Posted by: medicblog999 | September 9, 2010

ECG Geek 11 – Part two.

If you havent read part one of this post, then you can find it here, and here is the initial 12 Lead again :

Click to Enlarge

As most of you got right, I assumed that this patient may well have suffered the effects of a syncopal episode as a result of a dysrhythmia brought on by the presence of long QT Syndrome.

For those of who are not entirely familiar with this syndrome, there is a good explanation to be found over at emedicine.com, but in its most basic of forms this is a congenital abnormality which delays the repolarisation of the ventricles to the point that potentially fatal arrhythmias may occur including Torsade de Pointe and Ventricular Fibrillation. It can also be responsible for causing patients to have palpitations and syncopal episodes which may well have been what happened to my patient on that day, although that is something that I can only speculate on. Another interesting point to consider with long QT syndrome is that it can be exacerbated by activity and various drugs. For all I know, as Heather moved the sofa in her front room, that may have stressed her heart just enough that the QT interval lengthened just long enough to cause her to enter a short period of Torsade de Pointe which caused her to lose consciousness and have a hypoxic seizure.

The important point with her ECG is the recognition of the potential of a serious cardiac problem. She may well have had a ‘first fit’ and the prolonged QT interval may not have been a contributing factor, but it is essential that we captured the ECG at that time and are aware enough to be able to convey our own concerns to the hospital staff at the point of handover.

What concerned me at the time of handover to the crew was the fact that they had no appreciation of the potential seriousness of Heathers condition. However, as paramedics in the UK we are taught only to recognise various rhythm abnormalities, heart blocks and certain ST segment abnormalities. Everything else that I have learned is of my own volition and outside of the remit of my training department, therefore it goes without saying that many of my paramedic colleagues would not know about long QT syndrome, never mind be able to diagnose it from a 12 lead ECG.

The patient did get transported to A&E though, and I had the chance to follow her up on the coronary care department later in the day.

I always like to get a second opinion of my interpretation whenever I am not 100% sure about it, and the Sister in charge of the coronary care unit is always my first choice. She agreed that the patients QT interval was indeed in the realms of Long QT syndrome, however, since she had been admitted, there was a far more urgent matter pending :

Click to Enlarge

Whats changed from the first ECG to this new 12 lead tracing, taken approximately 2 hours afterwards? (other ECGs were obtained before this one but were the same as the pre-hospital recording)

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Responses

  1. Anterior MI?

  2. Inferior infarct and a bit of RBBB (?incomplete)
    Also P-waves are looking a bit flat

  3. STE in II, III, aVF with STD in aVL, V5, ?V6 = ?acute inferior STEMI (modulo iPhone screen :P)

  4. Both me and the Mrs. can see changes in III and V1 so I wonder if the problem could be right sided? She had no opinion on what the problem might be but saw the same changes I did.

  5. Inferior elevation and the beginning of reciprocal changes in the high lateral leads. IWMI? Perhaps the LQT was the foreshadowing…

  6. Now I see it, phone not so good for photocopies… Chris is right, inferior MI would explain the long QT

  7. One thing I can say with absolute certainty is that downsloping ST-segments in lead aVL have allowed me to catch many a subtle acute inferior STEMI. Throw in the inferior T-waves that are now “popping,” the slight ST-elevation (in leads with very small QRS complexes) and you’ve got a very strong case for acute inferior STEMI. Since this is my new favorite ECG interpretation trick, I created an image that “stretches” leads III and aVF vertically while preserving the ST/QRS ratio.http://i12.photobucket.com/albums/a234/firemedictb/EMS%2012%20Lead/III_avF_stretch.jpg

  8. I concur with the IMI interpretations. I also have to wonder if there was an earlier transient event that caused a BP drop, which lead to the syncope. Either way, it was a good pickup on a subtle case.


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