Wednesday, 25 February 2015

ECG of the Week - 23rd February 2015 - Interpretation

The following ECG is from a 50 yr old male. Nil relevant past medical history. The patient had an out-of-hospital witnesses cardiac arrest with immediate bystander CPR. On paramedic arrival he was found to be in VF and ROSC was achieved following DC cardioversion.

On arrival to the Emergency Department the patient was agitated and combative with episodic abnormal posturing. 

Vital signs: GCS ~5-7 (M=2-4 E=1 V=2), BP 136/78, RR 12, Temp 36.5 (97.7F), BSL 8.4 mmol/L, Sat 100% on 15L/min

The patient received iv sedation to facilitate initial assessment, his ECG is below.

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Click to enlarge
Rate:
  • 66
Rhythm:
  • Sinus arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (160ms)
  • QRS - Normal (80-100ms)
  • QT - 415 ms (QTc Bazette 435 ms)
Segments:
  • Inferior ST Depression
Additional:
  • U waves precordial leads
  • Notched P wave in inferior leads with bifid p wave in V1
    • Consistent with LAE pattern
Interpretation:
  • Non-diagnostic ECG
    • Minor ST segment change
    • Nil clear arrhythmogenic cause
    • Nil evidence of acute myocardial infarction

What happened ?

The patient was promptly intubated following RSI, a VBG showed relatively normal acid-base and electrolytes. Urgent CT head was performed which was normal and an emergent coronary angiogram showed only minor vessel irregularity.

During his ICU stay the patient had 2 further episodes of VF requiring DC cardioversion, rhythm strip of one event below.

Click to enlarge
Long-short coupled PVCs with resultant VT --> VF
The patient was treated with quinidine and a cardiac MRI showed an isolated area of delayed enhancement in the anterolateral basal mid LV wall with features favoring  cardiac sarcoid with a differential of acute myocarditis. The patient had an AICD inserted and was discharge from hospital following an 11 day stay.

Sometimes the emergency ECG doesn't always give us the answer !



References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.