A 61-year-old man calls the Paris Fire Brigade dispatch center with a complaint of dental pain. He reports feeling pain in the jaw for the past 35 minutes, which he says now extends to the armpits. He also reports that he experienced the same feeling the day before.

The patient’s age and hyperlipidemia were his only cardiovascular risk factors with atorvastatine and budesonide as the usual treatments. The physician stationed at the dispatch center rapidly sends a Paris Fire Brigade firefighter/BLS equipped with a multiparameter monitor which includes an ECG.


12-lead ECGs obtained by firefighter/BLS teams are sent to a
physician at the Paris Fire Brigade dispatch center.

When the team arrives on scene, they run a 12-lead ECG and although they have no visual access to the ECG, they send it via wireless connection to a national telecom service provider to the physician at the dispatch center.

The ECG is quickly examined by the physician at the dispatch center, and shows an ST-elevation myocardial infarction (STEMI) in the inferior leads (II, III and aVF), with reciprocal changes in V1–V3. (See Figure 1)

The physician at the dispatch center immediately sends an ALS-staffed team with a physician and a nurse to reinforce the BLS team.

At the same time, he alerts the coronography (i.e., percutaneous coronary intervention [PCI]) center of the imminent arrival of a STEMI patient.

Before transportation, the ALS team perfuses the patient and administers an anti-aggregating agent and anticoagulant therapy.

Upon arrival at the cardiologic center, the patient receives an angioplasty of his right coronary and interventricular arteries. (See Figures 2 and 3) He recovers fully without any after-effects or deficits.

Discussion

In the United States, 50% of acute coronary syndromes seem to have clinically atypical presentations (e.g., dyspnea, nausea, syncope or pain localized in the arm, the neck, the armpit or the stomach). The 12-lead ECG maintains the gold standard as the first line test.1

Currently more than a quarter of atypical STEMI don’t benefit from an ECG during the prehospital phase of care. The consequence is a longer delay for the initiation of early ALS interventions, and an increase in hospital mortality rates has been shown in studies conducted in the U.S. and China.2,3

Figure 1: ECG showing ST-elevation myocardial infarction (STEMI)

Studies from Europe, China and the U.S. have shown that a larger screening based on prehospital ECG could enable earlier diagnosis and transportation to a PCI center for 11% to 46% of atypical STEMI.2,4,5

It’s been shown that performing an early 12-lead ECG transmitted wirelessly by a paramedic or a nurse decreases the delay in making the diagnosis of STEMI.6,7

The EMS system in Paris is a sophisticated, physician-directed, multitiered system. The Paris Fire Brigade, a military-operated service, responds with firefighter/BLS teams as well as physician-staffed ambulances called “Ambulance De Reanimation” units that carry conventional monitor/defibrillators and mechanical chest compression devices.

Units staffed by firefighter/BLS teams are equipped with SCHILLER DEFIGARD Touch 7 12-lead ECG units with wireless transmission capability.

Figure 2: Right coronary artery (RCA) before angioplasty and stent

In this particular case, the transmission of the 12-lead ECG by a BLS team that was rapidly reviewed by a physician at the dispatch center shortened the delay in initiating definitive care. In other words, the earlier STEMI detection made it possible to gain time both in terms of ALS care and for the preparation of the coronary center.

BLS teams need regular training to perform the ECG and transmit it wirelessly. However, ECG capture and transmission is something that’s done routinely by BLS-trained personnel in the Paris EMS system, which makes it easy to accomplish.

The use of 12-lead ECGs has become a valuable diagnostic tool in the BLS response system and is increasing the sensitivity of STEMI detection, particularly in cases of atypical clinical symptoms. This will improve the prognosis of a great number of patients in Paris.

Figure 3: Interventricular arteries before angioplasty and stent

References

1. Cervellin G, Rastelli G. The clinics of acute coronary syndrome. Ann Transl Med. 2016;4(10):191.

2. Cannon AR, Lin L, Lytle B, et al. Use of prehospital 12-lead electrocardiography and treatment times among ST-elevation myocardial infarction patients with atypical symptoms. Acad Emerg Med. 2014;21(8):892–898.

3. Canto AJ, Kiefe CI, Goldberg RJ, et al. Differences in symptom presentation and hospital mortality according to type of acute myocardial infarction. Am Heart J. 2012;163(4):572–579.

4. Campo Dell’ Orto M, Hamm C, Liebetrau C, et al. Telemetry-
assisted early detection of STEMI in patients with atypical symptoms by paramedic-performed 12-lead ECG with subsequent cardiological analysis. Eur J Emerg Med. 2017;24(4):272–276.

5. Brunetti ND, De Gennaro L, Amodio G, et al. Telecardiology improves quality of diagnosis and reduces delay to treatment in elderly patients with acute myocardial infarction and atypical presentation. Eur J Cardiovasc Prev Rehabil. 2010;17(6):615–620.

6. Limido A, Mare C, Giani S, et al. PROVA E TRASPORTA project: Results of tele-transmission of the electrocardiogram from community hospitals and emergency service ambulances in the management of ST-elevation acute coronary syndromes. G Ital Cardiol (Rome). 2006;7(7):498–504.

7. Bussières S, Tanguay A, Hébert D, et al. Unité de Coordination Clinique des Services Préhospitaliers d’Urgence: A clinical telemedicine platform that improves prehospital and community health care for rural citizens. J Telemed Telecare. 2017;23(1):188–194.