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Post by pbruss on Feb 22, 2015 16:58:35 GMT -5
77 yo mane. type 2 DM, htn, hld, works as a valet at our hospital. no previous cardiac history. while running to get a car he developed sub sternal CP, pressure, sob, nauseous, diaphoretic, radiates to jaw. he come right into the ER and has an EKG which is attached. this EKG was done 20 min after onset of pain. what is your interp and treatment? Attachments:
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Post by kemple on Feb 22, 2015 18:13:15 GMT -5
Hyperacute T waves from early anterior MI? I would def start the cardiac workup and notify cardiology. Repeat serial EKGs to see if STEMI shows, when it does tell cardiology to notify the cath lab that they refused to notify when you first talked to them. This is assuming no old ekg that shows the same changes.
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Post by tyson on Feb 22, 2015 20:14:51 GMT -5
agree w/ kemple. appear to be de winter t-waves in precordial leads. slight elevation in AVR. guessing proximal LAD occlusion.
call stemi. heparin. repeat ekg. confirm your suspicion. would not wait for it to progress to your full blown stemi if don't see changes quickly. just get into cath.
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Post by slevittMD on Feb 22, 2015 22:58:51 GMT -5
I disagree with this being de winters t waves, which should have upsloping ST depression leading into the t-wave. Additionally, I do not think that I'd really call that aVR elevation. And, the significance of aVR is ST elevation with widespread ST depression elsewhere, which is not present here.
I agree with Dan that those look like hyperacute t-waves, but I think the more significant finding there is the fact that the t-wave is upright in V1 (which it should not be), and particularly that its larger than the t-wave of V6. This finding is suggestive of acute ischemia, especially if its a new finding. What would I do? Typical cardiac workup with repeat EKG in 20 minutes or so, not be surprised if the troponin is elevated or that morphs into a STEMI. Call cardiology for admit. I do not think this is a STEMI equivalent...at least not yet. There are certain indications to take someone directly to the cath lab and I do not think this is one of them. He will likely go in the short term, but still not STEMI equivalent.
Also need to check the K+, but I don't think thats the cause of the t-waves.
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Post by tyson on Feb 23, 2015 0:13:06 GMT -5
scott, i think you are probably correct regarding de winter's. soft call and likely more hyperacute than dewinters. but i do think there are some subtle st depression as well as minor coved st elevation in AVR. i'd be very interested in a repeat ekg.
i think this guy needs emergent rather than urgent cath lab.
scott, are you getting off the greens and the blue's yet? onto big boy slopes?
sounds like great month.
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Post by slevittMD on Feb 23, 2015 2:35:28 GMT -5
STEMI goes right to the cath lab, this is not STEMI or STEMI equivalent. If we go trying to send everything directly there, they're really going to start ignoring us! I think it would go sooner and later (and may show STEMI in the near future), but not immediate.
Absolutely great month!! You should do it next year! I haven't skied greens since I was too young to remember. Seeing as we're getting about a foot of snow tonight, I'll definitely be on big boy terrain in the AM!
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Post by pbruss on Feb 23, 2015 16:39:33 GMT -5
even though very slight i was concerned for dewinters, especially with his history and risk factors. i did call stemi but cards was not convinced. attached is his second EKG 20 min later. what do you think Attachments:
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Post by tyson on Feb 24, 2015 1:16:55 GMT -5
Now your looking at st elevation in v2. But non consecutive and probably not the 2 mm that you need of elevation. Still can't call stemi though we all know it's going there. Worsening ischemia in high lateral leads of I and avl.
What's the third EKG show?
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Post by kemple on Feb 24, 2015 13:21:03 GMT -5
The fact that the t waves have resolved combined with beginning ST changes screams STEMI. Cath lab stat.
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Post by pbruss on Feb 26, 2015 16:28:17 GMT -5
Concerning for a wellens wave in V2. Same as the first ECG, concerning but not 100% diagnostic.
Cards still not convinced because bedside trop was normal. But eventually took him to catch "urgently, but this is still not a STEMI" per cardiologist.
100% LAD, V fib arrest 3 times on the table.
Teaching point for me is don't sit on someone with a great story but has an ECG that is not 100% diagnostic. Don't have to always call a STEMI but get your cardiologist involved early, get serial ECGs, and don't let a normal trop rule out infarction.
Keep your eye on Amal mattus web sight for this case.
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Post by kemple on Feb 26, 2015 17:09:35 GMT -5
Defintely a good lesson.
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Post by slevittMD on Mar 9, 2015 9:57:43 GMT -5
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Post by tyson on Mar 11, 2015 20:39:01 GMT -5
the other thing disconcerting about this case is that Dr. Bruss had a patient with a very concerning story, EKG's showing acute injury and rapidly evolving changes and the cardiologists are stuck on the fact that bedside trop is negative. One would hope that a cardiologist would know not to expect a trop elevation <25 minutes after onset of pain.
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Post by slevittMD on Mar 12, 2015 10:38:01 GMT -5
One would hope a lot of things about cardiology that aren't necessarily true...
Dustin showed me an EKG yesterday from moonlighting that was very clearly avr elevation with diffuse depression everywhere else that cardiology actually admitted was a real thing, but not worthy of emergency cath. Of course, on cath the next day, the patient had severed diffuse disease.
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