I’ve got a new pointer!

It’s called a Sword-billed Hummingbird.  It lives just below the treeline in the Andes Mountains.  Its bill is longer than its body is.

sword-billed hummingbird 0263

Forget red and blue dots on the EKG’s, I’m going to try using him to point stuff out.  I’m back from Ecuador, we should be back to weekly quizzes.

20’s y.o. man s/p syncope.  He does have a systolic ejection murmur that increases with squatting.

Before we jump into the EKG, let’s look a little at the clinical data we have.  First off is a young person with syncope.  There’s a handful of things we have to specifically think about in young people who pass out.  While we should always look at everything on an EKG, you’re going to look at this one differently than a 50’s y.o. person having chest pressure.  What are the additional things we have to look for?  WPW, Brugada, and Long QT syndrome are essentially defined by their EKG’s.  In addition HOCM typically has less specific EKG abnormalities.  Congenital aortic stenosis should be considered though will be even less specific.  And of course, consider everything else on a medical syncope differential.

We also have data about a murmur.  This one increases with squatting.  Squatting forces blood and lymph out of the legs, increasing venous return to the heart.  Increased venous return should increase flow murmurs (as well as aortic stenosis and most other murmurs).  HOCM murmurs are the exception and decrease with increased preload because you get more blood flowing through the heart, which decreases the obstruction.

Let’s move on to the EKG.  QRS’s are a little greater than 3 big boxes wide so it’s a little less than 100, I’d eyeball it about 90.  The lead II rhythm strip clearly has P waves before each QRS with no dropped beats; it’s sinus rhythm.  Axis eval shows up in I, up in aVL; this is normal axis.  Remember WPW is on the differential in a young person who passes out.  I don’t see any delta waves, which are usually seen best in V3 and V4 (though not every patient with WPW has delta waves on every beat).  The QRS is narrow.

On to the ST waves.  Let’s zoom in on V1 and V2, they look weird.


We see an odd ST elevation that slopes down more or less straight into some inverted T waves.  It almost looks like a RBBB pattern except the R’ of the RSR’ in RBBB isn’t usually wider than the original R wave.  What else was on our original differential?  A person perhaps could argue this is LVH from congenitally narrowed aortic valve, but the odd RBBB/STE pattern is quite specific for something else on our differential, Brugada Syndrome, which is exactly what he turned out to have (in addition to a flow murmur).  He was admitted for an AICD.

Remember that Brugada is autosomally dominant, if you save this patient’s life then you also save the life of 50% of his first degree relatives if his mutation is fully penetrant and the math holds.

Take-homes from this EKG is that you have to think about WPW, Brugada, and Long QT (in addition to congenital aortic stenosis and HOCM) in every young person you see with syncope.




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