Tuesday, February 17, 2015

EKG Challenge No. 10: This one looks sick ...

You are working in the department when you get a pre-arrival for "abdominal pain".  You follow EMS into the room and are confronted with a middle-aged to elderly female who appears very pale and quite sick.  As she is placed on the monitor, you speak with her and she endorses some diffuse abdominal pain and nausea for the last two days.  Her initial blood pressure is 80/60 with a heart rate of 112, and you start working her up for all the badness that causes hypotension and abdominal pain in the elderly.  Everyone gets cracking on some IV access,  and you head for the ultrasound to help you better evaluate the cause of this patient's hypotension.  You start with the cardiac views of your RUSH exam, and see this:

 Given these findings, you order an EKG:

What is your differential?  What do you do next?  Please leave your comments.  Click here to read the case conclusion.

Thank you to Dr. Chris Holthaus for the echo video.


  1. ECG shows a poor R-wave progression with a pattern of ST-elevation consistent with STEMI, stress cardiomyoparthy, or pericarditis/myocarditis.

    Echo shows essentially akinesis of the apex and apical segments with paradoxical bulging during systole. There is also marked hypokinesis of the mid-septal wall; and while the lateral wall is not well visualized, the mid-lateral seems to contract better in comparison. Both basal segments contract normally by my inexperienced eye.

    Such a striking WMA on echo pretty much knocks pericarditis/myocarditis off our differential for now, leaving STEMI and SCM. The paradoxical apical movement certainly fits with SCM but the distribution could still indicate a mid-wraparound-LAD STEMI (fitting with the ECG) so the next step is likely going to be the cath lab—unless there's clinical/RUSH reasons to go down another path first.

    Great case! But I might suggest hiding the diagnosis a bit better because both the title of the ECG file and the other clips in the echo playlist give away the final diagnosis ;)

  2. I agree. Apical ballooning with septal hypokinesis, and ST elevations suggest Takotsubo cardiomyopathy. Of course this is a diagnosis of exclusion, even though there are some tell-tale ECHO findings. Many times this is discovered only after catheterization shows clean coronaries.

    ECG was looking more like pericarditis to me though, but that doesn't fit with clinical picture. This was on EMRap recently. Probably the only reason I remembered any of it.