Diabetic, malaise pt, no cp,sob/dib

[7887firemedic]

Had me suspicious, silent mi? Early repolarization????

 

[7887firemedic]

Obviously there is lvh, but when measured from the j point i came up with 4mm elevation. Will lvh show that much elevation?

 

[medicsb]

Not a good tracing. Have another?

 

[7887firemedic]

Best I could get, others were trash

 

[NomadicMedic]

Why would you say early repol? Was the guy a younger, fit, african american? I didn't see any notched J points.

Just looks like LVH to me, typical STEMI mimic.

 

[Handsome Robb]

What he said. ^

 

[RocketMedic]

Depends on patient presentation, but I'd be strongly suspicious of dismissing it as "just" LVH. Something in this seems to be more of a lateral slowing, which could be ischemia. I'd transport him to a level-one cardiac center and get that ECG transmitted to the cardiologist if at all possible from the field...when in doubt, call out.

Out of curiosity, how was he presenting?

V3,4,5 all show that elevation and curve, but also look at V6- you've got that elevation and return to baseline with a U wave. Those are not good squiggles and I would be highly suspicious of an MI if new in presentation, or perhaps one of these:
(Shamelessly ripped from http://en.wikipedia.org/wiki/U_wave)
Prominent U waves are most often seen in hypokalemia, but may be present in hypercalcemia, thyrotoxicosis, or exposure to digitalis, epinephrine, and Class 1A and 3 antiarrhythmics, as well as in congenital long QT syndrome, and in the setting of intracranial hemorrhage.
An inverted U wave may represent myocardial ischemia or left ventricular volume overload.[2]
A U-wave could normally be seen in younger, athletic individuals. Reference: EKG-boken Ylva Lind, Lars Lind, Liber, 2011

With malaise, I'd suspect the worst- AMI (LCA?) or possibly metabolic derangement/electrolyte imbalance.

 

[VFlutter]

Anyone else notice the variation in T wave between the first and second beats in v4-6? The second beat looks more concave than the first

 

[RocketMedic]

Anyone else notice the variation in T wave between the first and second beats in v4-6? The second beat looks more concave than the first

Yep...electrolyte, potentially?

 

[NomadicMedic]

That's a pretty crappy tracing to call that a U wave. I'd agree with the possibility hyperK+, but the QRS is still rather narrow, but I'm guessing this is a newer onset.

I don't think I'd be overly excited about this patient from a cardiac standpoint... But I'd be working to get a cleaner 12 lead on the way in to the ED.

 

[Aidey]

Anyone else notice the variation in T wave between the first and second beats in v4-6? The second beat looks more concave than the first

Yes, and frankly due to that I would not treat this as a diagnostic quality 12 lead.

 

[7887firemedic]

Depends on patient presentation, but I'd be strongly suspicious of dismissing it as "just" LVH. Something in this seems to be more of a lateral slowing, which could be ischemia. I'd transport him to a level-one cardiac center and get that ECG transmitted to the cardiologist if at all possible from the field...when in doubt, call out.

Out of curiosity, how was he presenting?

With malaise, I'd suspect the worst- AMI (LCA?) or possibly metabolic derangement/electrolyte imbalance.

No transmitting capabilities, wish we could though.

Anxious and unable to describe. Couldnt tell me anything besides he didnt feel right. Red flag to me! Dialysis staff reported episodes of confusion and not acting normal.

Yep, caught my attention quickly plus pt was hypertensive and irregular pulse. Nothing sat right with me on this run, thats why i posted it all. I was/am not comfortable saying just lvh, just bbb etc... Especially on this pt

Yep...electrolyte, potentially?

Perhaps and a possabilty, pt recieved 2 hours of dialysis before staff called ems

That's a pretty crappy tracing to call that a U wave. I'd agree with the possibility hyperK+, but the QRS is still rather narrow, but I'm guessing this is a newer onset.

I don't think I'd be overly excited about this patient from a cardiac standpoint... But I'd be working to get a cleaner 12 lead on the way in to the ED.

Indeed, not the best tracing but best i could get, crappy backup monitor.

See above, this was the best out of all the 12 leads i did and pt was perfectly still, used a brand new pack of electrodes, sometimes we get the already opened packs with the dried out electrodes. Didnt want to spend any more time versus a 5 min transport

 

[7887firemedic]

And this was a dialysis pt, recieved 2 hours before staff called ems. Should have put that in my title, oops

 

[NomadicMedic]

Yeah the dialysis is a red flag for hyperK

 

[Brandon O]

Have a rhythm strip?

 

[Aidey]

That isn't hyper K though. Well, the pt could have hyper K, but the EKG isn't showing hyper K.

To get technical, a dialysis pt with long term poorly controlled potassium is unlikely to show EKG changes indicative of hyperkalemia unless they have an acute spike in their potassium intake/output that causes a significant elevation in serum potassium levels. When potassium levels rise slowly, the body reacts by leeching calcium from the bones and causing a rise in calcium levels to counteract the potassium. Because of this the EKG doesn't change, or the changes are subtle compared to the potassium level.

 

[NomadicMedic]

Right. I'm guessing the OP has got some zebra to spring on us, because as I mentioned before, it looks like a crappy 12 lead with LVH. No doubt the guy is sick, but I don't see a "holy #%&$" cardiac issue here.

 

[Christopher]

That isn't hyper K though. Well, the pt could have hyper K, but the EKG isn't showing hyper K.

To get technical, a dialysis pt with long term poorly controlled potassium is unlikely to show EKG changes indicative of hyperkalemia unless they have an acute spike in their potassium intake/output that causes a significant elevation in serum potassium levels. When potassium levels rise slowly, the body reacts by leeching calcium from the bones and causing a rise in calcium levels to counteract the potassium. Because of this the EKG doesn't change, or the changes are subtle compared to the potassium level.

Agreed.

The ECG shows a sinus rhythm with 1st degree AVB and high left ventricular voltage in V4-V5 consistent with LVH. The T-waves are, if anything, smaller than expected. The ST-segments are all presumably normal, with artifact obscuring the anterior precordials. I see no acute ischemic/infarction related changes and no changes suggestive of hyperkalemia.

Post dialysis I'd be more apt to believe this is a low-potassium problem or low-BGL problem.

Actually, I'd more likely believe this to be a volume problem over anything else!

 

[medicsb]

The precordial leads are too distorted to be sure of much of anything beyond what the limb leads show. If I was the receiving doc, this 12 lead would go to the trash while a better one was acquired.

 

[Aidey]

A dialysis pt with malaise is an infection until proven otherwise.