EKG

you’re not married to two hours

and even if you are…

Too often we bog down into default patterns.  It’s all too easy to just reflexively push every chest pain patient into a 3 sets of EKG’s and markers pathway and stop thinking about or re-evaluating them.

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50’s y.o. man with CP

Rate is pretty straightforward here.  There’s a little over 4 big boxes between the regular complexes, it looks to average in the 70’s.  There are two PAC’s, but otherwise this is sinus rhythm.

Axis is a little off.  It’s up in I (normal) but down in aVF so we have a left axis.  Frequently a left axis is associated with a fascicular or bundle branch block, but the QRS is nice and narrow.

The ST waves are the interesting part of this EKG.  I usually start with the chest leads, and there does appear to be subtle ST depression in V2.  Looking at I and aVL there may be early ST depression, there is a mildly biphasic repolarization in aVL.  If there’s depression in one place, is there elevation elsewhere? Let’s look more closely inferiorly.

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There’s a half millimeter or so of ST elevation in each of these leads.  More concerningly, the ST segments are quite bipolar in III, if this was in anterior chest leads we’d call them Wellen’s T waves (concerning for critical LAD stenosis).  I don’t hear that applied very often to other segments of the EKG, but you could do so here.

What to do with the patient?  It would be hard to convince a cardiologist to go to the cath lab immediately, though if pain is unrelenting you may be able to do so.  In this case the  patient was aggressively treated with aspirin, heparin (after the chest x-ray), a low dose nitro drip (it’s inferior!), some fluids (it’s inferior!), and pain control.  It’s at this point that you can make a mistake.  Don’t set this patient aside for 2 hours for repeat enzymes and EKG’s later, repeat it much sooner.  Our providers did indeed repeat the EKG much sooner, and what did they find?

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Now there’s no mistake to the inferior ST elevation with reciprocal changes to aVL, V1, and V2.  As always, don’t be mis-led by the STE coving up, not all STEMI’s have tombstone shaped ST waves.

The take-home from this patient early in the course of an Inferior STEMI?  Repeat the EKG, early and often when there’s slight abnormalities present that could evolve into a much more concerning EKG.

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