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Post by jpollock on Dec 7, 2015 12:17:19 GMT -5
A 25-year-old female was brought to the emergency department (ED) by ambulance in status epilepticus. She had no history of seizures or recent trauma, and her blood sugar was normal. Her blood pressure was 81/40 and her pulse rate was 84. The following electrocardiogram (ECG) was obtained. Attachments:
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Post by jpollock on Dec 7, 2015 12:18:44 GMT -5
Anyone care to comment on the EKG?
What is going on with this patient? What are you worried about?
Would you give any meds?
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Post by Bjs04f on Dec 7, 2015 23:11:59 GMT -5
easy there its only been up 10 hrs and were overworked tired residents. haha jk. Back to the case. The ekg is obviously terrible looking. the pt is hypotensive and seizing which would already concern me about tox. looking at the ekg im seeing ventircular bigeminy one atrial beat one ventricular beat. It also seems to be lengthening and becoming more irregular. So is this tox has she overdosed on grandmas dig or a Na blocking drug. is this electrolyte hypokalmia hypomag. So with this getting worse and the ongoing seizure slamming in mag and calcium wont hurt her unless shes hypercalcemic which seems unlikely as that shortens the QT
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Post by Bjs04f on Dec 7, 2015 23:12:29 GMT -5
we had recently talked about how seizures are freq misdiagnosed arrhythmias
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Post by jpollock on Dec 8, 2015 11:18:07 GMT -5
good! sounds like you win resident of the year! ugly ekg + seizure and you have to consider tox. while sometimes the EKG is ugly during the seizure and clears up when the seizure stops, this ekg is just ugly.
EKG: irregular with bigeminy. it does have some p waves followed by widened qrs ~120msec, alternating with wide QRS beats (no p wave and ~400msec)... so I would use the sinus beats as the baseline(still borderline widened. also of note is a raised R' in aVR. This is suspicious for Na channel blocker overdose.
Due to the combo of seizure, hypotension and widened QRS, this patient was given IV bicarb which resulted in QRS narrowing and improved BP. She was intubated for AMS. As BJS mentioned electrolytes as a possibility, she was also found to have a K of 2.1! but hyperkalemia could also cause an "ugly" ekg.
When she was extubated, she admitted to intentional Benadryl overdose. In addition to its anticholinergic and sedative effects, in overdose Benadryl will produce tachycardia, widened QRS, BBB, Na and K channel blockage, QT prolongation, T/U wave abnormalities, and thus predisposes to polymorphic Vtach!
While TCAs are a classic for this, I just wanted to list several other Na channel blockers:
antihistamines, escitalopram, quinidine, procainamide, lidocaine, propranolol, Dilantin, cocaine, & carbamazepine.
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