STEMI on telemetry?
First Glance:
From across the room it looks like a regular narrow-complex rhythm with ST elevations in lead III.
Discussion:
Zoom in. We see concerning findings in the upper trace (lead III) with ST elevations and significant Q waves. Note that the baseline wanders (likely respiratory artifact in this strip) and to accurately assess for ST elevation we should seek out a section with relatively flat baseline. The sections where the baseline is rising shows artificially large ST elevations of 5 or 6mm, and the parts where the baseline is falling show little to no ST elevation. In the flat sections it looks like 3mm. Does that mean we can put “3mm ST elevations” in the chart?
Nope. Tele monitors are not necessarily calibrated the same way as a 12L, so this would be a bit of a stretch. Further, notice that the voltage calibration is only at 80% here, so this is actually a little less than 3mm. Either way- we have a high suspicion for ST elevation but will need to evaluate further.
In the lower trace (lead ‘V’) we see 1mm ST elevation. The P wave morphology is consistent with placement of lead V1 or V2, so the deep QS wave could be normal here- not necessarily an infarction Q unless this is different from past strips. The fact that there is ST elevation in both inferior (III) and anterior (anteroseptal V lead) suggests either widespread ischemia, or another process such as pericarditis, etc.
In favor of pericarditis or early repolarization is the possibly benign morphology of the ST segment (concave up, not tombstoned), but this is not very specific. In favor of coronary involvement are the deep Q waves in III, although this could also be a result of a posterior fascicular block. But then arguably that suggests coronary involvement anyways.
Final Impression?
Sinus rhythm at 85bpm with concerning findings consistent with infarction and active ischemia.
Management implications:
Get 12L. Compared with prior EKGs. This patient will deserve a cardiac workup of some kind depending on clinical correlation (ACS vs pericarditis vs early repolarization, etc).
The Take-home Point:
Tele monitors are great for arrythmias but poor for ischemic findings. Evaluate all possibly ischemic telemetry with a real 12L as the ST elevations, Q waves, and various other findings are not reliably represented by a bedside monitor.
One star strip. Students should nail this.