ECG of the Week: ECG of the Week - 11th September 2017

Wednesday, 13 September 2017

ECG of the Week - 11th September 2017 - Interpretation

This ECG is from a 45 yr old who was found in a collapsed state in the street.

Click to enlarge

Rate:

66 bpm

Rhythm:

Regular
No clear p waves

Axis:

Normal

Intervals:

QRS - Prolonged (240ms)
QT - 520ms (QTc Bazette 545 ms)

Additional:

J waves leads II, III, aVF, V2-6
ST Depression leads II, III, aVF, V4-5
Subtle ST elevation leads aVR and aVL
T wave inversion leads II, III, aVF
Biphasic T lead V4-5 possible T-U fusion

Several differentials for these ECG features especially given clinical scenario including:

Hypothermia - must likely - junctional / escape rhythm, J waves, QT & QRS prolongation
Intracerebral pathology - clinical collapse, can cause J waves and QT prolongation
Drug toxicity - loss of normal sinus rhythm, can cause J waves, QRS and QT prolongation, also can be a cause of hypothermia

Remember J waves are not pathognomonic of hypothermia and can be seen in association with hypercalcaemia and raised ICP.

What happened ?

The patient had multiple acute medical issues:

Severe hypothermia - core temperature 25.9 C (78.6 F)
Coma - GCS 3 (E=1, M=1, V=1)
Hyperkalaemia (7.2 mmo/L) and acute renal failure
Hepatic failure with coagulopathy
Likely polypharmacy overdose

Despite early aggressive resuscitation, rewarming and renal replacement therapy the patient had progressive multi-organ failure and did not survive.

Causes of hypothermia

There are multiple potential causes of hypothermia including: