Monday, December 1, 2014

EKG Challenge #5: Chest Pain So Bad I Fell Out

A middle-aged woman with no significant medical history presents after a syncopal episode.  She is now complaining of shortness of breath and chest pain that radiates to her shoulder and jaw.  She has no other pertinent history besides being a smoker and her father having a myocardial infarction at an early age.  Her vitals are initially stable, but she soon becomes tachycardic and hypotensive.  Her labs are drawn and her ECG is below:

What is your differential diagnosis?  What would you do next?

Click here to be connected to the Case Conclusion.


  1. early presntation inferior MI
    ? brugada syndrome
    activate cath lab

  2. ddx:
    1 anterior stemi
    2 big pe
    3 pericardial effusion/tamponade
    3 dissection
    4 can't exclude brugada yet

    to do:
    1 quick bedside US, eval for effusion and check RV, with phone on shoulder to
    2 activate cath lab if US not obvious
    3 if you want you could check posterior leads for reciprocal depressions

    Yay, great case, can't wait for the conclusion...

  3. With the inferior Q waves, ST elevation in V1-V3 and hypotension this could be a right sided infarct. Another ECG with right sided leads would be helpful.

  4. S1 Q3 T3, concern for syncope and hypotension secondary to a saddle PE embolus. Vigorous fluid resuscitation, emergent ECHO, consider tPA either with confirmation or as a heroic measure, emergent thrombectomy.

  5. Elevation v1v2v3?
    I am just learning ekgs
    Hopefully anyone can put me right please

  6. Due to the elevation in AVR I am going with LMCA occlusion

  7. Agree with the Colonel. Although there is anterior ST elevation, she is also exhibiting evidence of right heart strain. Sudden onset CP with syncope argues more strongly for large PE.
    What's the most common EKG finding in PE?
    Sinus tachycardia. (HR of 150 here)
    What's the classic EKG finding in acute PE?
    S1 Q3 T3 (clear in this patient)
    What other EKG findings are to be found in acute PE?
    Anterior ischemia - TWI most commonly, also RBBB.

    What would I do?
    IVF, activate MI pager, and if I'm able to get better BP, then get an emergent CT PE protocol. If there's not an obvious large embolus then continue with cath lab activation.
    Once PE is confirmed, this patient needs thrombolytics unless she had trauma with fall, in which case I would go for catheter-directed intra-arterial thrombolysis.
    If still unstable, then bedside Echo looking for RV dilation and strain. If present, thrombolysis.

  8. Great discussion everyone, will have the case conclusion up tomorrow. Stay tuned.