular heartbeat" and that he has been advised multiple times to "get a pacemaker" but he refused to, because he didn't feel like it. He states that he had a cardiac catheterization "in my 30's" for an unknown reason. Functional capacity is good. Rhythm strip is attached (sorry for the quality). Do you get a 12 lead ekg?

better yet, tell them to do it under local so that you can bow out of the equation..

 

[huktonfonix]

yes, because this may influence my management. for example, am I going to want to place pacer/defib pads on this guy, will I want a chemical pacer handy, etc.....

 

[Medicine2009]

Definitly the answer is yes,

 

[isoman2000]

yes, I mean why not? It may not tell you anything but it can cover your ass if things go bad.

 

[jwk]

yes, because this may influence my management. for example, am I going to want to place pacer/defib pads on this guy, will I want a chemical pacer handy, etc.....

MD answer

yes, I mean why not? It may not tell you anything but it can cover your ass if things go bad.

CRNA answer

 

[jwk]

72 year old male for upper endoscopy.
Hx of CVA/TIA 3 years ago, no residual deficits, hx of htn as well.
The pt. states that he has an "irregular heartbeat" and that he has been advised multiple times to "get a pacemaker" but he refused to, because he didn't feel like it. He states that he had a cardiac catheterization "in my 30's" for an unknown reason. Functional capacity is good. Rhythm strip is attached (sorry for the quality). Do you get a 12 lead ekg?

Just for the heck of it, I'll play devil's advocate and say NO for the sake of argument. (although truth be told, we probably would do one )

What will the 12-lead tell you that you don't already know? You already know he has a slow irregular rhythm, that he's been getting along fine without a pacemaker, and that his functional capacity is good. (you didn't indicated whether he plays tennis or golf daily). This is a 3-5 minute case in my facility, and a 72 year old for anything is going to get cautious, slow administration of propofol (which is all I would use for this).

As huktonfonix indicated, a 12-lead might influence your management, but that rhythm strip alone would probably influence it in just the same way.

 

[urge]

I get an ekg on everyone over 50.


The ekg you showed calls my attention more on his repolarization pattern than on his irregular sinus rhythm. I wonder if he is at risk of ventricular dysrhythmias

 

[militarymd]

NO.

what the fu ck for?

So you can tell him that he has an irregular heart beat BEFORE you give him his propofol????

And don't give me the "something could happen"...

He could get hit by a car on his way home..

 

[jwk]

I get an ekg on everyone over 50.

We have no pre-set requirements for anything on MAC cases in GI.

 

[isoman2000]

It may not tell you anything the obvious corollary is that it may, and then you would change your plan, but odds are it will not given the history inn the scenario, I am sorry that I do not state the obvious.

 

[Noyac]

NO.

what the fu ck for?

So you can tell him that he has an irregular heart beat BEFORE you give him his propofol????

And don't give me the "something could happen"...

He could get hit by a car on his way home..

We all know that the ECG won't change your plan.
We also know that most would get an ECG b/4 any surgery if one has not been done in the past 6-12 months.
We know it won't change the outcome one bit.

But my reasoning is that since he seems resistant to having his heart evaluated this is an opportunity to do this. I would not begin to state that it would have any bering on my anesthetic. If I'm going to put external pacer pads on him I can see the need for them once I hook up the monitors.

I think this is an effective use of the ECG protocol as opposed to everyone over 50 gets one.

 

[militarymd]

We all know that the ECG won't change your plan.
We also know that most would get an ECG b/4 any surgery if one has not been done in the past 6-12 months.
We know it won't change the outcome one bit.

But my reasoning is that since he seems resistant to having his heart evaluated this is an opportunity to do this. I would not begin to state that it would have any bering on my anesthetic. If I'm going to put external pacer pads on him I can see the need for them once I hook up the monitors.

I think this is an effective use of the ECG protocol as opposed to everyone over 50 gets one.

u just said it right there....the guy doesn't want anything done for his heart....
He's been told already that he needs a CIRD, and he doesn't want one.

As for a work up....a 12 lead is not a work up for some one who needs a IRD.

The workup is done in the EP lab.......or with a holter monitor which is worn for days at a time....not a 12 lead that captures literally 10 seconds of his rhythm.

 

[9french]

72 year old male for upper endoscopy.
Hx of CVA/TIA 3 years ago, no residual deficits, hx of htn as well.
The pt. states that he has an "irregular heartbeat" and that he has been advised multiple times to "get a pacemaker" but he refused to, because he didn't feel like it. He states that he had a cardiac catheterization "in my 30's" for an unknown reason. Functional capacity is good. Rhythm strip is attached (sorry for the quality). Do you get a 12 lead ekg?

Get the EKG. Although it is likely some weird repolarization thing going on, there is ST depression. I would want to make sure that there is not clear electrocardiographic evidence of ischemia.

Before someone says that there is nothing in the history to suggest ischemia, I am not so sure. Why is he having an EGD? Is it for "GERD sx", i.e. epigastric pain which can be an anginal equivalent? Does he have a h/o a GI bleed? Could he be profoundly anemic? That with the knowledge that he likely has some sort of atherosclerotic vascular dz secondary to his h/o stroke, as well as his rhythm strip make an EKG very prudent.

 

[cleansocks]

(just a 4th year student) Doesn't the fact that people have advised him to get a pacemaker suggest that he has a dangerous rhythm that is perhaps not elucidated by the given rhythm strip? For example such a bigeminal pattern could be caused by a mobitz II block; could anesthetic agents worsen such a rhythm? Also, he's 72 and about to undergo an unpleasant procedure - I might be concerned that the ST depression we see in whatever lead that happens to be represents an inverse change from ST elevation elsewhere and there could be a small but real possibility that his anxiety is causing a catecholamine surge to the extent that he is suffering from some sort of silent acute event. Finally if he's got HTN and a h/o cardiac cath presumably from coronary disease when he was younger and now has this strange rhythm, I would be concerned about a cardiomyopathy (ie eccentric or concentric both possible based on the history) that may show up on an EKG as LVH or PRWP. So with my current level of knowledge I think if I saw this history I'd get an EKG.

 

[militarymd]

(just a 4th year student) Doesn't the fact that people have advised him to get a pacemaker suggest that he has a dangerous rhythm that is perhaps not elucidated by the given rhythm strip? For example such a bigeminal pattern could be caused by a mobitz II block; could anesthetic agents worsen such a rhythm? Also, he's 72 and about to undergo an unpleasant procedure - I might be concerned that the ST depression we see in whatever lead that happens to be represents an inverse change from ST elevation elsewhere and there could be a small but real possibility that his anxiety is causing a catecholamine surge to the extent that he is suffering from some sort of silent acute event. Finally if he's got HTN and a h/o cardiac cath presumably from coronary disease when he was younger and now has this strange rhythm, I would be concerned about a cardiomyopathy (ie eccentric or concentric both possible based on the history) that may show up on an EKG as LVH or PRWP. So with my current level of knowledge I think if I saw this history I'd get an EKG.

all true, but in real life...that's just:

 

[militarymd]

Get the EKG. Although it is likely some weird repolarization thing going on, there is ST depression. I would want to make sure that there is not clear electrocardiographic evidence of ischemia.

Before someone says that there is nothing in the history to suggest ischemia, I am not so sure. Why is he having an EGD? Is it for "GERD sx", i.e. epigastric pain which can be an anginal equivalent? Does he have a h/o a GI bleed? Could he be profoundly anemic? That with the knowledge that he likely has some sort of atherosclerotic vascular dz secondary to his h/o stroke, as well as his rhythm strip make an EKG very prudent.

The real life answer:

1) because he has an esophagus
2) because some GI guy needs to send his kids to college
3) because the owner of the surgery center has a note to pay.

All that other stuff you said...maybe true, but it's all just

Sh it happens....it will happen whether you

before, during, or after.

 

[Arch Guillotti]

Before someone says that there is nothing in the history to suggest ischemia, I am not so sure. Why is he having an EGD? Is it for "GERD sx", i.e. epigastric pain which can be an anginal equivalent? Does he have a h/o a GI bleed? Could he be profoundly anemic?

Those are all good thoughts but none of them applied to this guy. Not anxious and no catecholamine surge.

 

[Arch Guillotti]

the real life answer:

1) because he has an esophagus
2) because some gi guy needs to send his kids to college
3) because the owner of the surgery center has a note to pay.

exactly!

 

[OB1🤙]

My only contribution to this thread: nothing pissed me off more as a medicine intern than attendings/residents trying to convince themselves that patients like this need a hyperacute full-court-press cardiac workup because of their "angina equivalents."

 

[Noyac]

I'm curious, when did cardiologists start doing cardiac cath's? This guy had one about 40 yrs ago.

 

[Arch Guillotti]

From wikipedia:

History

Main article: History of invasive and interventional cardiology

The history of cardiac catheterization dates back to Claude Bernard (1813-1878), who used it on animal models. Clinical application of cardiac catheterization begins with Werner Forssmann in the 1930s, who inserted a catheter into the vein of his own forearm, guided it fluoroscopically into his right atrium, and took an X-ray picture of it. Forssmann won the Nobel Prize in Physiology or Medicine for this achievement. During World War II, André Frédéric Cournand and his colleagues developed techniques for left and right heart catheterization.

Curiously this gentleman was a decent historian, he stated that the cath gane him a "blood clot in my lungs"!

 

[Noyac]

From wikipedia:

History

Main article: History of invasive and interventional cardiology

The history of cardiac catheterization dates back to Claude Bernard (1813-1878), who used it on animal models. Clinical application of cardiac catheterization begins with Werner Forssmann in the 1930s, who inserted a catheter into the vein of his own forearm, guided it fluoroscopically into his right atrium, and took an X-ray picture of it. Forssmann won the Nobel Prize in Physiology or Medicine for this achievement. During World War II, André Frédéric Cournand and his colleagues developed techniques for left and right heart catheterization.

Curiously this gentleman was a decent historian, he stated that the cath gane him a "blood clot in my lungs"!

Yes I read that but when did they start cath'ing people regularly. I read also that the first PTCA was 1974.

 

[bne_12mne]

Looks like dig toxicity to me. What's his K+? Is he on dig?

 

[Arch Guillotti]

I have no idea what his labs were. He showed up for an endoscopy w/out any previous labs or workup (not that one was necessarily needed). Anyways, I fudged the scenario a little bit. The strip I posted was actually post-procedure. Why? Because there is no 12 lead or ekg to compare it to. I got involved in this in the PACU when the nurse came to me with the strip and asked what I wanted to do. Of course the first thing I asked was if there was anything to compare it to. The nurse showed it to me because she thought it looked "funny" and she was right. The pt. meanwhile was putting on his drawers and getting ready to head out the door. According to the nurse the report she got from the CRNA doing the endoscopy was that although there was no formal record of it the pts. rhythm strip looked "just the same" as before the case. Anyways I let the dude go w/out doing anything and since he has no ED visits in the computer since then I am going to assume he hasn't croaked.

MMD is right although I think had I seen this pt. preoperatively I probably would have gotten a 12 lead.

 

[Noyac]

I have no idea what his labs were. He showed up for an endoscopy w/out any previous labs or workup (not that one was necessarily needed). Anyways, I fudged the scenario a little bit. The strip I posted was actually post-procedure. Why? Because there is no 12 lead or ekg to compare it to. I got involved in this in the PACU when the nurse came to me with the strip and asked what I wanted to do. Of course the first thing I asked was if there was anything to compare it to. The nurse showed it to me because she thought it looked "funny" and she was right. The pt. meanwhile was putting on his drawers and getting ready to head out the door. According to the nurse the report she got from the CRNA doing the endoscopy was that although there was no formal record of it the pts. rhythm strip looked "just the same" as before the case. Anyways I let the dude go w/out doing anything and since he has no ED visits in the computer since then I am going to assume he hasn't croaked.

MMD is right although I think had I seen this pt. preoperatively I probably would have gotten a 12 lead.

If you are wishing you had one to compare with then you have your answer.

 

[cchoukal]

So for those who would get an EKG, what would you do with it? What would you have to see to delay the case and refer to a cardiologist? Complete AV block? Ischemic changes? Left Bundle?

 

[huktonfonix]

What would I do with the EKG? Look at it, interpret it and see if I need anything additional on standby for the case. Its highly unlikely Im gonna see anything worth cancelling this case for since hes apparently active and not passing out on a regular basis. As far as a cardiologist goes, Im sure this guy should see one although it sounds like he has and has refused intervention. Im not sure what else theyre gonna do for him. Now the question is what might I want standing by for this quick simple case? While I may not necessarily require him to have the pacing pads on since hes surviving at baseline just fine without them, I may want to know that the crash cart ICD has pacing capability and is readily available just in case. Now when would I actually cancel this case? I wouldnt unless he had other symptoms indicating to me that I should (new chest pain, syncope, etc..)

 

[Arch Guillotti]

If you are wishing you had one to compare with then you have your answer.

lol, right. I think that the reasoning that you posted above is the most practical (for me, at least). I absolutely do not think we should get ekg's on everyone at soem arbitrary age cut-off. And I was a bit puzzled by his history of a cath many years ago but he was a reasonable historian.

 

[militarymd]

If you are wishing you had one to compare with then you have your answer.

so it's different now....what are you going to do?

restrain the dude and not let him go home?

 

[Noyac]

so it's different now....what are you going to do?

restrain the dude and not let him go home?

Mil, if you look at the tracing can you tell me what it is?

I can't. To me it looks like either a anterior hemiblock + RBBB in the V leads which is most likely. But I can't say that it isn't an acute posterior infarction by that tracing. I need more leads to determine this. Now if he had a previous ECG that showed this then I'm golden. If not I'm getting one.

And if it is a post infarct, yes I'm keeping him at least until cards sees him and takes over. Remember, he is having an EGD. Small risk but the workup for infarct is not EGD but frequently we confuse it with GERD. Sure his history can give you clues but you already know he is noncompliant, right.

 

[militarymd]

"rhythm strips" are just that...."rhythm strips"....they are not "diagnostic" ...and therefore are not meant to do anything other than give you a basic rhythm....sinus...not sinus...etc.

I see the above ALL the time....and I get called about it ALLLLL the time...and my answer has always been the same....."what's the patient doing".....

If the patient is behaving in a way that would make me order a ECG, then I would....if the patient is behaving in a way that you would expect them to behave.....vitals, signs, symptoms....(like pulling on his pants)....then I would not do anything.

That damn "rhythm strip" that we use in recovery causes more problems than they are worth in the VAST majority of cases.

They DO NOT diagnose ischemia.....they give you a "rhythm"...so unless you are expecting some fatal dysrhythmia, then it's pretty much worthless.

Now ...Lead V is different, but no one ever really does that...and EVEN with lead V....Bayes theorum still applies.

Mil, if you look at the tracing can you tell me what it is?

I can't. To me it looks like either a anterior hemiblock + RBBB in the V leads which is most likely. But I can't say that it isn't an acute posterior infarction by that tracing. I need more leads to determine this. Now if he had a previous ECG that showed this then I'm golden. If not I'm getting one.

And if it is a post infarct, yes I'm keeping him at least until cards sees him and takes over. Remember, he is having an EGD. Small risk but the workup for infarct is not EGD but frequently we confuse it with GERD. Sure his history can give you clues but you already know he is noncompliant, right.

 

[Noyac]

I agree we see this often. My partner had a case yesterday were the pt kept going in and out of a wide complex sinus rhythm. He caught it with a ECG in the pacu for documentation. I think that is a worthy cause for a ECG.

So this guy is having heartburn.

No reason to get an ECG?

Wouldn't that be part of a normal workup for heartburn anyway?

If the primary didn't get one for his heartburn, I am.

I am taking this pts history into consideration.

BTW, thanks Mil I love this. You are helping me as much as the rest.

 

[militarymd]

I agree we see this often. My partner had a case yesterday were the pt kept going in and out of a wide complex sinus rhythm. He caught it with a ECG in the pacu for documentation. I think that is a worthy cause for a ECG.

So this guy is having heartburn.

No reason to get an ECG?

Wouldn't that be part of a normal workup for heartburn anyway?

If the primary didn't get one for his heartburn, I am.

I am taking this pts history into consideration.

BTW, thanks Mil I love this. You are helping me as much as the rest.

it is a neat little discussion....whether we are going to function as "doctors" or not....and I'm sort "not" in this case.

 

[dragonfly99]

Internist here. Yes I would get one if I saw this. As you all mentioned, very likely nothing will change, but would want one before the procedure just in case something went bad DURING the procedure. Getting one preprocedure on a guy with known vascular disease and who was "told he needed a pacemaker but refused it" is very different than knee-jerk getting on everyone >50 years old. If you had an old ECG similar to this current rhythm strip, could skip the ECG given that he's asymptomatic.

The fp or internist should have gotten one on the chart before he was sent for the EGD...perhaps the patient was supposed to have one in the past but never came in for it? I'm sure there's an old ECG somewhere...just never made it to y'all's chart. I would have gotten one when he showed up for the procedure, if I hooked him up and saw that on the rhythm strip...

 

[militarymd]

tell me what you know of the "rhythm strips" that we use...and where we place the leads...

like...is it standardized....mm/s rate......etc....and how it compares with a 12 lead diagnostic ecg.

Internist here. Yes I would get one if I saw this. As you all mentioned, very likely nothing will change, but would want one before the procedure just in case something went bad DURING the procedure. Getting one preprocedure on a guy with known vascular disease and who was "told he needed a pacemaker but refused it" is very different than knee-jerk getting on everyone >50 years old. If you had an old ECG similar to this current rhythm strip, could skip the ECG given that he's asymptomatic.

The fp or internist should have gotten one on the chart before he was sent for the EGD...perhaps the patient was supposed to have one in the past but never came in for it? I'm sure there's an old ECG somewhere...just never made it to y'all's chart. I would have gotten one when he showed up for the procedure, if I hooked him up and saw that on the rhythm strip...

 

[Tenesma]

with a rhythm and history like that, and EKG becomes pointless...

i would just have a pacer in the room --- and also have an esophageal pacer handy--- that way GI dude can throw it alongside his tube if he gets too brady.