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Post by pbruss on Apr 19, 2015 10:45:07 GMT -5
this is a case womack had, sorry for the poor images i had to take a cell phone pic. 46 yo female with DM and fam history of early CAD come in with sudden onset sub sternal CP radiating to left arm, nausea, vomiting, and diaphoresis. attached is her ECG. what do you think. Attachments:
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Post by Bjs04f on Apr 19, 2015 12:16:39 GMT -5
ST depression II II AVF with sick sinus syndrome, these runs of sinus tach interspersed there are concerning may be necessary to full eval (ie electrolytes, tox, etc) symptoms of this are due to hypoprofusion, but rarely is SSS secondary to ACS. Pacing may be an issue if shes becoming hypotensive or severely symptomatic. However having gotten the last right, this ones probably a tad off base
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Post by tyson on Apr 19, 2015 22:12:31 GMT -5
it's not uncommon to see arrythmias with inferior ischemia/ MI's(especially AV blocks) so I don't know if that's lending itself to this rhythm. obvious scooping or st depression in inferior leads. but like brandon said, have to look at K+, Ca2+, Mg. The corrected QTc seems to be in neighborhood of 520-560 msec.
I'd get electrolyte I-stat. Correct any underlying deficiencies. Doesn't qualify as stemi at this time, although you could potentially argue it's a stemi equivalent with unstable rhythm and ongoing chest pain and evidence of ischemia, but incumbent upon us to correct any reversible causes first.
serial EKGs.
do you have repeat ekg?
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Post by pbruss on Apr 20, 2015 5:40:19 GMT -5
interesting interp tyson. is there a formula or scoring system that could tell us if that QTC could be concerning for acute infarction? if so what is it?
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Post by Bjs04f on Apr 20, 2015 9:21:46 GMT -5
there is a qtc st change formula but the thing is crazy long and if cardiology wont believe hyperacute T waves and wellens theyre definitely not buying that....bastards
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Post by pbruss on Apr 20, 2015 11:24:30 GMT -5
spot on. womack did not do this, he just called cards and said she looks like crap and they took her after a while. see below for all the facny math. there is an online equation www.mdcalc.com/subtle-anterior-stemi-calculator/It is critical to use it only when the differential is subtle LAD occlusion vs. early repol. If there is LVH, it may not apply. If there are features that make LAD occlusion obvious (inferior or anterior ST depression, convexity, terminal QRS distortion, Q-waves), then the equation MAY NOT apply. These kinds of cases were excluded from the study as obvious anterior STEMI. ST elevation (STE) is measured at 60 milliseconds after the J-point, relative to the PR segment, in millimeters. (1.196 x STE at 60 ms after the J-point in V3 in mm) + (0.059 x computerized QTc) - (0.326 x R-wave Amplitude in V4 in mm). SO for her: STE 60 ms after J point in lead V3 - 1 Computerized QTc - 520 R-wave amplitude in V4 - 7 total29.6 This score suggests this ST elevation is due to STEMI, not early repolarization; however, the closer the score is to 23.4, the more difficulty in differentiating these two conditions. |
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Post by pbruss on Apr 20, 2015 11:25:12 GMT -5
oh and she was a stemi
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Post by tyson on Apr 20, 2015 11:54:36 GMT -5
that's a great ekg. sounds like good work/outcome btw you and gigantor.
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