I was sitting at the desk writing up some notes when the triage nurse stuck the following ECG strip under my nose.
The story was that this chap was a hypertensive, obese, diabetic vasculopath with impaired renal function who had presented with a fever of 39 deg and nasty looking diabetic feet (see Clinical case 047 for example…). He was looking unwell so she did an ECG on the off chance he might be having a silent infarction.
So here we are – sick looking, high-risk sounding patient.
Q 1: What else do you want to know?
No chest pain; No previous IHD documented; Previous ECGs? – he had a normal exercise stress test 2 years ago with a normal baseline ECG in the chart
OK, all you smart ED types. Can you make the diagnosis? What is going on here? There might be a trick or two …..
The Answers you seek…
Ok a few observant comentators noted the machine was running at 50mm/sec – and the V leads were missing. The patient was running at 126 bpm clinically and on the monitor. Unfortunately our new nurse who was not familiar with the machine pushed the wrong buttons and gave me a terrifying minute or two as I made my way to the bedside! The penny eventually dropped and I could breathe a big sigh of relief!. The true ECG showed a tachy @ 126 with a RBBB pattern and no convincing P waves. So channeling
Chris Watford (Emcrit) I did a Lewis lead config – and the P-waves popped up like they should! Sweet – we were back to boring old sinus tachy in a septic patient and all was well!
Lessons learned here…
1. Always look at the patient before the ECG, or at least shortly thereafter!
2. If something doesn’t add up, check the basics, repeat the test and ask, ask, ask
3. Septic patients can develop nasty arrythmias – SVT, AF, transient heart blocks (RBBB), VT etc – so beware the sepsis with tachy, find those P-waves – as all the other options are not good for their cardiac output.
4. Lewis leads (S5) actually works, it is cheap, easy and makes you look smarter!
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
LMCA occlusion?
Palpitations cannot show on an ECG. AN ECG will show you the elraceictl activity but palpitations are something you feel.If you had palpitations and your ECG is normal it just means you are one of those people who is more aware of their heart beat. Most of us only feel out heart beat after exercise or if there is a really fast heart rate but some people can feel it all the time -sounds like you are one of them.
Well I guess I should say how about a little history and a physical, but while we’re talking can I get a K+, and a bedside echo?
Nice call Seth…. but no, no cigar. Not LMCA blocked. Look a little closer, or stand back a bit – whatever works! Casey
Mike. History and physical come after US. Nothing to say other than he looks sick. K+ is 4, normal.
ECHO ( by me) LV is clapping along and walls almost kissing, no obvious RWMA. Hyperdynamic LV, flat collapsing IVC. Improves with 2 L of fluid.
Lactate is 3.5 mmol if you care to know
There is a trick…..
It wouldn’t hurt to see the other leads but it’s a regular rythm with some takycardia. P-waves are small which makes it a bit tricky but I’m wondering if there’s a 2:1 blocked flutter (either look on the HR-trend on them monitor or lewis lead/esofageal lead to rule the flutter in/out). I’ll leave the rest of the interpretation until I get the other leads.
50 mm/s..
The strip is running at double speed…
Two questions to help clarify the situation:
1. Do you have V-leads to show us?
2. Does your facility commonly use 50mm/sec tracings?
50 mm/s?
Why at 50mm/sec?
can we have a lewis lead please? rates a bit variable but not what computer calculated
medication list ..? digoxin
can I have the other ECG leads , V6…this looks like LBBB
funny RhYthm, looks junctional
previous normal ECG…the guy sounds septic.. suggest new LBBB prob ischaemic related but how recent? Echo suggests old Event given no obvious RWMA
fluid responsive so treat for sepsis and do serial troponins. admit patient for sepsis
Global subendocardial ischemia NSTEMI
http://hqmeded-ecg.blogspot.com/2012/02/five-primary-patterns-of-ischemic-st.html?m=1
Where’s the rest of the leads!