Friday 7 December 2012

ECG of the Week - 10th December 2012

This ECG is from a 69 year old male.
Have a look and think about what is going on, and what are you going to do ?





Click to enlarge

5 comments:

  1. Rate: yikes, err 40 bpm vent rate, no appreciable atrial rate
    Regularity: regular
    P-waves: none appreciated
    PRi: nonexistent
    QRSd: wide-wide @ 200 ms
    BBB: V1+ (qR it looks), RBBB
    Axis: indeterminate frontal axis, ventral Z-axis
    QTi: normal (< 1/2 R-R)
    T-waves: hard to interpret if appropriately discordant in most leads, but they tower over many of the QRS complexes
    ST-segments: elevated/depressed in multiple leads

    DDx:
    - Extensive MI (from thumbnail that's what I thought)
    - Hyperkalemia (rate, lack of atrial activity, bizarre appearance all point in favor)

    Depending on presentation will plot the course, a decent choice if you're not sure is probably calcium. Pacing won't be effective in HyperK+ without it.

    Labs and echo too.

    Very neat ECG!

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  2. Agreed... Would be helpful to know some history to lean one way or another.

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  3. Hopefully haven't double posted. Having commenting problems.

    What would I do? Google and Wiki causes of QRS widening.

    On a more serious note -
    ABC's
    If patient is clinically stable, take a history to establish underlying aetiology. In particular medication and whether there is any use of TCA or intentional drug ingestion.

    Ask for help from Dr Larkin.

    ABG/VBG to quickly exclude hyperkalaemia and assess UEC as well as acid-base balance (provided one hasn't haemolysed he darn sample)

    Treatment would depend on the underlying aetiology and patient's clinical status.

    Buy a coffee from T5 after referring onward to the appropriate inpatient team!

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  4. And also assess if patient needs pacing.

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  5. Hi guys,

    Thanks for the input this ECG seems to have generated more comment than usual.

    I would love to give you more information on this case but I actually don't have any info other than the ECG 'punchline'. I don't know any past medical history or the circumstances of the presentation.

    We look at a great number of ECGs every day without any, or very little, clinical context. This highlights the need for a systematic approach to ECG interpretation and formulation of a list of differentials. These can then be refined following history, examination, other investigation results, and they also allow us to prioritise workload, investigations, and treatment.

    Kevy, hope your buying the coffee after dragging me in to help :-)

    John



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