Monday, March 30, 2015

EKG Challenge No. 12: Once Upon a Time in Triage

You are working as the "triage physician" in a busy city emergency department when a 34 yo female presents with chest pain.   The pain is retrosternal and burning in nature and has been persistent for 3 hrs.  It is associated with some nausea, but no shortness of breath or diaphoresis.  You order a GI cocktail and get an EKG:

 What is your differential diagnosis?  What would you do next?
 Read the case conclusion here


  1. The general go-downwardness of II catches my eye most. Then the general go-upwardness of aVR. The TWI of I, II, III, and aVF is odd. And to finish it up, there's the old S1Q3T3-ishness.

    DDx: inferior ischemia (due to the TWI), PE (due to the S1Q3T3 and patient history), and lead placement reversal due to aVR looking like an aVF and vice versa.

    Plan: go check the lead placement and ask questions to complete a Well's score.

  2. Leads likely attached incorrectly. Can't correctly interpret EKG until lead attachment corrected.

  3. Agree with lead placement errors with aVR being upright. However, P wave inversion can be seen in dextrocardia as can an upright in aVR. In addition p wave inversion can be seen in junctional rythm with retrograde conduction, T wave inversion in inferior leads could indicate ischemia. So, 1st check leads, if correct would perform an ECHO, which could detect both dextrocardia and wall motion abnormalities of inferior ischemia, if normal consider EP study. Most likely leads, then consider dextrocardia, then inferior ischemia then junctional with retrograde P.
    Martin Docherty