EKG of the Week 2017 8-13

This EKG comes courtesy of Dr. Zhong and Dr. Zhi.

A 72 year old male with a history of schizoaffective disorder presents from a psychiatric center for lethargy and hypoxia.

Vital signs: Pulse 60, Respirations – 18, Blood Pressure – 107/76, O2 sat 80% on room air, Temp - 88.9.

His EKG is below.

2017 8-13.jpg

Because you have an awesome EKG tech, you are also presented with an old EKG on the patient (below).

2017 8-13 previous EKG.jpg

1.       What does the current EKG demonstrate?

2.       What is the clinical significance of this finding?

 

ANSWER:

The EKG demonstrates Osborn waves (best seen in leads V4-V6)

Osborn waves are seen in hypothermia.

 

The EKG shows a widened QRS complex with positive deflections at the end of the QRS complex in leads V4-V6. These deflections are called Osborn waves or J waves.

2017 8-13 with arrows.jpg

The EKG also shows ST elevations in leads V2 andV3. However, these were already present on the old EKG.

Hypothermia causes several EKG changes including bradycardia, lengthening of all intervals (PR, QRS, QT), atrial fibrillation and Osborn waves.

Osborn waves are deflections at the J point in the same direction as the QRS complex. The height of the Osborn wave is proportional to the degree of hypothermia. Osborn waves appear when the core temperature drops to approximately 87 degrees F (30.5 degrees C). The mechanism for the generation of Osborn waves is unclear, but it may be due to unequal depolarization and repolarization.

 

(Vassallo et al. A Prospective Evaluation of the Electrocardiographic Manifestations of Hypothermia. Acad Emerg Med 1999; 6:1121– 1126)

 

EKG of the Week 2017 7-30

This EKG comes courtesy of Dr. Gupta and Dr. Giovanni.

A 31 year old female with a history of congestive heart failure presents to the ED lethargic and tachycardic. Her EKG is below.

 

1) what is the rhythm?

2) what is this rhythm suggestive of?

3) what is the treatment?

ANSWER:

The rhythm is Bidirectional V-tach

The rhythm is suggestive of Digitalis toxicity

The treatment is Digoxin  Fab Fragments

 

The EKG demonstrates a wide complex tachycardia which is consistent with ventricular tachycardia. However, when you look at the rhythm strip, the QRS complexes appear to go in different directions. This is called bidirectional v-tach and is very suggestive of digoxin toxicity.

Dig toxicity can cause many EKG changes including PVC’s, high grade AV block, and AV block with increased automaticity. Bidirectional ventricular tachycardia is nearly diagnostic, although it may also occur with poisoning by aconitine and other uncommon xenobiotics (Thank you Dr. Kessler!!!).

Dig toxicity is treated with Digoxin Fab Fragments (Digibind). This binds to the digoxin and prevents it from causing further poisoning.

 

 

EKG of the Week 7-16

This EKG comes courtesy of Dr. Ann Giovanni.

A 70 year old female with a history of CAD with a previous stent, hypertension, and high cholesterol presented to the ED complaining of pressure like chest pain which developed while walking in the grocery store. She has associated nausea and vomiting. 

V/S: BP 160/90, Pulse 72, Respirations 18, O2 sat 100% on room air. 

Her EKG is below.

1.       What does the EKG demonstrate?

2.       What is the significance of these findings?

Answer:

The EKG shows diffuse ST depressions in leads V2-V6, I and aVL as well as II, III and aVF. There are ST elevations in leads V1 and aVR.

It suggests an occlusion of the Left Main Coronary Artery.

 

The EKG shows diffuse ST depressions in leads V2-V6, I and aVL as well as II, III and aVF. There are ST elevations in leads V1 and aVR.

We know that when there are both ST depressions and ST elevations on the same EKG, the pathology is where the elevations are. The depressions are only a reciprocal change. So, where is this MI located?

This pattern of diffuse ST depressions with ST elevations in leads aVR and V1 suggest an occlusion of the left main coronary artery (or triple vessel coronary disease). The pattern predicts left main occlusion with 80% accuracy. We don’t often see patients with left main occlusion because they typically present as a v-fib arrest. However, when we do see these patients they are often quite sick and may be in cardiogenic shock.

This patient went to cath and was found to have an occlusion of the distal left main coronary artery. He had CABG surgery and did well.

 

 

Aygul et al. Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction. J Electrocardiology 2008;335-41.

Vorobiof et al, Lead aVR: Dead or Simply Forgotten? JACC 2011;187-90.

 

Torsion: Enter the Whirlpool

By Nicholas Otts, MD

Edited by Gal Altberg, MD and Abbas Husain, MD

A Common Problem:

11 year old male complaints of two episodes of testicular pain associated with nausea and vomiting, but in the emergency department the pain resolved. His testicular exam is non contributory. Ultrasound of his scrotum shows increased flow to left testicle. Torsion ruled out?

A Small Dose of EBM:

Testicular torsion has a bimodal distribution - initial peak during first year of life followed by the pubertal surge in adolescence; thus, torsion is primarily a PEM problem. Classically, ED residents are taught to evaluate torsion with an ultrasound, using power doppler to assess flow to involved testicle. If no or decreased flow compared to other side, there is a much higher concern for torsion.  

(http://paediatricem.blogspot.com/2015/05/testicular-torsion.html)

What about normal or even increased flow? Does that rule out torsion? What if pain has resolved. What about intermittent torsion?

(https://www.123rf.com/photo_3011933_two-almond-nuts-put-side-by-side-isolated-on-white-background.html)

Intermittent testicular torsion, in which the spermatic cord twists and spontaneously resolves, is often a harbinger of final torsion. It is a problem that needs surgical correction, and, thus a diagnosis that cannot be missed.

On ultrasound, however, it can look like other causes of testicular pain. With flow returned to the testicle, the subsequent inflammation can appear as increased flow on doppler, which can be mistaken for orchitis. Further, the epididymis, near the spermatic cord, is often inflamed with or without return of flow, appearing enlarged and hyperemic on ultrasound, leading one to possibly suspect epididymitis.

Enter the Whirlpool

Whirlpool sign on ultrasound is another marker of torsion, and is created by a twisting of the spermatic cord (1,2,3). A good retrospective study at Texas Children’s showed that in patients with a surgical diagnosis of intermittent torsion, the whirlpool sign on ultrasound is a significant marker and can help distinguish this from other causes of testicular pain when doppler is non-diagnostic (4).

So, the next time you suspect torsion, think about intermittent torsion and make sure the ultrasound evaluation includes a good examination of the spermatic cord.

(http://www.aium.org/soundWaves/article.aspx?aId=654&iId=20130808)

A good article with video of whirlpool sign:

http://dx.doi.org/10.1594/ecr2011/C-0965

References:

1. Vijayaraghavan SB. Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion. J Ultrasound Med 2006; 25:563-574

2. Baud C, Veyrac C, Couture C, Ferran JL. Spiral twist of the spermatic cord: a reliable sign of testicular torsion. Pediatr Radiol. 1998;28:950–954

3. Esposito F, Di Serafino M, Mercogliano C, Vitale V, Sgambati P, Vallone G. The “whirlpool sign”, a US finding in partial torsion of the spermatic cord: 4 cases. Journal of Ultrasound. 2014;17(4):313-315.

4. Munden MM, Williams J, et. al. Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. American Journal of Roentgenology. 2013;201: 912-91

 

Hand, Foot, and...Lidocaine?

by Nicholas Otts, MD

Edited by Gal Altberg, MD

A Common Problem:

3 year old male presents w/ decreased oral intake associated w/ ulcerative and vesicular lesions in his mouth and irritability. Normal amount of wet diapers, no signs of dehydration on exam. Vesicular lesions on palms and soles as well.

(https://www.shutterstock.com/image-vector/hand-foot-mouth-disease-hfmd-illustration-265246085)

To give or not to give viscous lidocaine in an attempt to increase oral intake in a patient you do not wish to admit?

A Small Dose of EBM:

Treating pediatric viral stomatitis is a challenge. The primary goal is to avoid dehydration, and thus, admission for a primarily viral problem that will resolve with time. Oral medications commonly attempted in the ED include diphenyhydramine, coating agents (maalox), and viscous lidocaine (including combinations). For years, much of the EBM supporting either was case based and anecdotal. The desire to do something for these patients and their suffering parents is strong.

(http://njmommyblog.com/coxsackie-hand-foot-mouth-disease-signs-symptoms-survival/)

The most potentially toxic (1,2) but also potentially helpful medication is lidocaine.  Thankfully, a recent blinded, randomized, placebo-controlled trial examined this exact question (3).

In 2014, a trial out of Australia tested 2% viscous lidocaine against a placebo with improved oral intake after one hour as the primary outcome measure. The study had a good design and was powered appropriately.

In the end, however, the oral intake in both groups was not significantly different. Viscous lidocaine appeared to make no difference for all of the measured outcomes. Further, because viscous lidocaine has the most potential to cause harm out of the agents frequently used, it is a less than desirable choice.

(http://www.babyinfo.com.au/newborns-and-infants/understanding-hand-foot-and-mouth-disease)

Because  both the placebo and lidocaine groups in general showed significant improvement in oral intake as compared to the reported oral intake at home, it is suggested that simply the attention and instruction by the ED staff to the parents contributed significantly to the better outcomes.

This is a good trial, but there are some problems.  First, as pointed out by the famous NYC toxicologist Dr. Hoffman in a letter to the editor in response to the article (4), the trial did not account for pain at all as an outcome measure.  One can only use this trial to say that lidocaine did not improve oral intake, not that it does not relieve pain.

Further, the study only accounted for the first hour of oral intake post administration, and a longer term benefit of lidocaine was not assessed (but the timing was applicable to standard emergency department goals of disposition in these types of patients).

Bottom line: right now, due to potential for toxicity and no proven benefit in increasing oral intake, lidocaine may not be the best option for ulcerative lesions in the mouth. Good instruction to the parents and bringing attention to the issue of dehydration, however, may make all the difference.

References:

1. Hess GP, Walson PD. Seizures secondary to oral viscous lidocaine. Ann Emerg Med. 1988; 17(7) 725.

2. Questions and Answers: Reports of  rare, but potentially serious and potentially fatal adverse effect with the use of OTC benzocaine gels and liquids applied to gums or mouth. www.fda.gov/Drugs/DrugSafety/ucm250029.htm

3. Hopper SM, McCarthy M, Tancharoen C, et al. Topical Lidocaine to improve oral intake in children and painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial. Ann Emerg Med. 2014; 63: 292-299.

4. Hoffman R. Viscous Lidocaine Treatment for Painful Oral Infections in Children: Disappointingly Dismissive of Pediatric Pain. http://dx.doi.org/10.1016/j.annemergmed.2014.02.026