ECG Case (1)

[Mustafa]

Around 07:00 AM,  a 39 yr old man  was brought  to the emergency department by an ambulance. They  found him lying near the stoop of an apartment building. The paramedics were not able to obtain any history from the patient.  When arrival, The patient ‘s mental status still altered  and his skin is cold . his  vital signs were as follows:  heart rate of 38 beats p/m, blood pressure of 88/40 mm Hg, respiratory rate of 24 breaths  p/ m and oral temperature of 35.4°F. His oxygen saturation could not be obtained with the pulse oximeter. At first glance, The patient appears to be a homeless, disheveled man and looks older than his chronologic  age, with a faint smell of alcohol on his breath. No obvious  signs of head trauma are noted. The patient is far from stupor, easy to wake up but unable to follow simple commands. His pupils are isocor with normal pupillary reflexes. Physical examination of the patients’  heart are notable for marked bradycardia and the  examination of the lungs reveals a remarkable  rhonchi  over  the right lower lung field. Laboratory values were ordered. His blood glucose level  was 104 mg/dL. 1a. Mention most notable abnormalities demonstrated by  the ECG? 1b. What is your diagnosis based on the answer of the first question? 2. What is the most possible  etiology in this  case? 3. What is the most possible complication of this diagnosis? 4. What are the treatment?

[Yaxya]

1-Mention most notable abnormalities demonstrated by  the ECG
ST elevation in V1 V3 V4 V6
pathological Q wave in V6
2-What is your diagnosis based on the answer of the first question?
ST elevation MI
3-What is the most possible  etiology in this  case?
it might be thrombosis or hyperlipidemia as result of heavy alcohol consumption
4-What is the most possible complication of this diagnosis?
heart failure,myocardial rupture,VSD,MR,arrhythmia,post MI pericarditis.
5-What are the treatment?
ACE inhibitors,fibrinolysis agents,
surgical like:CAPS or PCI.

[Mustafa]

Dr Yahya, you are almost there and so close.

[Admin]

1a. Mention most notable abnormalities demonstrated by  the ECG?
There is a J wave also called the Osborn wave, (the J wave is the convex positive deflection at the junction of the QRS complex and the early part of the ST segment).
Although typically most prominent in the inferior limb leads (II, III, aVF) and the lateral precordial leads (V5, V6), all leads are involved as hypothermia worsens and the deflection heightens.

1b. What is your diagnosis based on the answer of the first question?
Hypothermia which typically results in a lethal arrhythmia. cardiac output progressively declines below 30°C (86°F) owing to depressed
cardiac mechanics, including a reduced heart rate.

2. What is the most possible  etiology in this  case?
Our patient is homeless and alcoholic.

3. What is the most possible complication of this diagnosis?
Loss of consciousness, coma and death, in case of heart it may end with arrythmia, atrial flutter then heart failure.

4.   What are the treatment?
Intubate the patient, warm him with external heat exchangers and give fluid replacement.
Dr.Mahdi

[Mustafa]

Assalam,


Dr. Mahdi, you have answered all questions. I would like to add some notes

1a. one more classic abnormality associated with hypothermia is also demonstrated by the ECG of this patient; a profound sinus bradycardia.

3. Most possible cardiovascular life- threatening or complication of hypothermia is cardiogenic shock ( sinus bradycardia at rate 45 beat p/m). Indeed you did mention the other complications such as malignant dysrythmias .

4. In this case, the cornerstone of treatment is rewarming the patient and is typically sufficient for him to regain normal myocardial contractility and rhythm.
Indications for intubation are same as in normothermic patients. Because hypocapnia can increase ventricular irritability, avoiding overzealous ventilation is imperative.


take home message for this case:
The ECG must be interpreted within the clinical context: In this case, the apparent elevations of the ST segment should not be misinterpreted as evidence of myocardial injury. Other ECG findings of hypothermia, not seen on this tracing include prolongation of the PR, QRS, and QT intervals.
Hypothermia is often diagnosed before ECG is performed. However, the ECG can provide important clues to the diagnosis and yields critical information regarding the overall severity of the patient's condition from an electrophysiologic standpoint.

The 15 points goes to dr. Mahdi.



References
McCullough L, Arora S: Diagnosis and treatment of hypothermia. Am Fam Phys 2004
Marx JA: Rosen's Emergency Medicine Guide: Concepts and Clinical Practice. St Louis: Mosby-Year Book; 2002.

[Admin]

Thanks Mustafa, ofcourse there is sinus bradycardia but what do you think about rhonchi?, does it have significance in this case apart from it's indication of an infection which may precipitate hypothermia beside alcoholism and hypoglycemia.

[Mustafa]

Salam dr. Mahdi,

the remarkable rhonchi over the right lower lung is a secondary and therefore not  significant in the intial therapy. To regain optimal rythm is of paramount importance in the perclinical assessment.

[Admin]

thanks