12 lead. Thoughts?

NomadicMedic

NomadicMedic

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79 year old female, unresponsive after a fall. Large hematoma on left sode of face, eye swollen shut. Dialysis pt, last dialysis on sat. Due again tomorrow. Also hx of lung CA and COPD. Blood sugar 126. Pressure 138/p HR 77, resp 16.

Here's the 12 lead.
4a545c8f-c74b-fb80.jpg


Hyperkalemia?
 
Hard to see on phone screen but that looks like a Wellens pattern to me
 
Smash said:
Hard to see on phone screen but that looks like a Wellens pattern to me
Click to expand...

So, I learned something new today. I have never been taught about Wellens, so had to go look it up.
 
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n7lxi said:
Hyperkalemia?
Click to expand...

If it is, I would think it is pretty early on. I don't think the T-waves are that tall or peaked. Also, it doesn't appear there is any sort of widening of the QRS complex, although I think that would be a later finding.
 
Differentials of anterior T-wave inversion:

- Pulmonary Embolism
- Wellen's Warning
- CNS changes

Another thing to consider is the R-wave progression (or Z-axis). The T-wave inversion seems to correspond to the transition, so it may just be something on their baseline ECG.

The T-waves themselves do not seem peaked enough to definitively go "HyperK+", but certainly reasonable to consider it as a possibility.

As for the likelihood of these based on the scenario? I'd rate CNS/Neuro and PE as high on my list as besides the isolated TWI the remainder of the ECG is unremarkable.
 
Epi-do said:
So, I learned something new today. I have never been taught about Wellens, so had to go look it up.
Click to expand...

As did I!

I did the same thing you did.

I learn something new from this site every day.
 
You can also see those deep symmetric t-wave inversions in head injury.
 
Yes, hyper K, but not significantly. Those T waves are classic for low level elevated potassium. Peaked and symmetrical.

Edit: And I'm not talking about the inverted ones, those aren't a potassium thing.
 
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I think we can safely say that the differential is rather long and that almost all possibilities are plausible.

Was it an arrhythmia due to ischemia that triggered the syncope? Possible.

Could it be changes associated with a head injury? Its possible - need a CT to be mostly sure (subarachnoid could possibly not be seen).

Could these findings be associated with hyperK in a dialysis pt.? Again, it's possible, though I'd place this a little lower on the list considering that she hasn't missed a session. (Assuming she wasn't down for a prolonged period of time.)

Could this be completely incidental; a normal for her? Absolutely (need an old ECG to know).

I recommend follow-up, if possible. but if they tell you her K is 6 (or 7 or 8 - considering that ECG changes are variable), I'd still be hesitant to call the changes as being secondary to hyperK, unless it reverted after the K was returned to normal.
 
I agree with the others in that the differential list based on the 12-lead and brief PE/HPI is numerous. The T-waves do look a little taller than normal and peaked which would lead me to think hyperkalemia given the history.
 
And symmetrical, which is an often overlooked but important piece of information. Ordinarily T waves are asymmetrical, and symmetrical T waves, in conjunction with other changes, are indicative of several things including hyperkalemia, Long QT and various types of neurological insults.
 
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I'll follow up and see what the story was. Thanks all.
 
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