I’m not going to lie. The obstacles we face seem pretty insurmountable some days. This probably wasn’t really a fair EKG to put in an EKG quiz; it was probably more to re-assure myself. Keeping a WIDE differential however is a pretty common theme when you look back on a case. It doesn’t mean you’re committed to the so-called million dollar work-up in every patient, but definitely at least think of multiple organ systems that could be involved.
At least 99% of the time this EKG is just sinus tach from pain from a kidney stone. Would it change if I told you that an hour later there were very few RBC’s in the urine? I signed her out with a stone protocol CT pending. Let’s leave off there for now and go through the EKG.
Rate is just under 3 big boxes wide so a little faster than 100. The V1 rhythm strip shows P waves throughout so it’s sinus tach. Axis is normal, QRS is narrow. There is some TWI in V1 and V2, but that can be a normal finding when concordant with the QRS. (But it can also be a sign of some other things, let’s come back to that). A couple people questioned Brugada (consistent with a few recent EKG’s I’ve shown), but there isn’t really STE in V1 or V2. I can see how the shape of V1 would make a person consider it though.
Let’s return to the case. Now what if I told you that stone protocol CT that I signed out came back normal for stone though there was a small pleural effusion. My colleague who went back and re-examined her found her still tachycardic and uncomfortable despite pain meds. Let’s go back to the TWI in V1 and V2; that can be a sign of R heart strain. The patient has flank pain but no stone, persistent mild tachycardia, possible R heart strain and a small pleural effusion. Looking again at the EKG there’s a subtle S wave in I, and a q wave in III, though the T wave looks to be up in III; there’s a borderline S1Q3 though not quite the full (but non-specific) S1Q3T3. I’ll cut to the chase, the PE protocol CT is positive and the patient gets admitted for anti-coagulation.
Take-homes? First of all, keep a wide differential. Kudos to my partner for not just stopping when the initial work-up was negative and re-assessing the patient with an open mind. Flank pain PE is very much a thing, I know I’ve seen one about every 3 years. Second is that there’s several (non-specific) findings on an EKG that can suggest R heart strain, one of them is TWI in V1 and V2. It’s harder to get excited about when it’s concordant with the QRS, but try to keep it tucked away as a possibility at least.