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You can read the case conclusion here.
Monday, July 20, 2015
EKG Challenge No. 14: Elderly gentleman BIBW (brought in by wife) ....
On a Sunday afternoon, an elderly gentleman is brought into the emergency department by his wife complaining of chest pain that began one hour ago. He is diaphoretic and appears uncomfortable. An EKG is obtained:
You have no prior EKGs available for comparison, but the patient denies any prior history of acute MI or CHF. Interpret the EKG. What do you think is going on? What do you do next?
You can read the case conclusion here.
You can read the case conclusion here.
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DeleteI suppose an infarct(ation)
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ReplyDeleteTrigeminal unifocal PVCs, without a SpO2 pleth or pulse rate tough to know if they are perfusing or not, however even if they're not the normal QRS complexes have a rate >60ish, so we can rule out symptomatic bradycardia as a problem.
ReplyDeleteThe rhythm is supraventricular in origin, for every QRS that isn't a PVC we have a p-wave, and the PRI isn't prolonged, not progressing in length, randomly dropping complexes, or completely dissociated, so we can cross out 1rst, 2nd, and 3rd degree blocks; and call it a Sinus Rhythm. I hesitate to call it NSR, mostly because NSR shouldn't have trigeminal PVCs.
Looking at the QRS complexes, without using a ruler and just counting, the QRS appears to be just over 0.12seconds, terminal deflection in V1 is negative, so it's a LBBB, and there is also Left Axis Deviation, so this is consistent with the LBBB.
This LBBB isn't normal looking, so Sgarbossa criteria can come into play as well, which will support the Dx of Septal-Anterior STEMI with Lateral extension.
-Lead I & aVL have cordinant T-waves, which indicates a significant ST changes in LBBB, and aVL has ST Elevation in addition to T-wave inversion, so I'm comfortable calling both of those changes together STEMI equivalent.
-Leads V1-4 all look like a LBBB, however add Sgarbossa criteria into it and V2 has >5mm ST Elevation, now if we use modified Sgarbossa criteria, the ratio between the STE & S-Wave depth is >0.2, which is highly specific for Dx of STEMI; and all of these changes leads me to Septal-Anterior STEMI.
-Lead V5 also has a cordinant T-wave, indicating ischemia changes.
-Finally Leads II, III, & aVF, ST segments are depressed, and cordinant T-waves are present in all, making the inferior leads our reciprocal changes.
T-waves in V2-5 appear to be hyper-acute to me, they don't have the normal appearance of a LBBB.
So my synopsis of this ECG: Acute Anterior-Septal STEMI with Lateral Extension in the presence of a LBBB, and a Sinus Rhythm with Unifocal PVCs that are likely due to ischemia of the conduction system.
Unfortunately this man didn't present by calling 911 and getting in my ambulance, but hopefully he presented to a ED with PCI capability.
Treatment Plan (Since I'm a Paramedic, I'll treat as if he did call 911):
-ASA 160mg PO
-Oxygen w/ EtCO2 monitoring just to keep SpO2 >94%
-12-Lead Transmission to VHR Cardiologist to confirm STEMI and activate cath lab
-I highly doubt I would get orders for TNK, because this is a rather complicated STEMI, but depending on transport time to hospital & availability of the cath lab I might, but again, doubtful.
-IV access x2 in the left arm so then right radial isn't impeded for the cath
-Ticagrelor 180mg PO
-Enoxaparin 30mg IV and 1mg/kg SQ
-Nitro 0.4mg SL PRN depending on BP & pain
-Fentanyl 25mcg SIVP PRN titrated to pain
-Depending on distance to hospital, he may get either a Nitro patch or a Nitro Drip
-Defib Pads connected to the monitor, however not attached because we're going to do serial 12-Leads.
Once he's out of my care, he'll go for cath and they'll likely be finding the lesion to be somewhere LCA, and depending on how many vessels are involved, this poor guy might get a CABG.
Also where I work we have the REMCON study, essentially it's evaluating if remote ischemic conditioning has positive effects on an MI, so the patient might be randomized into that as well.
Cheers,
Sean EMT-P / Advanced Care Paramedic
Edmonton, Alberta, Canada
V.trigeminy
ReplyDeletelbbb
Modified Smith Sagarboss criteria + ve in chest leads
AWMI
V.trigeminy
ReplyDeletelbbb
Modified Smith Sagarboss criteria + ve in chest leads
AWMI
V.trigeminy
ReplyDeletelbbb
Modified Smith Sagarboss criteria + ve in chest leads
AWMI
Lots going on here... Wouldn't say LBBB since its not wide enough and since QRS is an average of 80-120ms in width. Thoughts?
ReplyDeleteSorry meant that to say 80-100ms...
ReplyDeleteThis ECG demonstrates what you can discern in the setting of a Bundle Branch Block. Generally, with BBB the terminal portion of the QRS complex and the ST Segment-T waves move in opposite directions. These are termed secondary T waves, are discordant, and are normal in the setting of BBB. If you look at limb leads II, III and aVF the terminal portion of the QRS complexes in the non-PVC complexes are negative, as are the ST Segments -T waves. These are primary ST-T waves changes, are concordant, and are suggestive of myocardial ischemia.
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