12-Lead ECG in ROSC

The other day I heard a story of an ED doctor geting angry at the paramedics who had brought in a cardiac arrest who the medics had had gotten pulses back on in the field. The doctor was angry because after he had done a 12-lead on the patient in the ED, he’d discovered the patient was a STEMI. He was furious that the medics hadn’t done a 12-lead on the way in and discovered this themselves.

My initial reaction was what is he crazy? In 16 years as a medic I have never done a single 12-lead on any cardiac arrest I have rescusitated. Why not? Working as a single medic most of the time I am pretty busy with post-rescisitation care. That’s my easy excuse, but I have done a number of rescusitations with other medics, and I have to say it has never occured to me to do a 12-lead. We are still usually too busy (shaking each other’s hands), bagging the patient, hanging dopamine drips, etc, and remaining vigilant to losing pulses.

So, it is with great interest, I read the following article:EMS 12-leads after ROSC.

The bottom line for me in the article is a good number of these patient’s are going to have ECGs showing a STEMI. It seems reasonable. There are probably many systems doing this routinely.

If possible, I will definately try to do one the next time I have a ROSC.
And I’ll be curious if that knowledge will change the way the patient will be initially treated when I bring the patient in.

15 Comments

  • medic.dan says:

    That really is an interesting set of research, and may impact my own field procedures. What I wonder is WHEN. With a short transport time, there just ISNT an opportunity to get as 12, and as you said, even less if you are working as an independent medic. What is this going to change for your pre-hospital treatment? ER treatment? Will this patient really receive PCI or tPa, if the ER cannot confirm cognitive damage from the code?

  • VA PhireMedic says:

    PCLike you, I’ve never thought of doing this, especially as a solo medic…the other problem is that I’m in a rural system and we hardly ever have an arrest that is even in VT/VF when we arrive. Because of extended response times I’d say 97% of our arrests are asystole and we hardly ever have any success in resus. But I will defiantly keep this in mind if the opportunity arises!Best,LAM

  • Walt Trachim says:

    Interesting article, and you’re right – it certainly makes sense that the cause of many codes is an MI. At least the research seems to bear this out.On the other hand, not necessarily having enough resources to get a 12-lead done is really pretty common. Especially, as you said, it’s not always a priority when you’re working on keeping the patient alive after getting them back. I’m also in the boat of short transport times in 2 of the 3 places I work, but in the system where I have the longest transports we had some changes made to our LP-12 where we can transmit faster than we used to. Perhaps it would be easier to get a 12-lead in on these trucks….

  • Anonymous says:

    Just an FYI, but here in Austin, TX we have had a quite a few ROSC turned STEMI pts, so it is commonplace to perform a post-ROSC 12 lead. Eric

  • fiznat says:

    I actually do routinely take ROSC 12 leads. I’m not sure where I picked that up. Maybe it is part of the new instruction or I got it from my preceptor, I can’t be sure.Anyways, in my limited experience I’ve found that just about every ROSC 12 lead I do looks like an MI. As an example, here is my most recent one:http://1.bp.blogspot.com/_sSKdi8LFqnY/SMr0HZ3L8TI/AAAAAAAAALo/50PG7I1RjzI/s1600-h/ROSC12.jpgI always assumed that they would all look like MIs, or at least with significant ischemia considering the assumed hypoperfusion of the organ during arrest.

  • Anonymous says:

    Peter, I think in the new instruction it has been preached to us to absolutely do a 12 lead in a ROSC. While I have had in the last year (my 1st year mind you) a few ROSC working with other medic’s we just never had the time, as you said just far too busy with other care. Today however I had a heroin OD that briefly went into Cardiac Arrest, found down within 2 minutes by local PD, and revived very shortly after arrival, as part of my post resuscitive care I made sure to include a 12 lead ECG to rule out any ischemia that may have developed or been an underlying factor.

  • Anonymous says:

    Last time I checked, ASA and nitro can’t be given down an ET tube. Our job is to keep patients alive until we get to the hospital, not mess around with diagnotic tools just because we have them at our disposal. What difference is it going to make in your treatment?

  • WTF says:

    ha ha anonymous, good line of reasoning! I say we throw out assessment in general because hey, if it doesn’t change what I do within the next 5 minutes then I guess it has no value at all, right? There is thing called continuity of care, my friend. Whether you choose to believe it or not we are part of a system that has goals beyond what may be achieved in the back of your ambulance. You have to think farther than the end of your nose, I admit, but our responsibility doesn’t stop on our arrival at the hospital doors.

  • TOTWTYTR says:

    We’re supposed to do them if possible. Of course a bigger priority is therapeutic hypothermia, which also keeps us busy. We have some medics who do them regularly, but I think they just circle the block around the hospital until they get it all done.

  • brendan says:

    What difference is it going to make in your treatment?Change of destination. In my state, codes go to the closest ER (obviously) but not all of them have cath labs. Why bring somebody back from an arrest-inducing MI just to take them someplace that can’t fix the problem?

  • PDXEMT says:

    In addition to the above comments, a ROSC 12-lead showing a STEMI will allow for the thing a normal STEMI 12-lead does (in a good system) — namely, early notification and activation of the cath lab. I can think of at least one cardiac arrest I worked a long way down the VF algorithm (at least four rounds of antiarrythmics), got pulses back, did a 12-lead, confirmed a huge STEMI, and then lost pulses again before arrival at the ED.Based on my 12-lead, the ED doc called the cath lab team in and resuscitated the pt very aggressively (“just run the dopamine wide open — and go get the levophed!”) in order to make him a viable cath lab patient.I think a 12 lead is one of the first things to do on a ROSC patient, especially from a VF/VT arrest. If you have your airway secured, etc, it takes a good medic all of two minutes to do a 12 lead.

  • Medic13 says:

    Oddly, just about 6 hours ago I had another ROSC code. The first 12-lead (less then 10 mins after ROSC) showed STEMI. The thing is that with each progressive 12-lead the STEMI went away (over a 10 minute period) and it was a simple NSR. I believe that some of these patients could just have a STEMI due to the hypoperfusion of the heart during the cardiac arrest and as oxygen is returned to the organ things get better. Though I must caution, I have had other ROSC that have had the STEMI throughout transport.

  • Tom B says:

    Or, the STEMI was due to coronary vasospasm which somehow resolved. It’s impossible to know. Until we have more data, ROSC patients showing STEMI should be cathed (and hypothermia induced if still unconscious) wouldn’t you agree?

  • Cheating Death says:

    Anon-With that logic why waste time and money sending us through medic school. If all you want us to do is throw a protocol with no assessment, any chimp could learn that.We do NOT practice EMS to the lowest common denominator. We are here to think, then treat our patients.

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