EKG of the Week 2017 11-5

This EKG comes courtesy of Dr. Eric Golike.

A 47 year old male with a history of HTN and high cholesterol was awoken from sleep with chest pressure through his mid chest. The pain is non-radiating. It began two hours prior to arrival in the ED and has been constant.

The EKG is below.

2017 11-5.jpg

1.       What does the EKG demonstrate?

2.       How should this patient be managed?

 

ANSWER:

The EKG shows ST elevations in leads V2-V5, I and aVL with reciprocal depressions in leads II, III and aVF. There is an underlying right bundle branch block.

This EKG meets STEMI criteria. The patient should go to the cath lab for emergent PCI.

 

The EKG shows an underlying right bundle branch block (RBBB). The criteria for a RBBB are:

1.       Widened QRS complex

2.       RSR’ pattern in leads V1-V3

3.       Deep terminal S waves in leads V5, V6, I and aVL

4.       Secondary ST/T changes in leads V1-V3

In addition, there are ST elevations in leads V2, V3, V4, V5, I and aVL with reciprocal depressions in leads II, III and aVF. This represents an anterolateral acute MI.

A left bundle branch block can mimic ST elevations and can mask the presence of an MI. So, ST elevations in a left bundle branch block may not signify an acute MI. Sgarbossa’s criteria are needed to determine if the ST elevations represent an acute MI. However, a right bundle branch block does NOT mask ST elevations. So, if you see ST elevations in the presence of a right bundle branch block, it is indicative of an MI.

This patient was seen at a community hospital which does not have PCI capabilities. He was transferred to the University Hospital and went straight to the cath lab where he was found to have a 100% proximal LAD occlusion.

2017 11-5 cath pre PCI.jpg

Two stents were placed and flow was restored:

2017 11-5 cath post PCI.jpg

EKG of the Week 2017-5-28

This EKG comes courtesy of Dr. Khodorkovsky.

An 87 year old male with a history of HTN presents to the ED for chest pain and shortness of breath which began the night before. He vomited this morning.

V/S: Pulse 102, Respirations 16, BP 86/52.

He is ill appearing on exam.
His EKG is below.

1.       What does the EKG demonstrate?

2.       What is the diagnosis?

3.       How would you manage this patient?

ANSWER:

The EKG shows sinus tachycardia with an anterolateral ST elevation MI.

The diagnosis is Cardiogenic shock

Cardiogenic shock is managed with aspirin, anticoagulation, vasopressors, and urgent cath.

 

The EKG demonstrates ST elevations in leads V1-V6, I and aVL with reciprocal depressions in leads II, III and aVF. This is consistent with an anterolateral STEMI. It usually suggests a proximal LAD occlusion.

The patient’s clinical condition (acute MI with tachycardia and hypotension) is consistent with cardiogenic shock. Cardiogenic shock is a state of heart failure that results in inadequate cardiac output, hypoperfusion, and end-organ dysfunction. The most common cause is LV dysfunction from an acute MI. It carries a very high mortality rate (50-80%).

The acute MI should be managed as all other MI’s with aspirin and anticoagulation. To manage the shock, Dobutamine can increase cardiac output but it causes hypotension. Norepinephrine is the preferred first-line adrenergic agent.

Cardiac cath with PCI is the treatment of choice.

Our patient went to the cath lab and was found to have a 100% occlusion of the proximal left main, as well as 70% occlusion of the proximal RCA. His ejection fraction was 10%. An intra-aortic balloon pump was placed. He was treated with vasopressors. Unfortunately he expired the following day.

 

Reference: Moskovitz et al. Cardiogenic Shock. Emerg Med Clin N Am 33 (2015) 645–652.