Nerdicus Electrocardiogramus

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airwaymastaflex

airwaymastaflex

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To all the ECG lovers out there...

Case2_EKG2.jpg


And the differential is?????
 
sorry... no old EKG. Patient is a 75 year old female
 
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I can't quite make out the P waves, but I'll go with Wenkeboch as the rhythm, lateral T wave inversions. Brugada?
 
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Irr. ~HR 70, Normal axis, 2nd degree Heart block Type II with possible digitalis effect, cannot rule out ischemia of lat wall and/or HypoK+

Admit with r/o MI profile depending on pt stability to low level monitoring with Cath or Nuke stress test in AM pending Troponins.
 
Ryan said:
Irr. ~HR 70, Normal axis, 2nd degree Heart block Type II with possible digitalis effect, cannot rule out ischemia of lat wall and/or HypoK+

Admit with r/o MI profile depending on pt stability to low level monitoring with Cath or Nuke stress test in AM pending Troponins.
Click to expand...

Frickin Ryan. You bastard.
 
More info...

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]PMH:[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]1. degenerative joint disease [/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]2. undiagnosed hypertension. [/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]3. no known history of coronary artery disease[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]4. tonsillectomy and varicose vein stapling[/SIZE].

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]SH: Second hand smoking and occasional alcohol use.
[/SIZE].[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]FH: Esophageal cancer[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]Meds: fexofenadine and hydrocodone as needed for pain
[/SIZE].

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]On physical exam her blood pressure was 158/84 mm Hg, heart rate of 78 beats per minute, temperature of 97.1F, respiratory rate of 22 breaths per minute and SaO2 88%.[/SIZE].
 
airwaymastaflex said:
More info...

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]PMH:[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]1. degenerative joint disease [/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]2. undiagnosed hypertension. [/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]3. no known history of coronary artery disease[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]4. tonsillectomy and varicose vein stapling[/SIZE].

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]SH: Second hand smoking and occasional alcohol use.
[/SIZE].[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]FH: Esophageal cancer[/SIZE].
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]Meds: fexofenadine and hydrocodone as needed for pain
[/SIZE].

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]On physical exam her blood pressure was 158/84 mm Hg, heart rate of 78 beats per minute, temperature of 97.1F, respiratory rate of 22 breaths per minute and SaO2 88%.[/SIZE].
Click to expand...

It would be nice to have a CC.
 
ahhhh you're right. I think it will give it away but here it is.

[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]A 75-year-old Caucasian woman presented with sudden onset of shortness of breath for the past four days. The patient had progressively worsening dyspnea on exertion. However, on the day of admission she had dyspnea at rest without associated chest pain or palpitations. Review of systems was positive for low back pain of three weeks duration. She denied fever, chills, cough, abdominal pain, weight gain or loss, changes in bowel and urinary habits.[/SIZE].
 
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]The initial laboratory studies were significant for a brain natriuretic peptide (BNP) level of 648 pg/mL, hematocrit of 32.7%, hemoglobin of 11.1 gm/dL, and potassium of 3.2 mEq/L. There was no elevation in cardiac enzymes. Her blood gas: (Ph 7.44, Pco2 44 mmHg, Pao2 58 mmHg)[/SIZE].
 
Anybody in her house on digitalis? Was a level sent? If Wellen's, how do we account for the t wave inversion in lead I?
 
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airwaymastaflex said:
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]A 75-year-old Caucasian woman presented with sudden onset of shortness of breath for the past four days. The patient had progressively worsening dyspnea on exertion. However, on the day of admission she had dyspnea at rest without associated chest pain or palpitations. Review of systems was positive for low back pain of three weeks duration. She denied fever, chills, cough, abdominal pain, weight gain or loss, changes in bowel and urinary habits.[/SIZE].
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airwaymastaflex said:
Oh and she smoked crack 2 weeks ago.
Click to expand...

75 year old crack smoker. Those are the best.
 
wandering atrial pacemaker -- Irregularly irregular rhythm + lead II has 3 different P waves with differing morphologies and PR intervals

I dont think there is a second degree block. There is a P for every QRS.

TWI anterolateraly could be ischemic



active pulmonary disease? electrolyte abnormalities? cardiac enzyme elevation?
 
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Looks multi focal atrial arrythmia secondary to acute CHF and/or pulmonary HTN from smokin crack, which is a cause of sick sinus rhythm. Diffuse ischemia from pericarditis is possible.

What is the CXR and are there rales?
 
I just like the OP's avatar. When I look at his posts, out of the corner of my eye, it seems like Cartman is a school teacher pointing to the blackboard with his nightstick.
 
I must say that I'm not sure where you are going with this from an EM perspective. If you are asking what the differential is obviously it ranges from ACS/PE/ too rare crazy drug/viral induced cardiomyopathies and dyskinesia of the heart… … Although I did state that hypo-K+ is a possibility and she has a K= of 3.2 that is low, but NOT low enough to cause inversion of the T waves like THAT. If the changes are new… and I MUST assume the lateral T-wave inversions are new, given her presentation and no old EKG than there is some type of early ischemia or repol event causing the electrical inversion in the ventricles. In my mind that means that either the apex of the ventricles are very slow to repolarize (HELLO early ischemia… negative troponin ONCE means NOTHING) or the base of the ventricles are very quick…. Seeing that she is not on Digoxin AND she has a rather long QT the base of the ventricle are less likely to be "quicker" than the apical portion… in real life this pt needs to be treated for ACS Heparin, ASA, Beta-blocker, nitro etc.. and sent to cath or at least get a STAT echo… that is where the definitive answers will be found. So my bet is on the former (one of the weird cardiac dyskinesia problems) not to mention a bnp above 600 seems to point toward cardiomyopathy induced CHF. So there is some distal / apical ventricular problem. As an EM Doc I DON'T CARE what is going on in the ventricle… just that it is BAD right now. REGARDLESS the findings she needs to be treated as ACS so she can get the cath and the pt can get definitive treatment ... whether that was the heparin you give in the ED (ACS, PE), getting a stent or finding something rare or funky cardiomyopathy on the cath.

Sorry I ramble a little, it's like I'm tired or working to much or something????? Imagine that.

Tkim… Aren't you in NY? Wazzzup! DUDE! Long time no see. Hows the wifey and kid (Kids?).
 
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StudentDoc327 said:
wandering atrial pacemaker -- Irregularly irregular rhythm + lead II has 3 different P waves with differing morphologies and PR intervals

I dont think there is a block. There is a P for every QRS.
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Keep in mind that a P for every QRS doesn't rule out a "block." You might be better off finding a P without a QRS.

Will
 
tkim said:
The fam is doing good. And yours? How's PA treating you?
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We love it here! Kinda scary eh? I still have my westernu account or you can PM me in here. You know that Jackie is down at ERMC in Philly? Got to run

-Ryan
 
I second Wellen's syndrome. Needs immediate cath, at least a cardiologist at bedside refusing heart cath, because this is indicative of "The widow maker lesion". Note the article states that should recieve early heart catheterization even though it is not STEMI.

See link below, looks pretty similar to me.

Emedicine:http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijc/vol3n1/wellens.xml

Serap Sobnosky, Rajan Kohli, Samer Bleibel: Wellens' Syndrome. The Internet Journal of Cardiology. 2006. Volume 3 Number 1.


"Although the electrocardiographic (ECG) changes for Wellens' syndrome are easy to recognize, many cardiac care unit nurses and staff physicians may not be aware of their significance. Wellens' syndrome is a pattern of ECG T-wave changes associated with critical, proximal left anterior descending artery (LAD) lesion. Thus, it is vital that this finding gets recognized promptly. Classically, the ECG findings of Wellens' occur during the pain free period of angina. We present a clinical variation of Wellens', where the typical ECG findings manifested during the pain episode."
 
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[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]The patient was transferred to the Coronary Care Unit with a preliminary diagnosis of Acute Coronary Syndrome. She was started on aspirin, metoprolol, simvastatin, nitroglycerin, heparin and integrilin. She also underwent an emergent angiography which revealed a severely depressed left ventricular systolic function and global hypokinesia with an estimated left ventricular ejection fraction (EF) of 25 percent. There were no significant fixed lesions noted on angiography (left main, right coronary artery, posterior descending branch and posterior lateral branch were all patent; the left anterior descending and the diagonal arteries had a 10 percent stenosis each (Figure 3 & 4). Echocardiogram done on the same day revealed an EF of 25%, mild LVH with apical, anteroseptal, distal inferior and lateral wall motion abnormalities. [/SIZE].

Their discussion....

"The differential diagnosis of LV dysfunction with normal coronaries in an otherwise healthy female is quite limited. It includes cardiomyopathies (caused by virus, alcohol or infiltrative disorders) and apical ballooning syndrome."

This patient had a rare syndrome called the apical ballooning or Tako-tsubo syndrome

From an EM stand point however, I appreciate everyone's input on ED management.
 
"I just like the OP's avatar. When I look at his posts, out of the corner of my eye, it seems like Cartman is a school teacher pointing to the blackboard with his nightstick. "

you just gave me a great idea...
 
Looks inferior, with ST elevations is II, III, AvF (also laterally in V6), with recip changes in V1-V3. Would like to see a right sided ECG to rule out right ventricle involvement before doing anything to drop preload.
 
airwaymastaflex said:
How about this one? 28 y/o guy with chest pain
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Well the top of my differential list is pericarditis (with perhaps some fusion beats), but MI ought to be considered also (although odd in a 28yr old).

Ugh.. this year as a surgical intern has really blunted my EKG skills (skillz?). It'll be nice to get back into the ER in July.
 
Doctor Bob said:
Well the top of my differential list is pericarditis (with perhaps some fusion beats), but MI ought to be considered also (although odd in a 28yr old).

Ugh.. this year as a surgical intern has really blunted my EKG skills (skillz?). It'll be nice to get back into the ER in July.
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Maybe I'm wrong, but I didn't think you got reciprocal changes with pericarditis. I thought all leads were elevated (actually more like PR depression with pseudo-elevation of the ST).

My vote is for MI or thoracic aortic dissection with extension into the coronary arteries. A clinical history would help point to the correct one, but most likely it's an MI. Even if he is 28 years old, he needs to go to the cath lab. Because of our fantastic American diet, we are seeing more people in their 20's who are having MI's.
 
airwaymastaflex said:
[FONT=Verdana, Arial, Helvetica, sans-serif][SIZE=-1]"...in an otherwise healthy female is quite limited. It includes cardiomyopathies (caused by virus, alcohol or infiltrative disorders) and apical ballooning syndrome."
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1. I'm not certain she would classify as an otherwise healthy female with a h/o crack. Common things being common, I sense the origin of her non-ishemic cardiomyopathy is in her habits.

2. looks more inferior MI than pericarditis, especially with CP. In the ER setting, he needs an echo and to go down the hall to cath. The etiology for a 28yo can be determined later -- i.e., is he the grandson of the first EKG and do they have the same supplier, familial hypercholesteremia, some wierd vasculitis, too many Big Mac attacks?

To miss an MI in a young guy is to need asset protection.
 
DogFaceMedic said:
To miss an MI in a young guy is to need asset protection.
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Which is why, regardless of the patient or presentation, it still needs to be in the differential.

However, I thought the idea of this exercise was to develop the differential, not necessarily the diagnosis up front.

To tunnel vision in on an MI is to miss other things. I'm not saying my idea of pericarditis is right, but EKG or no EKG, chest pain in a 28 year old male ought to include it in the differential... along with the MI of course (and a host of other things).

And that's what the eventual work up will do... eliminate the wrong parts of the differential.

Unlike every other area of medicine, EM is a field of sensitivity, not specificity.
 
Doctor Bob said:
Which is why, regardless of the patient or presentation, it still needs to be in the differential.

However, I thought the idea of this exercise was to develop the differential, not necessarily the diagnosis up front.

To tunnel vision in on an MI is to miss other things. I'm not saying my idea of pericarditis is right, but EKG or no EKG, chest pain in a 28 year old male ought to include it in the differential... along with the MI of course (and a host of other things).

And that's what the eventual work up will do... eliminate the wrong parts of the differential.

Unlike every other area of medicine, EM is a field of sensitivity, not specificity.
Click to expand...

Agreed. It could go either way.
 
12 year old EKG - the med student is pimping us (ie, he didn't see this patient). Inferior wall STEMI. 28 years old? I'm betting from Bangladesh. When I was prelim in Queens, it was common - seriously - to see AMIs in Bangladeshis under age 35 - common. We even said that it should be an independent risk factor.
 
12 year old EKG - the med student is pimping us.
Click to expand...

Question: Is pimping easy?

Hells yea.

Somehow that is also correct.
 
The second EKG I'm going to send to the cath lab. I might tell the cardiologist that "hey, this might be pericarditis, but..." especially if there are _no_ risk factors, but very bad things can and do happen when there are no risk factors.

I did that last night, actually. Young-ish guy (30), with a really good story of abrupt onset chest pressure, disphoresis, SOB, nausea, the whole nine yards. Didn't improve with movement, improved greatly with nitro... Sent him up. Told him I hoped it was "only pericarditis" but since his ST elevations seemed concentrated in contiguous leads, I wasn't going to take a chance. No reciprocal changes, which is why I was holding out hope this dude wasn't infarcting.

The call from cards an hour later confirmed clean coronaries and pericarditis. It's a much better call than "the dude you sent up coded before we could even get access."
 
More history on this guy... This is the nephew of the 75 year old lady that smokes crack who's EKG is shown initially. He had an MI last year at the age of 27, got cathed, did not follow up with cardiology since and is not taking his meds.

His girlfriend brought him into the ED after finding him unresponsive. He came to his senses within seconds of her stimulating him. He presented to the ED in tears saying he had substernal chest pain radiating to left arm 7/10 sharp. Pain is worst when he lies flat and is relieved when sitting. He notes the pain starting 6 hours ago, took some aspirin, and then only remembers finding himself on the floor with his girlfriend at his side.
 
airwaymastaflex said:
More history on this guy... This is the nephew of the 75 year old lady that smokes crack who's EKG is shown initially. He had an MI last year at the age of 27, got cathed, did not follow up with cardiology since and is not taking his meds.

His girlfriend brought him into the ED after finding him unresponsive. He came to his senses within seconds of her stimulating him. He presented to the ED in tears saying he had substernal chest pain radiating to left arm 7/10 sharp. Pain is worst when he lies flat and is relieved when sitting. He notes the pain starting 6 hours ago, took some aspirin, and then only remembers finding himself on the floor with his girlfriend at his side.
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Am I missing something? That EKG says it was July 4th, 1997. You sure it happened last year?


Will
 
Willamette said:
Am I missing something? That EKG says it was July 4th, 1997. You sure it happened last year?


Will
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You guys should look at the URLs of these images he is posting. This is the case where he got the first one (no crack smoking):
http://www.amc.edu/amr/archives/200602/case2.html

The second one is from a totally different website, but I can't access any info on the case. I doubt they are related though.
 
airwaymastaflex said:
How about this one... 38 y/o guy felt funny at a baseball game
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As doctors know, the story is an important part of the case. You've already been shown to have made up the history on two other cases, which makes it all deceptive. Just posting EKGs with made up histories is not helpful.
 
dsc00814g.jpg


This isn't a hard one, but I couldn't figure out if this was afib or aflutter?

1. I don't see a sawtooth pattern, which makes me want to rule out aflutter. At the end it does start to look a bit sawtooth, though!
2. First part has more chaotic P waves or just electrical activity, like in afib. However the R-R seems pretty regular, except between the 2nd and 3rd QRS complexes, so it makes me think it isn't afib?
3. Ventricular rate is about 150, so suggestive of a possible 2:1 AV block like in atrial flutter.

Overall I'm guessing it is atrial flutter. Any help in how to approach this properly or where I am going wrong?
 
leviathan said:
dsc00814g.jpg


This isn't a hard one, but I couldn't figure out if this was afib or aflutter?

1. I don't see a sawtooth pattern, which makes me want to rule out aflutter. At the end it does start to look a bit sawtooth, though!
2. First part has more chaotic P waves or just electrical activity, like in afib. However the R-R seems pretty regular, except between the 2nd and 3rd QRS complexes, so it makes me think it isn't afib?
3. Ventricular rate is about 150, so suggestive of a possible 2:1 AV block like in atrial flutter.

Overall I'm guessing it is atrial flutter. Any help in how to approach this properly or where I am going wrong?
Click to expand...


The R-R looks variable in all - although a 12-lead would help find flutter p waves in other leads. One tool, if not too tachy, is measure P-R for regularity. P-R looks variable.
This is one where the calipers are helpful. It looks like Afib.

If very unstable in the ER the treatment is still the same - juice. And, if not done well, a side order of silvadene.

I was with a cardiologist a few weeks ago on a SVT case that turned out to be flutter. She gave adenosine without warning; not great bedside manner. The pt thought she was having the big one.

As a note: Apollyon seems entirely accurate about the OP
 
leviathan said:
dsc00814g.jpg


This isn't a hard one, but I couldn't figure out if this was afib or aflutter?

1. I don't see a sawtooth pattern, which makes me want to rule out aflutter. At the end it does start to look a bit sawtooth, though!
2. First part has more chaotic P waves or just electrical activity, like in afib. However the R-R seems pretty regular, except between the 2nd and 3rd QRS complexes, so it makes me think it isn't afib?
3. Ventricular rate is about 150, so suggestive of a possible 2:1 AV block like in atrial flutter.

Overall I'm guessing it is atrial flutter. Any help in how to approach this properly or where I am going wrong?
Click to expand...

Alternating or intermittent fib/flutter is not at all uncommon and, at first glance, this is what I thought was going on here.

And while it is of academic interest, practically, it doesn't matter. If HD unstable --> better living through electricity. If HD stable --> better living through chemistry. They both need rate >> rhythm control
 
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