Clinical Case 049: the Unseen ECG

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.

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 …..

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!

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!



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