Monday, 17 May 2010

67 y/o male CC: Syncope


A 67 y/o male has fallen to the ground at his residence. His "partner" called 911 after seeing that he was unconscious. Upon your arrival the patient is alert and requesting that you pick him up because he really needs to make a bowel movement. The patient denies syncope but states that he does not remember falling.

Here is the initial ECG and the subsequent 12-lead ECG. Sorry for the poor quality.





What do you see?

What do you want to know?

What do you want to do?



****Update 5/20/2010****



His Vital Signs

HR correlates with monitor, pulse not palpable at radial.

Initial BP 78/60

AAOx3, normal mental status, just wants to make a bowel movement.

Skin - Pale, more pronounced and white from the waste down. Skin was relatively dry.


****Update 5/23/2010****


A new 12-lead ECG is captured during transport.

The patient's vital signs do not improve dramatically with IV fluids.

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13 comments:

  1. ventcular junctienal rhythm ?

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  2. Cor Pulmonale? possibly Pulmonary emboli? I'd say RBBB pattern, indeterminate axis, ST depression and inverted Ts in V1-V4 plus low voltage are in favor of emphysema, cor pulmonale...then there is ST elevation in V5-V6.and inferior leads.I'm not sure...

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  3. Ventricular junctional rythm with RBBB

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  4. 1 .SINUS RYTHM ,
    2.ANTERIOR LATERAL MI ,
    WE HAVE ST ELEVATION FROM V1 TO V6
    AND DEPESION 2 3 AND AVF

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  5. I don't think that that case of acute MI

    I don't know his BP

    I have case like that in the pass and maby it's same maby we have here SSS?

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  6. I see my comment up there but I didn't post it here!!! It's what I wrote in your facebook page and i have no idea how it ended up here!

    Anyways...I wanna add a few things:
    what's the BP?What's the exam?does he have JVD? what are his comorbidities?
    I still think it's an acute RV failure due to a massive emboli.

    Update is greatly appreciated:)

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  8. Ok ,I think I got it this time:

    RBBB and Lateral MI:

    ST elevation in v5-V6,aVL is evident and is indicative of STEMI of lateral wall...in fact it's been so bad that the poor guy has lost voltage over lateral leads and is in cardiogenic shock.

    v1-v3 ST and T changes are NOT due to ischemia, since you want to see the ST segment to go to the "same" direction of the bundle block in order to call it ischemic.Opposite direction is nl and because of the block.

    He seems to have had a non-sustained VT too in the long lead record.However i'm not sure if it's really a wide complex tachcardia bcuz of the quality..

    Thank you so much for the update and all the effort you make to educate medical professionals.ECG is a fascinating subject:)

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  11. I think the rythm is junctional in origin ..
    There is complete RBBB with right axis deviation , but the question is it new or old ??. CHECK an old ECG if available..

    There is hyperacute T wave in the inferior leads and lateral leads with minimal STE in V5 am thinking about inferolateral STEMI, well the histroy of syncope is very suggestive.. Anyway serial ECG's is necessary to catch any changes.

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  13. I think patient needs permanent pacemaker, because of alternating RBBB with LBBB (Class I C Recommendation).

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