EKG of the Week 2019 1-6

This EKG comes courtesy of Dr. Ann Giovanni.

A 63 year old male, with a history of HTN and DM, was teaching computer class when he had a syncopal episode. EMS was called and he had a second syncopal episode while on the EMS monitor. The rhythm strip is below.

2019 1-6 EMS strip.JPG

He woke up on his own prior to being shocked by EMS. He arrived in the ED with no chest pain and no shortness of breath but feeling like he was going to pass out.

His ED EKG is below.

2019 1-6.jpg

1.    What does the EKG demonstrate?

2.    How would you manage this patient?

ANSWER:

The rhythm strip demonstrates ventricular fibrillation. The EKG shows downsloping ST segments in leads V1-V3 consistent with Brugada syndrome.

Patients with Brugada syndrome require placement of an ICD.

 

Evaluating patients after syncope can be challenging. In the absence of a clear history suggesting a particular cause (i.e. subarachnoid hemorrhage, pulmonary embolism), we are often left wondering whether the patient had a cardiac arrhythmia as the cause of their syncope or was it a more benign cause. The only way to know for sure is to have the patient on an EKG machine at the time of the syncope which usually doesn’t happen. Otherwise we are left with looking at an EKG taken after the syncope to see if it gives us clues that the patient may have had an arrhythmia as the cause of their syncope (i.e. prolonged QT, WPW, Brugada, ARVD).

In this case Dr. Giovanni’s team was fortunate that EMS had the patient on a monitor at the time of a syncopal episode and was able to capture the ventricular fibrillation. Now we know that the patient’s syncope was certainly due to a dangerous arrhythmia. The next question becomes why did the patient have spontaneous v-fib? The EKG gives us the answer.

The EKG demonstrates a sinus rhythm with a 1st degree AV block and PVC’s. There are also downsloping ST segments in leads V1-V3 leading into inverted T waves. There is no isoelectric separation between the QRS complex and the T wave. This is consistent with Brugada syndrome.

Brugada syndrome is a genetic (autosomal dominant) sodium channel defect. It predominantly affects males (90%). Patients with Brugada syndrome are at risk for ventricular arrhythmias such as polymorphic V-tach and v-fib. Patients who had a syncopal episode who have an EKG pattern consistent with Brugada syndrome likely had a ventricular arrhythmia. There is no specific treatment for Brugada syndrome. So, these patients require placement of an ICD to manage their ventricular arrhythmias.

 

It's 2019, let's chat....

Created by the Division of Diversity & Inclusion

Happy new year to all! Every year that goes by, I marvel at how quickly the year has passed. Nevertheless, 2019 is here and, with it, comes a chance to learn and grow. Late last year, I became increasingly aware of an issue that affects all of us. The issue is that of the disturbing rate of physician mental health issues and, specifically how it relates to physician suicide. I know, not the most uplifting topic for the first post in the new year, but an important one to be aware of. However, what’s more important than recognizing that physician suicide is a thing, albeit an unfortunately prevalent one if we read or listen to the news, is the larger issue of how we treat physician mental health issues. Slowly, but surely, the conversation is starting to shift towards understanding that marginalizing mental health issues among healthcare providers, specifically those of us who deal with frontline traumatic cases, is detrimental to all. It is no longer acceptable to hide the fact that issues like depression and anxiety affect many of us. The fear of being stigmatized by our colleagues and medical boards is a large reason that many physicians do not seek the appropriate care they need. The time has come for this to stop. Maybe 2019 will be the year that we can change this.

Check out this recent article published in ACEPNow about one physician’s struggle to retain her medical license to practice after appropriately seeking care for her mental health issues.

Also, here’s an article I recently wrote for FemInEM about physician suicide. Look out soon for a FemInEM podcast I also recently had the pleasure of doing about this very topic. It was educational for me and, hopefully, will be for all of you who listen.

EKG of the Week 2018 12-23

A 34 y/o female presents to the ED complaining of palpitations.

The EKG is below.

2018 12-23.JPG
  1. What finding does this EKG demonstrate?

  2. What is the next step?

ANSWER:

The EKG demonstrates limb lead reversal of the right arm and left arm.

Repeat the EKG with appropriate lead placement.

 

The EKG appears to demonstrate T wave inversions in leads II, III and aVF and can be mistaken for inferior wall ischemia. However, a closer look at the EKG reveals that in lead I the P wave is inverted, the QRS complex is predominantly negative, and the T wave is inverted. In lead aVR, the P wave is upright, the QRS complex is predominantly positive, and the T wave is upright. This is the opposite of what you expect to see in a normal EKG. This clues you in that the right and left arm leads have been reversed. With limb lead reversal, T wave inversions may appear that are not really signs of ischemia.

The findings on EKG in reversal of right and left arm leads are:

  1. inverted P-QRS-T waves in lead I

  2. upright P-QRS-T in lead aVR (as opposed to the expected inversion of these waves in a normal EKG)

  3. QRS vector in lead I does not match that of lead V6

 

Inversion of the P-QRS-T complex in lead I can also occur with dextrocardia. However, with dextrocardia, there will be a lack of normal precordial R-wave progression from leads V1–V6. In reversal of the arm electrodes, the precordial leads will not be affected so R wave progression should be normal.

Reversal of the right leg and left leg leads usually causes no change on the EKG because the right leg lead is only a ground and does not record any electrical activity.

(Harrigan et al. Electrocardiographic Electrode Misplacement, Misconnection, and Artifact. J Emerg Med. 2012;43(6):1038-1044.)

EKG of the Week 2018 12-2

This EKG comes courtesy of Dr. Elias Youssef.

A 66 year old Female with a history of hypertension and hyperlipidemia, presented with abdominal pain radiating to the back and left lower extremity. The pain was sudden onset just prior to arrival.

Her EKG is below.

2018 12-2.jpg

1.       What does the EKG demonstrate?

2.       How would you manage this patient?

ANSWER:

The EKG shows ST elevations in leads II, III and aVF as well as V4-V6 with reciprocal depressions in I and aVL as well as R waves and ST depressions in leads V1-V3, suggesting an infero-postero-lateral STEMI.

 The patient’s symptoms were concerning for an aortic dissection which was confirmed on U/S and CT. The patient was taken to the OR.

 

The EKG shows ST elevations in leads II, III and aVF which suggests an inferior wall MI. There are also ST elevations in leads V4-V6 suggesting lateral wall involvement as well. In addition, the findings of R waves with ST depressions in leads V1-V3 suggest posterior wall involvement.

Remember that ST elevations are not 100% specific for MI and can be mimicked by other disease processes. This patient’s history was concerning for an aortic dissection. If a dissection extends backwards towards the coronary arteries and causes a coronary artery dissection, ST elevations can be manifested on EKG. The most common artery involved in a retrograde dissection is the Right Coronary Artery. This will usually cause ST elevations in the inferior leads.

This patient had a bedside ultrasound which showed an aortic dissection flap with no pericardial tamponade. Below is a slice of the patient’s CT scan.

2018 12-2 CT.jpg

It demonstrated an aortic dissection from the aortic root to the iliac bifurcation with occluded blood flow to the left iliac. The patient was taken to the OR. She was found to have a dissected ascending aorta with a dissected right coronary artery.

Remember to pay attention to the history. It will clue you in to the diagnosis.

Gallbladder Explosion

Authored by Sandi Chen, and Mario Corro Reviewed by SIUH Sono Division

85 year old female with history of HTN and hypothyroidism presents to ED for epigastric pain that started a week ago. Pain is postprandial, moderate in intensity, stabbing, continuous and radiating to the RUQ. Associated with nausea but no vomiting. Currently denies abdominal pain but complains of nausea. She denies any fever, chills, constipation or diarrhea. The following images were obtained.

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Questions:

 

1. What is seen on the above ultrasound image?

 

2. What disease processes could lead to this ultrasound finding?

 

3.  What are the ultrasound criteria for cholelithiasis? 

 

4. What are  sonographic findings in acute cholecystitis? 

 

5. What complications can arise if the above condition is not treated?

 

Answers:

  1. Gallbladder perforation (yellow arrow)

    1. Pericholecystic fluid and 

    2. True gallbladder lumen filled with stones and sludge (red arrow)

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2. Gallbladder perforation is most commonly due to occlusion of the cystic duct by gallstone and subsequent retention of contents. The associated rise in luminal pressure limits venous and lymphatic drainage, leading to vascular compromise, necrosis, and ultimately perforation. May also arise due to laparoscopic cholecystectomy.

 3. Cholelithiasis (blue arrow): highly reflective echogenic focus within gallbladder lumen, normally with posterior acoustic shadowing. Stones will also show gravity-dependent movement.

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4.Cholecystitis:   * = most sensitive

    1. Presence of ultrasonic Murphy sign*

    2. Gallstones visualized, especially if in gallbladder neck*

    3. Anterior gallbladder wall thickening >3mm

    4. Presence of pericholecystic fluid

    5. Hydrops (>5x10cm)

(None of the above signs are pathognomonic)

5.Pericholecystic abscess, cholecystoenteric or cholecystobiliary fistula formation, bile peritonitis, pancreatitis, subphrenic or hepatic abscess formation

EKG of the Week 2018 11-4

This EKG comes courtesy of Dr. Majlesi.

An 81 y/o male presents to the ED complaining of generalized weakness, difficulty speaking and shuffling gait. He has no chest pain or SOB. His vital signs are normal.

His EKG is below.

2018 11-4.jpg

1.       What are the findings on this EKG?

2.       What can explain these findings?

ANSWER:

The EKG shows an extreme right axis deviation with negative complexes in leads I and II and positive complexes in lead aVR. 

Several things can cause these findings including COPD, limb lead reversal and dextrocardia. In this case, the patient was found to have situs inversus.

 

In a normal EKG, the P waves in leads I and II should be upright and the P waves in lead aVR should be inverted. This EKG shows the opposite - negative complexes with inverted P waves in leads I and II and positive complexes and upright P waves in lead aVR.

This pattern can be seen in severe COPD or in limb lead reversal (if the right arm lead is placed on the left arm and the left arm lead is placed on the right arm). However in that scenario, the precordial leads should be normal. In our EKG, the R wave progression in the precordial leads is reversed. The QRS complex is positive in lead V1 and negative in lead V6. This occurs because the entire heart is reversed.

Our patient’s Chest X-ray is below.

2018 11-4 CXR.jpg

As you can see, the heart is reversed and on the right side of the body. Additionally, you can see the liver on the left side and the stomach bubble on the right side. This represents complete situs inversus. This is why the patient’s EKG is essentially reversed.

92 Year Old Male With Difficulty Breathing

Authored by: Ahad Anjum, Brittany Choe Edited by: SIUH Ultrasound Division

92 y M hx of afib, CLL, Lymphoma pw difficulty breathing and cough. The following was found on bedside sono of the right lung. 

QUESTIONS:

1. What is seen on the above ultrasound image?

2. What disease processes could lead to this ultrasound finding? 

3.  What are the names of the ultrasound signs seen above? 

4. What is Light's Criteria? What would you expect the results to show if you were to aspirate a sample from this finding? 

ANSWERS

1. Pleural effusion with debris (red star), most likely indicative of an exudative effusion 

2.  Malignancy, pneumonia/parapneumonic effusion, lymphoma

3. Tongue Sign (white arrow) showing the lung parenchyma floating in hypo echoic fluid indicating a pleural effusion, Spine sign (black arrow) indicates a fluid filled medium above the diaphragm in which the spine is visualized on ultrasound, which is normally not seen through a regularly aerated lung 

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4. Pleural fluid protein/serum protein >0.5, Pleural fluid LDH/Serum LDH >0.6, Pleural fluid LDH > 2/3 upper limit of LDH