I'll warn you up front that the patient insisted on being transported to a hospital without specialty services so we have no information about diagnostic testing that might confirm the diagnosis.
EMS is called to the scene of an "unresponsive" patient.
Upon arrival, paramedics find a 79 year old female with no complaints. The patient's family states that the patient's eyes rolled back into her head and she became unresponsive.
More disturbingly, the family states that she was not breathing and did not have a pulse prior to EMS arrival. CPR was performed.
At the time of EMS evaluation the patient is oriented to person and place but not time or event.
Vital signs:
Resp: 26
Pulse: 112
BP: 125/77
SpO2: 84 RA
Patient is resting in her right side.
Skin is pink, moist, and hot to the touch with no cyanosis.
No accessory muscle usage. No JVD, tracheal deviation or pitting edema.
The family states that the patient was diagnosed with ventricular tachycardia within the past week for which she takes amiodarone.
No known drug allergies.
Patient was placed on the cardiac monitor (this rhythm strip was captured later in the call).
A 12-lead ECG was captured.
Serial ECGs were performed en route to the hospital.
Do you see anything unusual that is cause for concern?
The pulse ox wave form does not match the ecg...
ReplyDeletethat rate in the bottom tracing of the first strip seems consistent the respiratory rate and etco2. the waveform is strange though.
ReplyDeleteINITIAL STIPE- WIDE QRS COMPLEX WITH MULTIPLE VPC-QUADRIGEMINY PATTERN
ReplyDeleteNEXT ECG- ALSO MULTIPLE VPCS
Compare the first 12 lead with the final 12 lead(+/- 18 minutes later) T wave inversion in 12-Lead 6 comparably different to "baseline" at 12-Lead 2. Are we seeing an MI progress? Maybe CPR knocked the problem loose temporarily?
ReplyDeleteprolonged QT duration in the last ECG, and certainly a weird ST/T configuration - comparing the 1st 12 lead to the last, that anterior leads show increasing T wave height but definitely a morphology that I haven't seen before. I doubt that they are U waves. Looking forward to the final dx.
ReplyDeleteBrugada
ReplyDeleteIt is lije a Brugada, but she is an elderly patient
ReplyDelete"Disease characteristics. Brugada syndrome is characterized by ST-segment abnormalities in leads V1-V3 on ECG and a high risk of ventricular arrhythmias and sudden death. Brugada syndrome presents primarily during adulthood; age at diagnosis ranges from two days to 85 years. The mean age of sudden death is approximately 40 years. Clinical presentations may also include sudden infant death syndrome (SIDS) (death of a child during the first year of life without an identifiable cause) and the sudden unexpected nocturnal death syndrome, a typical presentation in individuals from Southeast Asia." from GeneReviews
ReplyDeleteOldest known person with Brugada Syn was 85 yo
ReplyDeleteIt's not brugada. You can't diagnose Brugada off a PVC.
ReplyDeletepossible WPW
ReplyDeleteMy initial thought was Brugada. Quadrigeminy in first two strips. Prolonged QT interval and possible Osborne wave in third strip V6.
ReplyDeletePlease tell the dx lol