12 Lead EKG’s and a LBBB – is it a STEMI?

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The classic finding of a STEMI on a 12 lead EKG is “2 up & 2 down.” This means, there needs to be ST segment elevation in two contiguous leads and reciprocal depressions in two contiguous leads on the 12 lead EKG. This is classic finding for a STEMI. But, a new LBBB can also represent STEMI.

The AHA doesn’t say a “new LBBB” is a STEMI. The wording is; “new or presumably new LBBB” is a STEMI. With this in this week’s EKG case study (CLICK HERE IF YOU MISSED THE CASE) patient, they fall into the category of “new LBBB.” We didn’t have to presume this one as we had an old EKG on him so we knew this was indeed a new LBBB.

We are dealing with an extremely hypertensive patient with a new LBBB. This is a tricky patient. No doubt. The proper thinking is that this 12 lead EKG represents a STEMI. With a STEMI, the pathophysiology is a blood clot. And the treatment is to bust that clot up with either a clot buster or roto-rooter (thrombolytics or angioplasty.)

This patient’s pain and LBBB resolved with aggressive reduction in his blood pressure, that was accomplished with NTG and IV beta blockage. As much as this patient appeared like a STEMI, this case represents a hypertensive emergency.

Do you know the 12 lead EKG criteria of a LBBB?

Do you know the how to utilize Sgarbosa’s criteria. See next week’s blog.

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John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.
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