EM Alliance ECG – Case 8

52 YOM, SOB, Hx Lung CA

ECG courtesy of  http://www.emalliance.org/

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21 Comments Add yours

  1. Tatsu Kuwasaki says:

    And just another note for the sceptics dissing the value of learning the extra knowledge, Amal in his one of the lectures present the case of fatality as a result of haemorrhargic tamponade secondary to pericarditis which was caused by administration of clopidogrel.

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  2. Tatsu Kuwasaki says:

    Once again, impressive display of knowledge, and thank you for sharing your thoughts.

    From the EM Alliance;
    This Pt had pericarditis post 3 days of radiotherapy resulted in SOB and hypotension.
    Pericarditis occurs globally over pericardium hence global ST elevation.
    PR depression are usually seen in viral pericarditis but this is an example of exceptions.
    Pericarditis resulted in pericardial effusion then tamponade causing haemodynamic instability.

    As you know, I’m a big fan of Amal Mattu and his teaching is to “ALWAYS’;

    1. Look at the Pt / clinical presentation may or may not include the characteristic chest pain (retrosternal, pleuritic, worse on lying flat, relieved by sitting forward), tachycardia and dyspnoea.

    2. Rule out ACS before start digging for ST elevation mimics such as BER, Pericarditis.

    Don’t go searching for pericarditis via global STE, PR depression etc as ACS can also present with PRD, it is often intermittent so may not be there.

    Look for;
    Reciprocal (any) ST depression (except for aVR or V1 as they are normal).
    Flat, horizontal, or angry looking ST elevation (morphology/shape of ST elevation).
    ST elevation in lead III>II

    * If you see any of above, treat it as ACS/STEMI and don’t go any further down the list below.

    Pericarditis/Myocarditis
    No reciprocal ST-segment depression
    Concave ST-segment morphology
    STE in lead II > III
    PR-segment depression (not specific)
    Spodick’s sign = downward sloping of TP segment (not sensitive or specific)

    LIFL also has a great info https://lifeinthefastlane.com/ecg-library/basics/pericarditis/

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    1. Tatsu Kuwasaki says:

      I just realised that free Youtube clips of Amal’s old lectures are taken off and no longer viewable…
      I highly recommend his ECG Weekly https://ecgweekly.com/mm-error/?code=100020
      It costs only US$26 annually and really worth it!

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      1. Jason says:

        I have a copy of these if anyone wants them.

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      2. Tatsu Kuwasaki says:

        Jason, I hope your copy is not from the Workshop series I bought a couple of years ago…

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      3. Jason says:

        No

        Liked by 1 person

  3. Steve Pudney says:

    looks pericarditis..ish with the widespread elevation, hx of lung CA might suggest a relationship between the two, along the lines of what Miriam was saying, the only thing with that would you see signs of right sided specific ischemia or damage, eg RBBB, hypertrophy . Awsum idea thanks for the invite!

    Liked by 1 person

  4. Jason says:

    Pericarditis/effusion: Hx of CA. Widespread ST elevation with no reciprocal changes, PRI depression. Lead II greater than Lead III, convex ST segments.

    Liked by 1 person

    1. Jason says:

      Concave not convex…Not enough coffee

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  5. Tatsu Kuwasaki says:

    Wow, impressive level of knowledge displayed here and thank you all for taking time and being brave enough to share your knowledge, as that’s exactly what we are hoping to achieve!
    I normally leave if for a block or two before uploading related FOAMs, as we don’t normally get this many comments (lol), but will try uploading something sooner this time.
    It would also be good if you could comment on the reason for stabbing at the differencials so others can learn from your thought patterns. Cheers guys!

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  6. Dean Roblyn says:

    Pericardial effusion and/or tamponade

    Liked by 1 person

    1. Dean Roblyn says:

      Further investigation such as equal radial pulse pressure, muffled heart sounds and an elevated pulsus paradoxus would be supportive to this DX.

      Liked by 1 person

  7. rodersp says:

    Yep I’ll go with early stage pericarditis (no flattening of ST segmant)
    Slightly tachy
    Widespread ST elevation with depression aVR and V1
    ST morphology concave

    Liked by 1 person

  8. Rod Love says:

    Looks like a variant of takotsubo – broken heart syndrome

    Liked by 1 person

  9. Sean Lester says:

    Firstly, thank you Tatsu for the invite. Very cool idea to be hosting this forum.

    The ST elevation appears too global to be related to STEMI (multiple coronary vessel involvement), coupled with the morphology of the segment would to me be more indicative of pericarditis. Additionally the global PR segment depression with reciprocal PR segment elevation in aVR would support this.

    Liked by 1 person

  10. Aaron Chisholm says:

    OK I’ll give it a crack.

    Rate/Rhythm: Sinus Tachycardia, Identical P waves with a 1:1 ratio with QRS, Normal PR interval
    Axis: Normal axis
    QRS: Narrow QRS, Normal QT
    Morhology: Subtle Osbourne waves in I, II, III, AVF, V5, V6 with a more prominent one in V4. T wave inversion in V1 & V2, otherwise asymetrical and not peaked, widened or flattened.
    STEMI Mimics: Morhpology indicative of LVH, no BBB, no pacing, no morphology consistent with hyperkalemia,

    At a quick glance, it would appear to be a large Anteriolateral STEMI possibly involving multiple arteries (RAD, Circumflex, LAD or a combination of those) or a Circumflex occlusion only but with a dominant Circumflex reaching wide, however, to have such a large STEMI and be only c/o shortness of breath is a bit strange and the Osbourne waves are an interesting finding, the T wave
    inversion could be a normal variant and the ST elevation doesn’t appear to be the typical convex shape.

    The ST elevation is fairly widespread right through leads I, II, III, AVF, V3, V4, V5 and V6 and it is consistently concave with marked PR depression and AVR ST depression so there is a high index of suspicion for Pericarditis.

    Another potential is benign early repolarisation. Again, widespread concave ST elevation, asymetrical T waves, and could also explain the osbourne waves however, there is reciprocal changes in AVR which don’t really seem consistent with BER and the ST elevation seems far too much to be BER but not able to rule out conclusively.

    I’m going to put my money on Pericarditis but also unable to completely rule out STEMI or BER

    Liked by 1 person

  11. Miriam says:

    Widespread ischaemia – what about something as basic as hypoxia secondary to lung CA?

    Liked by 1 person

  12. geehannah says:

    Wide spread ST elevation I,II,II,avF, V3-V6 = pericarditis?

    Liked by 1 person

  13. Tatsu Kuwasaki says:

    Good on you for having a go at commenting on the ECG as it is obviously a still daunting thing to do despite we are doing our best to make this forum free from any negative criticism.

    And yes, your interpretation is certainly one of the differencials.
    Can you think of any other pathologies?

    In terms of your obs re biphasic T waves, do you think the T waves on V1 deflect both positively and negatively across the isoelectric line?

    Please encourage others to post their guess as I can guarantee that it will not cost their job or reputation, lol 😄

    Like

  14. Andrew O says:

    I’ll have a stab at it… the STE in inferior aspects naturally suggests RCA occlusion, and the STE in anterior lateral aspects suggest Cx occlusion.

    Of note the biphasic T waves have an occlusion style pattern similar to De Winters or Wellens in V1.

    Overall the ECG suggests to me there’s a current infarct to the inferior and lateral aspects, but is progressing into a full occlusion of both LAD and RCA.

    Liked by 1 person

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