Looks like a normal sinus rhythm in the low 80's with diffuse ST elevation accompanied by PR depression. I would suspect pericarditis.... Not sure why he would be having seizure's though.
Don't forget illness and fevers can cause seizures in those with seizure disorders, so this could be pericarditis acting as a trigger for a seizure. Either way, this looks like pericarditis to me: Diffuse concave ST elevation as opposed to convex elevation, with elevation in lead II higher than lead III, and slight PR segment depression. If this is not pericarditis, then this will certainly be a very interesting case!
Past medical history? Physical exam? Vital signs? Current medications? It's a mistake to interpret an ECG in a vacuum!
I am particularly interested in knowing whether or not the post-ictal state resolved rapidly and whether or not the patient's neuro exam returned to normal. Also, if pulses were equal in all extremities and BP was similar on both sides.
I agree the general appearance of this ECG suggests pericarditis because of the diffuse ST segment elevation with notched J points in II and aVF, along with PR segment depression.
However, it's a little bit unusual in that there is no ST segment elevation in leads I and aVL.
The ST segments are, for the most part, upwardly concave. However, there is some upward convexity in lead III and V1, and the ST segment approaches "straight" in leads V2-V4.
On the other hand, there is no loss of R wave height which points to a non-AMI diagnosis.
Any patient with an abnormal neuro exam should be disqualified from a field-initiated Code STEMI. These patients need further workup prior to an emergent cath.
Just for fun, may we please know the computerized interpretation?
Unfortunately I don't have anymore than what I posted. The computer interpretation was not attached by the crew on this call. I will be posting what my training captain (probably the only person I talk to that might know electrocardiography as well as you) sent as the answer to this strip tease.
Something that stood out for me on this one was the age and presentation. I thought vasospasm, cocaine, hypoxia, etc..
Any patient who presents with possible STEMI on the 12 lead ECG and an abnormal neuro exam requires an emergent CT scan to rule out acute neurological insult as a cause of the ST/T abnormality.
Thank you sir, this relates to a previous strip tease I posted that showed non-cardiac ECG changes. This phenomenon was foreign to me not long ago, and I like discussing it. Tom, do you know what exactly causes the ECG changes from neuro problems?
This has come up many times at the EKG Club. I don't recall the exact mechanism, but if memory serves, it has something to do with the activation of neuro/neuro-hormonal pathways which can cause ST abnormalities and/or "cerebral" T waves.
The take-away point is that STEMI patients should not be obtunded or otherwise have abnormal neuro exams, and if they do, they need a CT scan prior to PCI (and especially prior to thrombolytics).
I think I have some peer reviewed literature about this phenomenon somewhere on my hard drive. If I find it, I'll let you know!
"Neurosurgical Emergencies, Volume I" from the American Association of Neurological Surgeons.
Page 141
"Electrocardiographic changes are common after subarachnoid hemorrhage and include arrhythmias and waveform changes consistent with ischemia or infarction. It is believed that most of these abnormalities are the result of a massive rise in circulating catacholamine levels occurring at the time of hemorrhage."
So Adam, were you alluding to cocaine induced seizure with the EKG reflecting the cocaine use? Tom, you are thinking a spontaneous head bleed or tumor causing increased ICP that leads to seizure with the EKG showing the effects on the heart of a massive sympathetic? I know that the catacholamine release has a part in the increased BP associated with cushings triad in the presence of increased ICP, but would we not see a slower heart rate? If the ICP is high enough to be reflected on EKG changes, then I don't think the patient would regain conciousness. Yes, the patient could be developing seizures from a tumor, but I am just not sure, with the limited info we have. Does the patient regain conciousness fully? What is his history? Any recent severe headaches? Photophobia, etc. I am just thinking aloud but I do not believe this is an MI, at least.
ST segment elevation must be explained, and if the etiology involves AMI, urgent, time-sensitive therapeutic decisions must be made.
If a patient with abnormal ST segment elevation (and changes on serially obtained 12 lead ECGs) presents with an abnormal neuro exam, the patient needs an emergent CT scan.
I said "chest and head" because aortic dissection can also cause ST elevation and neurological changes.
You said you see changes between these 2 strips. All I see is maybe some T-wave flattening, I still see the ST-elevation. Might this be due to potassium levels? Isn't there a large potassium release due to tonic-clonic activity?
This is another case of non-cardiac ST-elevation presented to me by my clinical coordinator. The exact cause of the changes is unknown but the patient did not suffer any cardiac damage. I wish I had a better answer to this one. Another case of benign ST-elevation in a young adult.
17 comments:
Looks like a normal sinus rhythm in the low 80's with diffuse ST elevation accompanied by PR depression. I would suspect pericarditis.... Not sure why he would be having seizure's though.
Coxsackie virus is the most common cause of viral pericarditis, myocarditis, and is a common cause of aseptic (ie. viral) meningitis. Start there?
Would the widespread ST elevation be indicative of ischemia due to the hypoxia from a prolonged tonic-clonic seizure ?
The answer is coming soon. Good guesses so far.
Don't forget illness and fevers can cause seizures in those with seizure disorders, so this could be pericarditis acting as a trigger for a seizure. Either way, this looks like pericarditis to me: Diffuse concave ST elevation as opposed to convex elevation, with elevation in lead II higher than lead III, and slight PR segment depression.
If this is not pericarditis, then this will certainly be a very interesting case!
Adam -
Past medical history? Physical exam? Vital signs? Current medications? It's a mistake to interpret an ECG in a vacuum!
I am particularly interested in knowing whether or not the post-ictal state resolved rapidly and whether or not the patient's neuro exam returned to normal. Also, if pulses were equal in all extremities and BP was similar on both sides.
I agree the general appearance of this ECG suggests pericarditis because of the diffuse ST segment elevation with notched J points in II and aVF, along with PR segment depression.
However, it's a little bit unusual in that there is no ST segment elevation in leads I and aVL.
The ST segments are, for the most part, upwardly concave. However, there is some upward convexity in lead III and V1, and the ST segment approaches "straight" in leads V2-V4.
On the other hand, there is no loss of R wave height which points to a non-AMI diagnosis.
Any patient with an abnormal neuro exam should be disqualified from a field-initiated Code STEMI. These patients need further workup prior to an emergent cath.
Just for fun, may we please know the computerized interpretation?
Great case!
Tom
Tom,
Unfortunately I don't have anymore than what I posted. The computer interpretation was not attached by the crew on this call. I will be posting what my training captain (probably the only person I talk to that might know electrocardiography as well as you) sent as the answer to this strip tease.
Something that stood out for me on this one was the age and presentation. I thought vasospasm, cocaine, hypoxia, etc..
Adam -
Now we have changes on serially obtained 12 lead ECGs! This is quite concerning.
I stand by my previous comment about abnormal neuro exams, but I'm leaning away from pericarditis.
This patient needs an emergent CT scan, chest and head.
Looking forward to hearing the answer!
Tom
Just so the others who read our comments can follow. Why do you advocate an emergency CT of the head on this patient?
Adam -
Any patient who presents with possible STEMI on the 12 lead ECG and an abnormal neuro exam requires an emergent CT scan to rule out acute neurological insult as a cause of the ST/T abnormality.
Tom
Thank you sir, this relates to a previous strip tease I posted that showed non-cardiac ECG changes. This phenomenon was foreign to me not long ago, and I like discussing it. Tom, do you know what exactly causes the ECG changes from neuro problems?
Adam -
This has come up many times at the EKG Club. I don't recall the exact mechanism, but if memory serves, it has something to do with the activation of neuro/neuro-hormonal pathways which can cause ST abnormalities and/or "cerebral" T waves.
The take-away point is that STEMI patients should not be obtunded or otherwise have abnormal neuro exams, and if they do, they need a CT scan prior to PCI (and especially prior to thrombolytics).
I think I have some peer reviewed literature about this phenomenon somewhere on my hard drive. If I find it, I'll let you know!
Tom
From a previous discussion at the EKG Club:
"Neurosurgical Emergencies, Volume I" from the American Association of Neurological Surgeons.
Page 141
"Electrocardiographic changes are common after subarachnoid hemorrhage and include arrhythmias and waveform changes consistent with ischemia or infarction. It is believed that most of these abnormalities are the result of a massive rise in circulating catacholamine levels occurring at the time of hemorrhage."
So Adam, were you alluding to cocaine induced seizure with the EKG reflecting the cocaine use?
Tom, you are thinking a spontaneous head bleed or tumor causing increased ICP that leads to seizure with the EKG showing the effects on the heart of a massive sympathetic? I know that the catacholamine release has a part in the increased BP associated with cushings triad in the presence of increased ICP, but would we not see a slower heart rate? If the ICP is high enough to be reflected on EKG changes, then I don't think the patient would regain conciousness. Yes, the patient could be developing seizures from a tumor, but I am just not sure, with the limited info we have. Does the patient regain conciousness fully? What is his history? Any recent severe headaches? Photophobia, etc.
I am just thinking aloud but I do not believe this is an MI, at least.
What I'm saying is this, Shaggy.
ST segment elevation must be explained, and if the etiology involves AMI, urgent, time-sensitive therapeutic decisions must be made.
If a patient with abnormal ST segment elevation (and changes on serially obtained 12 lead ECGs) presents with an abnormal neuro exam, the patient needs an emergent CT scan.
I said "chest and head" because aortic dissection can also cause ST elevation and neurological changes.
Tom
Ahh, I did not consider aortic dissection, but then again, I never equated neuro changes with it asside from the results of poor perfusion.
Tom,
You said you see changes between these 2 strips. All I see is maybe some T-wave flattening, I still see the ST-elevation. Might this be due to potassium levels? Isn't there a large potassium release due to tonic-clonic activity?
This is another case of non-cardiac ST-elevation presented to me by my clinical coordinator. The exact cause of the changes is unknown but the patient did not suffer any cardiac damage. I wish I had a better answer to this one. Another case of benign ST-elevation in a young adult.
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