Strip Tease 4

[chbare]

If the patient had no significant hemodynamic changes or indications of being in distress, and the only finding was an ECG with peaked T waves, I would not take active measures to treat the suspected hyperkalemia in the pre-hospital environment. Obviously, I would have calcium chloride ready to administer if needed and would emphasize the patient history and ECG findings in my radio report.

Take care,

chbare.

[FL_Medic]

Ready for more?

PT STATES HE WAS ASLEEP AND WAS WOKE OUT OF A SLEEP BY SEVERE SUBSTERNAL CHEST PAIN, 10/10 ON PAIN SCALE. PT STATES HE TOOK THREE OF HIS OWN NITROGLYCERIN AND CALLED 911. PT STATES AT TIME OF INITIAL EMS ASSESSMENT PATIENT'S PAIN WAS A 2/10 ON PAIN SCALE. PT DENIES NAUSEA, DIAPHORESIS, VOMITING, OR SHORTNESS OF BREATH. PT IS ALERT AND ORIENTATED. PT ADMITS TO DRINKING APPROX 5 ALCOHOLIC DRINKS THIS EVENING, AND STATES HE DID TAKE A VIAGRA THIS EVENING SEVERAL HOURS BEFORE BEDTIME. DURING INITIAL ASSESSMENT PATIENT STATES PAIN DID RE-OCCUR AND WAS NOW A 10/10, WITH RADIATION TO THE NECK AND JAW. PT IS STILL DENYING NAUSEA OR SHORTNESS OF BREATH.

Medical assessment:

Mental Status: Normal Mental Status for Patient, Oriented-Person, Oriented-Place, Oriented-Time, Oriented-Events, ; Neuro: Normal, ; Eyes: R: Reactive,; L: Reactive, ; Skin: Normal, ; Head/Face: Normal, ; Neck: Normal, ; LUQ: Normal (Soft, Non-Tender), ; LLQ: Normal (Soft, Non-Tender), ; RUQ: Normal (Soft, Non-Tender), ; RLQ: Normal (Soft, Non-Tender), ; GU: Normal, ; Cervical: Normal (No Pain or Deformities), ; Thoracic(back): Normal (No Pain or Deformities), ; Lumbar: Normal (No Pain or Deformities), ; Extremities: Upper R: Normal, ; Upper L: Normal, ; Lower R: Normal, ; Lower L: Normal, ;

Chest/Lungs: Chest Pain/Pressure (Non-reproducable), SEVERE PAIN 10/10 RADIATING TO NECK, AND JAW;

Vitals:

01:02 92/60 80 RR 20 Normal 97 Low O2 2/10 Right Arm (Supine)

01:12 88/60 78 RR 20 Normal 100 High O2 10/10 Right Arm (Semi-Fowlers)

01:24 86/56 72 RR 22 Normal 100 High O2 10/10 Right Arm (Supine)

01:31 118/63 72 RR 20 Normal 100 High O2 10/10 Right Arm (Trendelenburg)

01:38 108/60 68 RR 20 Normal 100 High O2 8/10 Right Arm (Trendelenburg)

Am I the only one seeing Osborn Waves here?

What was his temp?

Wouldn't the osborn waves be apparent on every complex within a single lead. I see them on maybe one or 2 complexes on the entire 12-lead. They could also be early-repol notches.

Edited April 21, 2009 by FL_Medic

[chbare]

Viagra and nitro? Lungs clear? A little fluid may be in order. I am not much into the old "shock position."

Take care,

chbare.

[FL_Medic]

Wasn't my call. I agree on the fluids, positioning doesn't hurt though.

[FL_Medic]

Anymore questions? We have talked a lot about hyperkalemia. Here is a guess, potassium is not the acute problem here.

I have a good follow up on this. Anyone want to diagnose and treat?

[Niftymedi911]

I'm gonna have to go with Acute Pericarditis Adam.

The lack of consistent and consecutive T wave inversions in the inferior leads don't really indicate true mycocardial injury.

The ST changes in all pericordial leads would indicate early repol.

But, the prominant ST elevation in V1-V6, with the distance of the ST segement divided by the tallest T-wave (ST/T Wave ratio) in V6 value is greater then 0.25, (0.33) ruling out Early repolarization and indicating possible Actue Pericarditis.

That's my crack at it.

Edited April 23, 2009 by Niftymedi911

[scubanurse]

Also known as J-waves, they are the upward deflection between the QRS and the T-wave. Best seen in the V-leads here

Thanks! I knew them as J-waves...

[FL_Medic]

I'm gonna have to go with Acute Pericarditis Adam.

The lack of consistent and consecutive T wave inversions in the inferior leads don't really indicate true mycocardial injury.

The ST changes in all pericordial leads would indicate early repol.

But, the prominant ST elevation in V1-V6, with the distance of the ST segement divided by the tallest T-wave (ST/T Wave ratio) in V6 value is greater then 0.25, (0.33) ruling out Early repolarization and indicating possible Actue Pericarditis.

That's my crack at it.

Fred,

First, read this, you'll appreciate it:

http://www.viamedica.pl/gazety/gazeta1/dar...indeks_art=1310

I'm with you on checking v6 for ST/T ratio (even though some heart docs preach V4), and I commend you on your effort to exclude early repolarization (one of the most common causes of STEMI mis-Dx).

Without changing your assessment strategy entirely, because it is a good one, I would like to add something. In the acute setting of rapid 12-lead interpretation when we are looking to exclude STEMI mimickers like early repol, make it easy on yourself. Reciprocal changes is a big one. S-T depression isn't the only possibility, what do you see in lead 3?

While early repol may cause ST-elevation (or J-point elevation) by dragging that J point up, not sure it would account for the discordant (inverted) T wave.

Early repol was an initial consideration for me as well with the notched J points which some have called osborn or J waves.

You have correctly ruled out early repol as a cause of this ST elevation.

Now lets talk about acute pericarditis:

A good Hx would help with your differential Dx. What would you ask?

The T wave inversion could be a clinical finding of CHRONIC pericarditis. ST-segment elevation in more than one coronary vascular territory makes the diagnosis of acute myocardial infarction highly unlikely. This is why the finding of diffuse ST-elevation coupled with PR depression is important.

This 12-lead does not show "diffuse" patterns of ST-elevation. The PR interval is not depressed. Use your TP segment, or bottom of your 1mv calibration line to determine true isoelectric line. The PR interval maintains it's position on that line (excluding some artifact).

I believe the Hx would follow this pattern, and r/o acute pericarditis.

Remember Fred, sometimes it is what it is. This might just be an easier strip than you were hoping for. I find myself looking for the same things when Corey sends out a simple BBB. We are always expecting more. Once again, I am very impressed with your analysis.

So knowing this, wanna retry?

Edited April 23, 2009 by FL_Medic

[Niftymedi911]

12 lead shows

Anteriolateral Wall AMI with poss borderline RBBB

Thanks for the compliment Adam, I've only learned from the best...... I too are not settling for just the basics, I tend to wanna know more and study more......

[FL_Medic]

Anyone disagree or have any other take on this??

You're welcome Fred.