Lead II strip
Pre-hospital 12 lead
12 lead ECG capture in the ED
This 60 year old male patient rang for an 999 emergency ambulance... c/o loss of balance... No other symptoms... On the arrival of the ambulance crew... This 60 year old male greeted them at the door, the patient seemed to be very unsteady on is feet and leaning postural wise to the left.
On examination this patient had a positive FAST test, slight problems getting is words out, slight facial drooping on the left side, and unequal grip strength... Patient denies any aches or pains and states he just wants to go to work for is last day before he retires...
Baseline observations taken from this patient are as follows:
HR: 81 bpm
BP: 135/75
Sp02: 98% on air
Blood sugar: 7.1 mmol/l
Resps: 20
GCS - 15 / p/t fully alert and well perfused (pink)
Temp: 36.7
This patient is normally fit & well... Nil reg meds ever taken... Patient never been diagnosed with any previous conditions.
Patient denies any previous episodes of any chest pain, no N&V, skin was dry, non-sweaty, no visual problems or headache...etc... just unsteadiness on his feet, losing is balance.
What do you think about this patient's ECG's???
Questions:
- What does the ECG's show?
- What are the likely mechanism of this?
- What are the likely causes of this?
- What are the key issues in managing this patient?
Very interesting case! The ECG taken in isolation would suggest inferior STEMI. The inferior Q-waves and terminal T-wave inversion suggest that it's been around for a while, and might even be reperfused. There are even some changes between the prehospital ECG and the ECG taken in the emergency department. However, any patient with an abnormal neuro exam needs a CT scan. I'm not sure what a FAST test is but I'm wondering if it's similar to our Cincinnati stroke scale.
ReplyDeleteTom
Tom: http://www.medicine.mcgill.ca/Strokengine-assess/module_fast_intro-en.html
ReplyDeleteI also keyed in on the inferior STE on the 12 lead, STE in II, III, aVF, and it looked like a little depression in aVL. Looks like the T waves are inverted in V4, 5, 6 at the ED. In regards to the mechanism, is this going to be a possible CVA with the damage in the brain affecting the Na & K channels in the heart similar to cerebral T-Waves or a subarachnoid hemorrhage? I would think the key issue is going to revolve around therapy that one might choose to treat a STEMI (Aspirin, or other "thinners" like heparin,etc...) that could complicate this if it is a cerebral hemorrhage?
ReplyDeleteStemi for sure but SAH?not so sure .Usually deep T wave inversion globally.
ReplyDeleteTom, FAST is simply a test of "Face, Arms, Speech". Is the patients face equal, is there any drooping or weakness, can they smile?. Can they raise up both arms, close their eyes and keep them level, and can they grip both hands equally (obviously excluding any previous injury). And finally is their speech slurred, are they using words that are inappropriate for the situation, or using the wrong words completely. Are they moving their mouth but not saying anything (indicating a problem with the speech centre but not the motor centre).
ReplyDelete