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Post by pbruss on Jan 5, 2015 7:37:34 GMT -5
57 yo man, smokes, HTN, NLD, has known gall stones. came into ED with and pain and heart burn. stated got worse after he ate 30 min ago and feels like his gallstones. he says his pain from his gallstones have been getting worse and can't wait to have his outpatient surgery done scheduled for next week. EKG is done as part of pre-op screening in ER and is attached. he also has CXR, CBC, CMP, and TROP for pre-op in the ER and all are normal. i also attached his previous EKG for comparison. what is your interp and treatment? Attachments:
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Post by Bjs04f on Jan 6, 2015 11:42:34 GMT -5
So new avr elevation. New v2 t wave inversion. Lateral lead st depression. Cancel surgery call cards. Need cath. In the meantime if he's having pain nitro and heparin. Add some aspirin
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Post by pbruss on Jan 7, 2015 8:59:41 GMT -5
nice read. this fictional case was a case referred to me by one of my colleagues. Stransky is right but there is one other thing that is concerning on the EKG and the history. he came into the ED because he pain got worse 30 minutes PTA. if you look closely at the EKG there is some ST depression in 2, 3 AVF that is concave up that is suggestive of subendocarial infarction (see attache ekg with baseline marked with white line). that with the changes Stransky mentioned and the fact that this EKG was done 30 minutes after onset of symptoms is concerning for early infarction. i think a repeat ekg in the ER 15-30 minutes after the first would have been helpfull to identify a possible early infarction in this case. since his ekg did not show anything obvious and his trop was negative (drawn 30 min after onset of symptoms so could be false negative) he was cleared for surgery. they could not extubate him after surgery and BP was very low. repeat trop was significantly elevated. Attachments:
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Post by pbruss on Jan 8, 2015 6:58:18 GMT -5
just read cath report, severe 3 vessel disease, needs CABG |
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Post by Bjs04f on Jan 8, 2015 22:21:47 GMT -5
well atleast hes already intubated so back to the OR it is
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Post by tyson on Jan 9, 2015 10:05:25 GMT -5
he also has new flipped T waves in AVL.
mattu has some lectures about how you might see changes in T wave inversions in AVL before you'd see any ST elevation in early STEMI's.
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Post by Bjs04f on Jan 9, 2015 10:27:58 GMT -5
similarly st depression may precede it as well. Also not related to this case, but read an interesting tidbit that while people always go "oh no reciprocal depression youre good." doesnt mean shit Reciprocal st depression has an odds ration of roughly 3.5, so specific but lack of st depression only confers a 0.3 risk reduction, so not great.
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Post by pbruss on Jan 12, 2015 18:07:38 GMT -5
i like the rage in your statment.
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Post by Bjs04f on Jan 12, 2015 21:04:52 GMT -5
Cardiology causes me to rage when we both know there is only one therapy proven to be beneficial, and theyre withholding it due to laziness. Kemple was told wellens isnt a thing, mind exploded
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Post by kemple on Jan 27, 2015 15:01:56 GMT -5
OMG that was a pain in the ass.
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