Posted by: medicblog999 | January 21, 2009

ECG (or EKG) Geek (part 1)

 

First an apology, I first posted this one last night but decided to take it down today whilst I verified that the way I presented this case did indeed ensure that confidentiality remained intact. (Im new to this and dont want to do anything I shouldnt). I am now sure that the post is okay to go out in the original form, so here it is again in case you didnt see it last night.

(Happy Medic – sorry I have lost the comment you made)

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I am a geek! There, Ive said it! For those who know me this is no surprise. I love gadgets, techy stuff and anything even a little bit complex.

Over the years I have developed a bit of a geek streak for ECGs too. I used to always struggle with reading ECGs when I was a nurse but since joining the ambulance service and really needing to know at least the basics, my personal interest blossomed and now I cant seem to get enough of them (God, that makes me sound really sad!)

Over the past few years my knowledge on the subject has developed to he point where I teach paramedics and nurses ECG interpretation up to a fairly advanced level, but every now and then I have a patient that stumps me and I have to really think about what I am seeing.

With this is mind, I thought I might share some ECGs with you all from some of the more unusual cases I have been to. Every once in a while I will come back to this topic and share another case study along with the relevant ECG. What would really be nice would be if you would like to comment on the ECG too. I may think I know quite a bit, but you might know more and I am happy to learn from anyone who can teach me more or even tell me that I am wrong in my interpretation.

So onwards to Case 1:

As always, certain facts and identifying factors have been changed to ensure anonymity.

40s female, phoned 999 after developing central chest pain whilst at work, collapsed whilst on the phone whereby a colleague took over the call and finished passing the details to control.

We were dispatched from station and arrived on scene approximately 6 minutes later to find the lady slumped in a chair, ashen, diaphoretic with a GCS of 12. No palpable radial pulse, but carotid present.

Obs: Pulse 72bpm, BP 80/40, SaO2 90% on air.

Responded quickly to voice and proceeded to tell us that the pain in her chest remained and had been there for the last 20 mins, radiating to her neck and jaw. No previous cardiac history, no relevant medical history at all, normally very fit and active.

We administered 100% O2 and moved her straight onto the stretcher and into the ambulance. 12 Lead ECG showed:

 big-old-mi-001crop

At the time, we were autonomously administering thrombolysis for acute STEMI, so I had to make the decision about what was going on so I could decide if she was going to get thrombolysed. It took a couple of seconds to really get a handle on this ECG but my interpretation and reasons are here:

Acute Anterior Lateral MI with reciprocal changes. Many people who have seen this ECG immediately think this is a LBBB, but there is an easy pointer to discount this, which is the normal QRS width in V2 and V3. It s  difficult to see the J point in most  leads, but I based my decision on the J point visable in V3 and tiny little notch at the top of the QRS in V4. I assumed the reasons for the pointy “shark fin” QRS was to do with the hyperacute T wave along with a possible hyperkalaemia (which was later confirmed)

So, now that I have made my clinical decision, we get on with our treatment. We give the usual aspirin and buccal GTN (once I get her BP above 90 systolic, by raising her legs a little), morphine titrated to effect, heparin and tenectaplase (the clot busting drug). 12 Lead ECG gets transmitted to the local Coronary Care Dept and we head off using lights and sirens.

That’s all the technical stuff out of the way, the easy part. The personal stuff that went on in the vehicle on route was the hardest thing I had to deal with that day though.

As we were working on her she stopped me, looked me right in the eyes and asked me if she was going to die.

“we are doing every thing we can to help you and you are getting the best treatment available in this country to treat your heart attack (correct at the time). We will be at the hospital in about 8 minutes and they will take over and get your heart sorted out”

“Im really scared, what about my kids, my husband, who will look after them?”

“Im sure that once you are sorted out, you will be able to look after them yourself”

“I’m going to die, I know I am. I don’t want to die by myself”

“Your not by yourself, I’m right here with you and I’m not going anywhere”

By now her resps were starting to drop off and her conscious level was decreasing. I had done everything that I could with my interventions and we were still about 5 mins out from the A&E. I stopped writing my form, went and sat by the head of the stretcher and held her hand. With my other hand I got out the bag and mask and placed it behind the back of the stretcher so she couldn’t see it and waited for the inevitable.

“I’m so scared, please don’t let me die!”

What can you say to that? Inside I was just fighting to keep it together myself. I have had many, many deaths but this was the first patient I had looked after who was actually going to die in front of my eyes. I stroked her hand and explained that I was going to put a mask over her mouth and nose to help her breath until we got to the hospital. By now she was not making adequate respiratory effort so I assisted her resps with the bag and mask. It looked like she was now unconscious, but I always still talk to my patients, just in case they can still hear me. I told her everything was going to be alright (god knows why I said this, was it for the patient or for me?)

About a minute after, she went in to cardiac arrest, I commenced CPR but by this point we were pulling up outside of the hospital. We had already diverted from the coronary care dept to A&E en route as she looked so poorly. We moved her into resus where the team worked on her for about 30 mins but she was never going to come back from an infarct like that.

One of the most upsetting jobs I have had so far, but also one of the most bizarre and interesting ECGs. Have another look at it and tell me your thoughts please.

Would you give a different interpretation of the ECG? Is there anything you have spotted that Imay have missed? Post a comment and let me know.

 

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Responses

  1. That’s an impressive ECG.

    The “shark fin” appearance of the QRS/T complex unusual indeed. The QT appears to be short (could be explained by hyperkalemia).

    Any idea about the K+ level? Was a post-mortem done? Thanks for sharing the case!

    Tom


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