EKG

Straining for the elevation

There’s elevation, and there’s elevation.  Sometimes it’s the top of a sand dune.  Sometimes it’s the top of a volcano (like Ecaudor’s Antisana, below).  The dunes are caused by wind (I think?).  The volcano by geologic forces.

 

When we see elevation on an EKG we tend to think of one cause.  But are there more?

20180326combo_
70’s y.o. man with dizziness and shortness of breath

The patient is tachy, the RR interval is a little more than 2 big boxes wide so we’re looking at 130’s or 140’s.  A couple of you were a little skeptical about there being P waves, but if you zoom in on the rhythm strips they’re there.

20180326combo_p

The PR interval looks reasonable and we see no PR depression.

The QRS is narrow, but a Q wave in III should draw the eye.

20180326combo_Q

Moving on to the ST segments we see right away in the above zoom that there’s an inverted T wave in III.  Looking elsewhere we see a millimeter of ST elevation in V1 and V2.

20180326combo_ste

Does that mean this is a STEMI?  It’s a little odd to see elevation most prominent in V1 and V2, and there isn’t really reciprocal change elsewhere (unless you count the T wave inversion in III which would be much more supportive if it was ST depression).  Is there something else that causes a Q wave in III and T wave inversion in III (and oh by the way an S wave in I?)  Something that could cause Right heart strain and an injury pattern in V1 and V2??  And a marked tachycardia??? If that doesn’t set off alarm bells then the patient’s CT angio should.

20180326PE_

The patient has a saddle PE.

The takehome from this EKG?  While ischemia has to be at the top of your differential when you see STE, remember that it’s not the only potential cause.

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