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FORUMS > EKG CHALLENGE [ REFRESH ]
Thread Title: Tricky one
Created On Tue Jun 23, 2009 12:43 PM
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nymedic88
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THE ANSWER HAS BEEN POSTED. IF YOU WANT TO GUESS-- DO SO BEFORE READING PAST COMMENT 10

Ill warn you now. This one is tricky.

http://i16.photobucket.com/albums/b35/johnms88/12lead16yom-1.jpg


16yom 10/10 CP, body wide weakness, mild SOB. PT wasn't receptive to us questioning him, was visiting family in from out of state. Mother was not with us, guardian (aunt) said no past medical HX other than he was in the hospital 3 days ago for flu like symptoms with a fever, and they were resolved with motrin/tylenol and rest. Acute onset 10/10 stabbing/non-radiating CP about 20 min prior to our arrival. Vitals all stable and in normal ranges.

THE ANSWER HAS BEEN POSTED. IF YOU WANT TO GUESS-- DO SO BEFORE READING PAST COMMENT 10

Edited: Thu Jun 25, 2009 at 9:34 PM by nymedic88

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sheerin
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did you palpate the chest? Did anything make the pain better or worse? Did it get worse when he tried to lay down or lean back?
Any fever?

I'm going to guess pericarditis, but you said it's tricky so I'm probably wrong


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Zorfox
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Did you happen to ask if leaning forward made the pain better? One simple answer like that and you pretty much have your diagnosis if he answers correctly lol. If you know what I am hunting for I think you have the idea .

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nymedic88
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Originally posted by: sheerin
did you palpate the chest? Did anything make the pain better or worse? Did it get worse when he tried to lay down or lean back?
Any fever?

I'm going to guess pericarditis, but you said it's tricky so I'm probably wrong


There is Nothing at all that makes the pain better or worse. Constant pain with occasional bouts of worse "stabbing" pain.

Mild fever but he was still getting off of a fever from a couple days prior I would assume. This is not relevant to what is causing this ekg to look as it does.

I will wait until Tom B chimes in to see if he has seen this before. A little hint, i have been told that this/an EKG is a primary diagnostic tool for a certain "something", secondary being angio.



Edited: Tue Jun 23, 2009 at 11:46 PM by nymedic88

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roblanious
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It is interesting. Despite the ST elevation in the inferior leads, there seems to be global T wave inversions, looking a lot like stage III of pericarditis. However the onset of stage III is usually at least a week, and I don't think this patient has been sick for even a week. The general body aches indicate myocarditis which this can very well be.

But again, since you said this is a tricky one, I must assume there is a catch as things arn't as obvious as they seem.

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nymedic88
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Originally posted by: roblanious
It is interesting. Despite the ST elevation in the inferior leads, there seems to be global T wave inversions, looking a lot like stage III of pericarditis. However the onset of stage III is usually at least a week, and I don't think this patient has been sick for even a week. The general body aches indicate myocarditis which this can very well be.

But again, since you said this is a tricky one, I must assume there is a catch as things arn't as obvious as they seem.



Nope. Seems to be the same track everyone is taking. I'm not going to lie, its unlikely that anyone will get the answer, but its definitely an interesting EKG. Ill throw out another hint...I think this is more difficult than I am making it out to be..haha.

The patient has a 5 inch scar vertically just to the left of the sternum.

Like I said, we will see if Tom B gets it before i reveal.

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roblanious
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Tom likes to hide in the shadows until it appears everyone has exhausted their input or everyone seems to be on a concensus that he disagrees with.

Mentioning a scar on the patient's chest was pertinent info. Any other assessment finding you are holding back from us?

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HEWITTC4
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Left ventricular aneurysm?

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nymedic88
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Originally posted by: roblanious
Tom likes to hide in the shadows until it appears everyone has exhausted their input or everyone seems to be on a concensus that he disagrees with.

Mentioning a scar on the patient's chest was pertinent info. Any other assessment finding you are holding back from us?


This was left from us as well until we did the 12 lead. Both aunt and he said no past medical hx.

Nope hewitt. OT..If someone wants to chime in....Would this show up on a 12 lead?


Edited: Wed Jun 24, 2009 at 4:33 AM by nymedic88

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roblanious
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Well, if I did not know it was a 16 YOM, and saw the EKG, I would be concerned about the T wave inversions and would think of anterio-lateral ischemia. This patient is probably too young for Cardiac Syndrome X as well. Either way what we see is a left axis deviation with a right bundle branch block and left anterior fascicular block. Our job is to go through the differential diagnosis for these. What are the causes of inverted T waves as well as the causes of the LAD with bifascicular block. Being the patient is a kid, I would like to know the PMX in addition to the HPI listed.

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nymedic88
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Originally posted by: roblanious
Being the patient is a kid, I would like to know the PMX in addition to the HPI listed.


The past medical hx is the key to this case. This 12 lead, as i said, is the primary diagnostic tool for the "issue" here (second being angiography as i said before). I believe all of the information I have given is enough to get the answer if you knew what you were looking at. But ill give another clue.

We found out after finding the scar that "Oh, I forgot!"...the PT has had 3 open heart surgeries. Why?

Edited: Wed Jun 24, 2009 at 4:58 AM by nymedic88

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roblanious
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There could be many cases of congenital problems like Tricuspid atresia or Ostium Premum ASD repair surgeries. But I must admit, off the top of my head I am stumped.

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nymedic88
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Originally posted by: roblanious
There could be many cases of congenital problems like Tricuspid atresia or Ostium Premum ASD repair surgeries. But I must admit, off the top of my head I am stumped.


Getting warmer.

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roblanious
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Funny how people claim to have no past medical history but they have scars up and down and across their chest and/or abdomen or take 100 different medications.

Well for an 16 year old it is obvious it is a congenital heart defect. Which one though will be interesting to know. Thanks for keeping us in suspence you jerk.

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Edited: Wed Jun 24, 2009 at 11:29 PM by roblanious

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nymedic88
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Originally posted by: roblanious
Funny how people claim to have no past medical history but they have scars up and down and across their chest and/or abdomen or take 100 different medications.

Well for an 16 year old it is obvious it is a congenital heart defect. Which one though will be interesting to know. Thanks for keeping us in suspence you jerk.


You will know once Tom pokes his head in.

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roblanious
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Oh, great, so now we have to wait on Tom. You just want to see if you can stump him. I see how you are.

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sheerin
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Is it Hypoplastic left heart syndrome?

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nymedic88
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Originally posted by: sheerin
Is it Hypoplastic left heart syndrome?


Nope.


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sheerin
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Just throwing out a guess, hypoplastic left heart syndrome is treated (but not cured) with a course of 3 open heart surgeries.

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nymedic88
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Originally posted by: sheerin
Just throwing out a guess, hypoplastic left heart syndrome is treated (but not cured) with a course of 3 open heart surgeries.


Yeah. Whats going on here is 3 as well I believe. Good guess.


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nymedic88
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Well, I don't feel like waiting anymore. I left tom a warning in the main post.

Our patient has only one ventricle. PT had the Fontan operation some time in the past (unsure when).

From the AHA
"The Fontan operation largely separates the heart into two circulations. This lets oxygen-poor blood go to the lungs and oxygen-rich blood go to the body. The Fontan operation substantially reduces the mixing of blue and red blood and produces a normal or near-normal oxygen supply to the body. It also reduces the risk of a stroke or other complications, and decreases the workload on the single ventricle. A Fontan operation can't be done if you have pulmonary hypertension (high blood pressure in the lungs)."

Can anyone chime in as to how rare this condition is?

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TomB
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Thanks, nymedic88!

I guess I need to check the board a little more often. Not much action lately.

Indeed, the history is the key to understanding this ECG. In particular we want to explain the ST/T wave abnormalities, particularly when SOB is present. Is this acute coronary ischemia? Do you give NTG to a 16 year old girl?

This ECG is showing a strain pattern (interesting that strain patterns are routinely the ECGs that paramedics have the most difficulty with). This one is more difficult in that it shows a right ventricular strain pattern or perhaps even a combined right and left ventricular strain pattern.

I say that because the limb leads are showing a pattern more typical for left ventricular strain and the precordial leads are showing a pattern more typical for right ventricular strain. Usually with right ventricular strain, there is a right axis deviation. See an example here.

Coincidentally, this was also a 16 year old female with a congenital heart defect and multiple operations.

With a common ventricle, left ventricular pressures are transferred to the right ventricle (which wasn't designed to handle it). You end up with right ventricular hypertrophy and hence the strain pattern.

Right ventricular strain is different from left in that the pouty-lipped ST-segment depression and asymmetrical T-wave inversions are found in the right precordial leads (which show prominent R waves).

Very interesting case!

Tom

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Zorfox
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There was an ECG? Guess I should have realized the thread I was reading before I posted earlier lol. Wouldn't have mattered though, when I did look at it I thought it was some sort of ASD as well. Some of us aren't quite as gifted as Tom . Nice explanation Tom. You really know your ECGs. But can you make the perfect martini?

Mike

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roblanious
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If you don't know of Tom, he is becoming internationally reknowned as far as his expertise on EKGs. I bet he could show a thing or two to quite a few ED attendings. I do like to see when even Tom has to scratch his head when looking at an EKG, though.

This was a good and informative case. Thanks NYMedic. It prompts me to also research further on this subject.

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Edited: Sun Jun 28, 2009 at 5:47 PM by roblanious

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TomB
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Internationally reknowned? That sounds pretty good, roblanious! LOL! I doubt I'm deserving of that much praise, but I'm trying to do my part for prehospital 12 lead ECG education. My blog is doing well, far exceeding my expectations when I started last October (I came up with the idea of a tutorial on axis determination while responding to a thread on EMS Village). These are exciting times for prehospital emergency cardiac care, especially with the advent of the D2B Alliance, the AHA's Mission: Lifeline, the emphasis on EMS-to-balloon (E2B) times, and regional STEMI systems, which will finally put the U.S. in alignment with ACC/AHA consensus guidelines. Once 12 lead ECG education becomes a core part of a paramedic's initial education (not just STEMI recognition, but STE-mimics which necessarily involves the fundamentals of 12 lead ECG interpretation) then we can put the rest this recurring issue of how the ECG will be transmitted to the receiving hospital for physician interpretation! The problem is, there is no consensus as to what a paramedic "needs to know" and it's not yet clear who will teach the teachers! What is needed is a national 12 lead ECG certification/exam.

Tom

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roblanious
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Originally posted by: TomB
These are exciting times for prehospital emergency cardiac care, especially with the advent of the D2B Alliance, the AHA's Mission: Lifeline, the emphasis on EMS-to-balloon (E2B) times, and regional STEMI systems, which will finally put the U.S. in alignment with ACC/AHA consensus guidelines.

Well, while EMT-Bs were designed for trauma, Medics were designed for cardiology. While I think we need to focus on more than just cardiology, I agree that we are currently playing catch up with the recent innovations in cardiology.
Quote
Once 12 lead ECG education becomes a core part of a paramedic's initial education (not just STEMI recognition, but STE-mimics which necessarily involves the fundamentals of 12 lead ECG interpretation) then we can put the rest this recurring issue of how the ECG will be transmitted to the receiving hospital for physician interpretation! The problem is, there is no consensus as to what a paramedic "needs to know" and it's not yet clear who will teach the teachers! What is needed is a national 12 lead ECG certification/exam.
Tom


I could not agree more. We need to raise the bar on minimal medic requirements, and we especially need to raise the bar on 12 lead interpretation with standardized minimum requirements that should be about equal to the competency of the average ED attending, at least. This would require, however, more education in the anatomy and physiology of the heart, and that is okay with me.

I advocate anyone interested in being a proficient medic to be advocates for 12 lead interpretation, and thanks, Tom for your great 12 lead blog site. You are actually being instrumental in working in achieving this, if indirectly.


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Mikey
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Do you think the high amplitude in the anterior leads is due to hypertrophy? Maybe the single ventricle having to compensate for the extra work?

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roblanious
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Looking at the lateral leads especially indicates LVH.
The S wave plus the R wave in V5 or V6 is not greater than 35 mm. However, I remember one of our cardiologists stating if the R wave is touching the S wave in strip above it, it is hypertrophy, and it looks like it here. Other criteria for LVH are R wave in lead I + S wave in III >25mm, with ST and T wave inversions (the strain pattern) in lateral leads and wide P waves as well as LAD make it almost certain.
I am almost sure the cause is the overworked ventricle, thus the strain pattern, but as Tom stated, most medics seem to be weak no strain patterns, and I am at the top of the list of those who need more education.

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Zorfox
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Originally posted by: roblanious
I advocate anyone interested in being a proficient medic to be advocates for 12 lead interpretation, and thanks, Tom for your great 12 lead blog site. You are actually being instrumental in working in achieving this, if indirectly.


Absolutely! I advocate the same. You will learn something, and for FREE! Does it get any better than that. If you don't learn anything then suggest something to Tom.

Thanks for all the great articles Tom! Keep it up you are making a difference!!

Click ---> Tom's Prehospital 12 Lead ECG Blog <----Click

Mike


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roblanious
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He has a link to his blog as part of his signiture. We rely on him quite a bit when we get stumped on EKGs, or when we think we know what is going on and he comes along and points out how much we may have been wrong.

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