Posted by: medicblog999 | September 6, 2010

ECG Geek 11 – Was it really ‘just’ a seizure?

This should be an interesting one for all.

Called to a 46 year old fit and healthy woman who had been busily doing some house work during the early evening. Her husband had just arrived home from work and was starting to make the dinner when he heard a loud bang in the front room. As he ran into the room he found his wife unconscious on the floor and turning a ‘funny colour’

Just under five minutes later I turned up in the rapid response car to find the patient, Heather, conscious alert and orientated; a little pale and feeling generally unwell.

Observations showed :

Pulse of 65 beats per minute, strong radial presence.

Resps of 20.

SaO2 of 98% on room air.

Blood Pressure of 125/75

Heather was previously fit and well and only took medication for occasional migraines.

She could not remember what had happened but stated that she felt faint after she had moved the sofa in the front room, then woke up on the floor. After noticing that she had been incontinent of urine, I asked her husband more information about the collapse and it then came to light that she was “shaking a bit and making grunting noises”.

Obviously, my thought processes move towards thinking that this could be a ‘first fit’, and my questioning follows that route. She denies any pain, anywhere, either before or after the collapse and confirms that nothing like this has ever happened before.

Whilst waiting for the crew I do a 12 Lead ECG which comes out looking like this: (I`ve deliberately smudged out the interpretation so as not to lead you one way or the other – I know, I know, I`m nasty like that!)

Click to Enlarge

So, taking the history into account along with the findings on this ECG, (I know it is a poor data quality ECG), Is there anything on there that would concern you, or was it just a simple seizure?

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Responses

  1. I’m taking a stab at it here because I’m by no means an expert with this particular part of cardiology, but the QTc seems prolonged to me… enough to make me think “Hmmmm” in regards to perhaps Long QT Syndrome leading to Torsade’s. A run of that could have caused hypoperfusion and a hypoxic seizure. Also, those T waves look fairly symmetrical in the anterior leads, but I’m on a pretty small screen right now so can’t say for sure.

  2. Prolonged QTc. Run of VT could have been possible!

  3. Going with long-QT syndrome. Something vaguely unsettling about the QRS in I and II, but that may just be because I’m using a tiny screen.

  4. I agree with the previous commenters. The QTc is longish at 482 ms. Usually I don’t think of a QTc < 500 ms as clinically significant but with the history of syncope it becomes significant. I also don't like the look of the T-waves in leads V2-V4. They are full and broad-based. Could be related to the prolonged QTc or they could be a primary T-wave abnormality related to ischemia/injury.

  5. crazy, I had almost this exact same Pt, except younger and with a u-wave…. I’m going with LQTS. The QTc plus syncope.

  6. Looks like it may be a 2nd degree heart block, but I’m only a Basic and haven’t had the chance to see many ECGs

    ~Brad
    @EMTGoose

  7. I’m gonna go with Long QT as well, as the only abnormality i can see is a QTc of 0.482. I’m thinking as well that while she was moving the couch, her intrathoracic pressure increased leading to increased vagal stimulus

  8. My vote is for LQTS

  9. I see a sinus rhythm at 71 with a physiologic left axis deviation. In the clinical context you present, I would evaluate this as a presumably normal electrocardiogram for this patient.

    In terms of the potential prolonged QT: I see normal PR and QRS intervals. At this rate, if there is a prolonged QT interval, it is almost certainly not clinically significant. Let’s look at the computer assessment: QT/QTc .444s/.482s. I think this might be a bit long. Looking at V1, I count a QT of .400 seconds and in V4 .408 seconds. The limb leads are a bit tough to evaluate. Let’s split the difference and call the QT .404 seconds. RR of .804 seconds Using the QTc=QT/(square root of RR) formula, we get a QTc of .440 seconds. Finally, we don’t see any ectopy or marked arrhythmia that might account for an R-on-T (if such a thing actually exists).

    In terms of the left axis, I disagree with the computer assessment of 2 degrees, because the area under the R wave looks larger in aVL than II. Not that it much matters.

    • Lead aVF is almost perfectly isoelectric. The perpendicular lead in the hexaxial reference system is lead I. Since lead I is positive that would place the frontal plane axis at 0 degrees. That makes 2 degrees pretty accurate (however it comes with such a number).

    • I agree that aVF is the most isoelectric of the limb leads and that perpendicular to aVF (+90 degrees) is a positive I (0 degrees). However, to then further refine our axis, can we not then look at the leads on either side of I? II at +60 and aVL at -30 is what I used before, but to be even more precise, let’s use an inverted aVR. Although they are similar, I still think that there is greater area under the R in aVL than over the QS in aVR–thus giving us a slightly negative axis.

      Although at this point I feel pretty silly for arguing the point. It really doesn’t affect the overall assessment.

  10. T wave on v-2-4, although I am assuming that it is artifact on 1- avr or is there a-Fib? I would want this pt taken to an ER (Not sure what the British Term would be!) for more evaluation, somthing is going on but I have no more than a gut feeling.

  11. V3 and V4 seam to have a small (sous-decalage) sorry do not know the english term , there is also a bit of artifact or like Mark Z saying maybe also fib , the patient add a alteration of conscience ! she as no memory of the event ,is pale. maybe BP drop ! due to … i would be guessing hart failure of some kind would not rule out STAMI on ECG and would not be able to give AAS and TNT (our protocols would suggest to if ECG STAMI result positive ) or could it be epilepsy ? did she have a head injury ? no mater i would probably bring her to the ER in urgent mode and would also advice the Hospital of my arrival just so that the MD would be waiting for me and be sean ASAP but even there are base in 12 lead are very basic

  12. […] you havent read part one of this post, then you can find it here, and here is the initial 12 Lead again : Click to […]


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