A new pointer?

Not that I’m ready to retire the swordbilled just yet, but this was what greeted me when I checked the beach this morning.


A little ominous right?  I’m not sure if this is technically a waterspout since it didn’t reach the water but it was cool none-the-less.

And speaking of ominous, let’s look at our subject EKG.

~90 y.o. man, s/p fall

Clinically we didn’t have a ton to go on, the patient was very demented and couldn’t really add a whole lot to what family reported (that they found him on the floor when they went to check on him when he didn’t respond to their daily phone call).

He’s slightly tachycardic with a rate just over 100 as evidenced by an R-R interval just under 3 big boxes wide.  In the lateral chest leads we’re able to see clear P waves so it’s a sinus tachycardia.  PR interval seems reasonable.  Axis is right with downward deflection in I.

QRS is a bit wide, in I and V1 it’s pretty definitely 3 little boxes wide.  What to make of the ST waves though.  There’s T wave inversion in V1, but that’s to be expected given the wide complex upright QRS there.  Let’s zoom in on V3 and V4, can you spot what looks off about it?


While the T wave is upright, the J point is very depressed.


There’s a name for this pattern (a depressed J point arcing up into early or soon-to-develop ST elevation).  People did very well with the Wellen’s EKG a week or so ago; this is another early ischemia pattern called DeWinter T-waves.  They weren’t present on his old EKG.  We repeated the EMS EKG as soon as he arrived.


Now he’s starting to develop tombstones in V3.  We had some extensive discussion with family and with cardiology.  Ultimately family didn’t elect for aggressive care or heart catheterization given his very advanced dementia.  We volume resuscitated him and (after our trauma work-up) heparinized him as well.  His initial troponin was in the 0.8 range and he did respond to supportive care without it elevating much further, but keep this pattern in mind when seeing patients with potentially anginal symptoms.  EKG’s are not static, they evolve, make sure you’re repeating them often enough to stay on top of the evolution (which is often a lot sooner than 2 hours from the initial!).

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