Strip Tease 10

[FL_Medic]

81 y/o female with altered mental status.

[Tom B.]

<s>It's the ghost rhythm. I've not seen it before</s>.

I can see it now!

Tom

81 y/o female with altered mental status.

Edited May 26, 2009 by Tom B.

[Kiwiology]

Rate: 60 (both atrial and ventricular rate are the same)

Regular: Yes

P waves: Yes, before each QRS (no extrasystoles)

PR interval: Seems normal but could almost be 0.16 seconds as the tracing is not great

QRS complex: seems to be an RS complex with no ventricular extrasystoles

T wave: Depressed, very depressed in V2-6 and appears nonexistant in aVL although the depression may be very small

Is this a bradycardic escape rhythm perhaps?

[Jeepluv77]

How come I still can't see it!?

[Kiwiology]

click the image and you can it opens in a new window

[fiznat]

copy this to your browser:

http://2.bp.blogspot.com/_7zQULPNQ7FQ/Shvo...tripTease10.jpg

Regular, narrow-complex rhythm with regular, monomorphic p-waves. There is left axis deviation, I'd guess at about -150 degrees. I'm going to call this a sinus rhythm (possibly sinus brady) with global T wave inversions. T wave inversion like this is indicative of cardiac ischemia, and should be treated as such. Another interesting thing I found is that a preponderance of patients presenting with these changes are female. Any idea if this was a man or a woman?

Edited May 26, 2009 by fiznat

[Tom B.]

The altered mental status has me concerned. I would immediately inspect the head for trauma and consider this a neuro patient until proven otherwise. Neurological truama and/or intracranial pressure can create T wave abnormalities. In addition, the QT interval is considerably prolonged (QTc of about 575). This patient needs a cat scan and blood work.

Tom

[fiznat]

In response to Tom:

I did read about that. Supposedly a good number of post-ictal patients have ECGs with global T wave changes like this. Maybe our patient had a seizure? Something to think about, as well as CAD/ACS.

[FL_Medic]

If anyone is wondering about the black bands. It is the Insert: SPOILER tool. It is being used to display the answers of the posters without them accidently being seen by the unwilling.

[FL_Medic]

The answer:

Highlight below, only if you want to see the answer.

This was an ECG from a medscape CME activity. I thought it would be a good example of non-cardiac ECG changes. This is an ECG from a patient with frontal bilateral subdural hematomas. Good job Tom and fiznat.