ST-T segment changes in prehospital emergency physicians in the field: a prospective observational trial

Mathias Maleczek, Karl Schebesta, Thomas Hamp, Achim Leo Burger, Thomas Pezawas, Mario Krammel, Bernhard Roessler, Mathias Maleczek, Karl Schebesta, Thomas Hamp, Achim Leo Burger, Thomas Pezawas, Mario Krammel, Bernhard Roessler

Abstract

Aims: Due to time-critical decision-making, physical strain and the uncontrolled environment, prehospital emergency management is frequently associated with high levels of stress in medical personnel. Stress has been known to cause ischemia like changes in electrocardiograms (ECGs), including arrhythmias and deviations in ST-T segments. There is a lack of knowledge regarding the occurrence of changes in ST-T segments in prehospital emergency physicians. We hypothesized that ST-T segment deviations occur in prehospital emergency physicians in the field.

Methods: In this prospective observational trial, ST-T segments of emergency physicians were recorded using 12-lead Holter ECGs. The primary outcome parameter was defined as the incidence of ST-T segment changes greater than 0.1 mV in two corresponding leads for more than 30 s per 100 rescue missions. The secondary outcomes included T-wave inversions and ST-segment changes shorter than 30 s or smaller than 0.1 mV. Surrogate parameters of stress were measured using the NASA-Task Load Index and cognitive appraisal, and their correlation with ST-T segment changes were also assessed.

Results: Data from 20 physicians in 36 shifts (18 days, 18 nights) including 208 missions were analysed. Seventy percent of previously healthy emergency physicians had at least one ECG abnormality; the mean duration of these changes was 30 s. Significantly more missions with ECG changes were found during night than day shifts (39 vs. 17%, p < 0.001). Forty-nine ECG changes occurred between missions. No ST-T segment changes > 30 s and > 0.1 mV were found. Two ST-T segment changes < 30 s or < 0.1 mV (each during missions) and 122 episodes of T-wave inversions (74 during missions) were identified. ECG changes were found to be associated with alarms when asleep and NASA task load index.

Conclusion: ECG changes are frequent and occur in most healthy prehospital emergency physicians. Even when occurring for less than 30 s, such changes are important signs for high levels of stress. The long-term impact of these changes needs further investigation. Trial registration The trial was registered at ClinicalTrials.gov (NCT04003883) on 1.7.2019: https://ichgcp.net/clinical-trials-registry/NCT04003883?term=emergency+physician&rank=2.

Keywords: Critical care; Emergency; Prehospital; ST-T segment; Stress.

Conflict of interest statement

The Authors declare that there is no conflict of interest.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Prisma flowchart. A Prisma flowchart of the participants including dropouts is shown
Fig. 2
Fig. 2
Distribution of ECG changes. The distribution of ECG changes between phases of a mission is shown. En-route is driving to the patient, patient care is the time between arrival on scene and start of patient transport
Fig. 3
Fig. 3
Differences in NASA-TLX. The boxplot on the left shows NASA-TLX of a mission by any ECG change occurring during patient care. The boxplot on the right shows NASA-TLX classified by most stressful alarm codes as defined by a Delphi process

References

    1. Petrie K, Milligan-Saville J, Gayed A, Deady M, Phelps A, Dell L, et al. Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):897–909. doi: 10.1007/s00127-018-1539-5.
    1. Howard L, Wibberley C, Crowe L, Body R. How events in emergency medicine impact doctors' psychological well-being. Emerg Med J. 2018;35(10):595–599. doi: 10.1136/emermed-2017-207218.
    1. Wong ML, Anderson J, Knorr T, Joseph JW, Sanchez LD. Grit, anxiety, and stress in emergency physicians. Am J Emerg Med. 2018;36(6):1036–1039. doi: 10.1016/j.ajem.2018.02.021.
    1. Bohström D, Carlström E, Sjöström N. Managing stress in prehospital care: Strategies used by ambulance nurses. Int Emerg Nurs. 2017;32:28–33. doi: 10.1016/j.ienj.2016.08.004.
    1. Ho RC, Neo LF, Chua AN, Cheak AA, Mak A. Research on psychoneuroimmunology: does stress influence immunity and cause coronary artery disease? Ann Acad Med Singapore. 2010;39(3):191–196.
    1. Guasch E, Mont L. Diagnosis, pathophysiology, and management of exercise-induced arrhythmias. Nat Rev Cardiol. 2017;14(2):88–101. doi: 10.1038/nrcardio.2016.173.
    1. Collet J-P, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European society of cardiology (ESC) Eur Heart J. 2020;42(14):1289–1367. doi: 10.1093/eurheartj/ehaa575.
    1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of cardiology (ESC) Eur Heart J. 2018;39(2):119–177. doi: 10.1093/eurheartj/ehx393.
    1. Rozanski A, Bairey CN, Krantz DS, Friedman J, Resser KJ, Morell M, et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med. 1988;318(16):1005–1012. doi: 10.1056/NEJM198804213181601.
    1. Doorey A, Denenberg B, Sagar V, Hanna T, Newman J, Stone PH. Comparison of myocardial ischemia during intense mental stress using flight simulation in airline pilots with coronary artery disease to that produced with conventional mental and treadmill exercise stress testing. Am J Cardiol. 2011;108(5):651–657. doi: 10.1016/j.amjcard.2011.04.010.
    1. Herm J, Topper A, Wutzler A, Kunze C, Krull M, Brechtel L, et al. Frequency of exercise-induced ST-T-segment deviations and cardiac arrhythmias in recreational endurance athletes during a marathon race: results of the prospective observational berlin beat of running study. BMJ Open. 2017;7(8):e015798. doi: 10.1136/bmjopen-2016-015798.
    1. Luurila OJ, Karjalainen J, Viitasalo M, Toivonen L. Arrhythmias and ST segment deviation during prolonged exhaustive exercise (ski marathon) in healthy middle-aged men. Eur Heart J. 1994;15(4):507–513. doi: 10.1093/oxfordjournals.eurheartj.a060535.
    1. Aggarwal NR, Patel HN, Mehta LS, Sanghani RM, Lundberg GP, Lewis SJ, et al. Sex differences in ischemic heart disease: advances, obstacles, and next steps. Circ Cardiovasc Qual Outcomes. 2018 doi: 10.1161/CIRCOUTCOMES.117.004437.
    1. Mieszczanska H, Pietrasik G, Piotrowicz K, McNitt S, Moss AJ, Zareba W. Gender-related differences in electrocardiographic parameters and their association with cardiac events in patients after myocardial infarction. Am J Cardiol. 2008;101(1):20–24. doi: 10.1016/j.amjcard.2007.07.077.
    1. Sachin Khane R, Surdi AD. Gender differences in the prevalence of electrocardiogram abnormalities in the elderly: a population survey in India. Iran J Med Sci. 2012;37(2):92–99.
    1. Hart SG. Nasa-Task Load Index (NASA-TLX); 20 Years Later. Proc Human Factors Ergon Soc Annu Meet. 2006;50(9):904–908. doi: 10.1177/154193120605000909.
    1. Tomaka J, Blascovich J, Kelsey RM, Leitten CL. Subjective, physiological, and behavioral effects of threat and challenge appraisal. J Personal Soc Psychol. 1993;65(2):248–260. doi: 10.1037/0022-3514.65.2.248.
    1. Tomaka J, Blascovich J, Kibler J, Ernst JM. Cognitive and physiological antecedents of threat and challenge appraisal. J Pers Soc Psychol. 1997;73(1):63–72. doi: 10.1037/0022-3514.73.1.63.
    1. Law KE, Lowndes BR, Kelley SR, Blocker RC, Larson DW, Hallbeck MS, Nelson H. NASA-task load index differentiates surgical approach: opportunities for improvement in colon and rectal surgery. Ann Surg. 2020;271(5):906–12. doi: 10.1097/SLA.0000000000003173.
    1. Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatr. 2019;173(1):44–51. doi: 10.1001/jamapediatrics.2018.3619.
    1. Marjanovic N, L'Her E. A comprehensive approach for the ergonomic evaluation of 13 emergency and transport ventilators. Respir Care. 2016;61(5):632–639. doi: 10.4187/respcare.04292.
    1. Tofil NM, Lin Y, Zhong J, Peterson DT, White ML, Grant V, et al. Workload of team leaders and team members during a simulated sepsis scenario. Pediatr Crit Care Med. 2017;18(9):e423–e427. doi: 10.1097/PCC.0000000000001258.
    1. Hart SG, Staveland LE. Human Mental Workload. Elsevier; 1988. Development of NASA-TLX (Task Load Index): results of empirical and theoretical research; pp. 139–183.
    1. Sackman H. Delphi assessment - expert opinion, forecasting, and group process. Santa Monica: RAND Corporation; 1974.
    1. Dalkey N, Helmer O. An experimental application of the delphi method to the use of experts. Manage Sci. 1963;9(3):458–467. doi: 10.1287/mnsc.9.3.458.
    1. Van Rossum G, Drake FL. Python 3 reference manual createspace. 2009.
    1. Harris CR, Millman KJ, van der Walt SJ, Gommers R, Virtanen P, Cournapeau D, et al. Array programming with NumPy. Nature. 2020;585(7825):357–362. doi: 10.1038/s41586-020-2649-2.
    1. Laukkanen JA, Kurl S, Lakka TA, Tuomainen TP, Rauramaa R, Salonen R, et al. Exercise-induced silent myocardial ischemia and coronary morbidity and mortality in middle-aged men. J Am Coll Cardiol. 2001;38(1):72–79. doi: 10.1016/S0735-1097(01)01311-0.
    1. Kurl S, Laukkanen JA, Mäkikallio TH, Rauramaa R. Asymptomatic ST-segment depression during exercise testing and the risk of sudden cardiac death in middle-aged men: a population-based follow-up study. Eur Heart J. 2009;30(5):558–565. doi: 10.1093/eurheartj/ehn584.
    1. Taelman J, Vandeput S, Spaepen A, Van Huffel S. Influence of Mental Stress on Heart Rate and Heart Rate Variability. In: Vander Sloten J, Verdonck P, Nyssen M, Haueisen J, editors. 4th European Conference of the International Federation for Medical and Biological Engineering: ECIFMBE 2008 23–27 November 2008 Antwerp, Belgium. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009. p. 1366–9.
    1. Suryanarayana PG, Kandala J, Marcus FI. High incidence of ST-T changes in women during tilt-table testing. J Electrocardiol. 2017;50(6):884–888. doi: 10.1016/j.jelectrocard.2017.06.004.
    1. Shattock MJ, Tipton MJ. ‘Autonomic conflict’: a different way to die during cold water immersion? J Physiol. 2012;590(14):3219–3230. doi: 10.1113/jphysiol.2012.229864.

Source: PubMed

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