68 year old female unresponsive on the kitchen floor

Here’s a wonderful case submitted by a faithful reader who wishes to remain anonymous.

EMS is called to perform a “health and welfare” check on a year old 68 year old female who has not been seen by the neighbors for at least 24 hours.

After several phone calls to the residence from dispatch and a discussion with the patient’s daughter, the fire department gains entry through a window in the back of the house.

The patient is found lying supine on the kitchen floor.

She is unresponsive with dried vomitus around the mouth.

Vital signs are assessed.

RR: 8 and shallow
Pulse: 46 and irregular
BP: 102/70

The cardiac monitor is attached.

SpO2: Initially does not register

Airway reflexes are absent.

The patient is intubated.

SpO2: 100 with oxygen via BVM

ETCO2: 20 mmHg

An IV is established.

BGL: 140

1 mg atropine and 2 mg naloxone are given with no effect.

Skin is pale and cold to the touch.

Physical exam reveals no head trauma.

A 12-lead ECG is captured.

You are 10 minutes from the local non-PCI hospital and 45 minutes from a STEMI Receiving Center.

What do you think is going on here?

See also:

Osborn waves (J-waves) of hypothermia

31 Comments

  • Bill C says:

    Hypothermia with very pronounced Osborn waves. Gentle handling, begin warming, warm IV fluids and transport to the local hospital.

  • Scott Kier says:

    Absolutely.. I know this one.. Osbourne waves.. definite local hospital transport.. needs rewarming.. even if there is an MI under there as well, there is a pretty severe life-threat as well..

    The only place I’m divided is passive rewarming.. could it be effectively done for the ambulance trip? That I’m not sure of.

    How about flying the patient?

    Just some thinking out loud there.. Cant wait to see the other responses..

  • Christopher says:

    I’m with Bill and Scott, Osborne/J-Waves. If you’ve got warmed saline, let some rip. Blankets too. Something to consider since the patient has been intubated is the need for paralytics should she warm up (no shivering). Patient goes to local hospital.

  • Dave B says:

    i can not add much, except that i believe the irregularities in rate and the prolonged QTc also suggest hypothermia.

  • Chris T says:

    I agree with above providers. Osborne/J-wave associated with profound hypothermia.
    Other 12 lead indications of Hypothermia, prolonged QRS, QT. Atrial fib.
    Caution- inverted T waves and concordant ST depression and Elevations. concern for infarct.
    Slow rewarming. And close monitoring. continue treatment already done. Pt needs to be rewarmed under controlled conditions. Only after pt is warmed up, or something changes at this point a repeat 12 lead. NO more medication interventions pt may be too cold. Electricity will likely place patient in asytole and keep them there. Lets support airway. gently rewarm. handle gently. get to hospital ASAP.

  • Dave B says:

    i saw that too, however, if you look at the 12 lead, the “ST depression” is in leads with a negative QRS… they appear to be “inverted” osborne waves… also, the T waves show appropriate discordance, with positive QRS/negative T and vice versa… i suspect this is normal for this pattern similar to other secondary ST changes, but i’d love confirmation from the gang.

  • Mike Sherriff says:

    Strip patient and two first responders, place all in large sleeping bag, cover with blankets…oh wait, you said 10 minutes, not ten hours :)

  • Elizabeth D says:

    that looks like a possibility of 2 types of heart blocks, one being a LBB block and/or Winckenback type 2 along w/ some st changes

  • Christopher says:

    Dave, I would imagine this ECG is non-diagnostic in the face of such profound hypothermic changes. However, in the spirit of treating the patient and not the monitor we can take the “life threats approach” (shamelessly stolen from the Standing Orders podcast) and take a stab at reasons she was found down:

    1. CVA, top on my list given age, responsiveness, and vomitus. T-wave inversion could be secondary to this.
    2. MI, close second given possibility of ischemic changes on the ECG.
    3. Simple hypothermia, maybe she wasn’t well and was too weak to get up.

    (Others include hypoglycemia, seizures, etc; but those appear to have been “ruled out”)

  • Bill C says:

    Given her likely lengthy of time on the floor she could be suffering the effects of rhabdomylosis, in addition to the hypothermia, which could also confound ECG findings if she has an excess of potassium along with hypocalcemia from muscle breakdown.

  • Chris T says:

    Dave B, looking closer I am more confident that you are right. There seems to be discordance. Just the nasty way it returns to baseline with the T wave My eyes still cross a little. Im always looking for that hidden MI.
    Bill, would you try to combat any of those with medications or is patient too cold.
    I dont think we have a temp on this PT my we should get one though I find most devices in the feild to be less than reliable.

  • Chris T says:

    From what I can compare to hypothermic EKGs that these types of changes occur around 86F and likely colder.

  • Probablywrong says:

    Could this patient have Rhabdomyolysis from being on the floor for so long, which resulted in renal failure and acidosis, and the abnormal EKG findings are Sine Waves?

  • Mark says:

    So I guess the underlying question is…what caused her to end up on the kitchen floor? I’d be curious if she had a stroke and that’s why she ended up getting hypothermic. (Not that that changes anything.)

  • Tom says:

    I’m going to say hyperkalemic resulting from Rabdo is the main factor causing this very unusual EKG. She is likely in a metabolic acidosis and the low EtCO2 suggests a compensation respiratory alkalosis. (or a massive PE) Anyone who has spent 24+ hours on a kitchen floor is likely hypothermic too, however I would suspect a very high K level on this lady when she is delivered at the closer non-PCI hospital.

  • Kiwimedic says:

    What signs of hyperkalemia Tom?
    T-waves are not overly high and those osborn waves are very pronounced…
    Has she shortening or rotation of one leg which immobilised her long enough for hypothermia to depress her GCS??
    or the stroke/MI cause is very plausible.
    Either way – rewarm in controlled environment and further tests at hospital.

  • Scott says:

    Strange … is the interpretation, interpreting the Osborne/ J waves as the T wave?

  • Brandon O says:

    Looks like it Scott… kind of easy to do, my eye did the same at first. Peculiar interpretation output overall though.

  • mike says:

    the question i have is how cold was the house, hypothermia could be the under lying problem, but it looks like an onset of a CVA first, yes skin is pale and cold to the touch,, yes there is a perfussion issue, would not rule out an MI,

  • Emma says:

    I think it is cva, mi, or seizures. eather way she has to be wormed up, bc we dont know how long she was on the floor, or when this has happen or how worm was it in the house?, Im with cris on this one.

  • Mark Smith says:

    This is A-fib with normal axis slow ventricular response and with obvious Osborn waves secondary to hypothermia of being on the floor for 24 hour or so.

  • Jim says:

    How about a little more scene info, that would help with the diagnostics.

  • Amanda says:

    Though hypothermia most common cause of Osborne waves some other possible etiologies are hypercalcemia,brain injury(possible CVA, or SAH. It’s also possible the hypothermia is caused from DKA. Is there any way to get hx from pt’s daughter? In any case gentle rewarming, & careful handling are necessities. Would also want to check her blood glucose.

  • Tom B says:

    Excellent point with regard to other causes of prominent J-waves. BGL was assessed @ 140.

    Tom

  • Bryan L says:

    I would question the accuracy of the capillary BGL in this circumstance – this patient is surely shunting in order to maintain end organ perfusion if we are thinking hypothermia.

    I agree that the etiology of her condition needs be determined, however due to the possibility of hypothermia and unstable vital signs, a reliable field diagnosis is unlikely.

    Can anyone provide evidence regarding the accuracy of EKG interpretation in the setting of acute hypothermia? Is it diagnostic? What can be inferred from it? (or not infer)

  • Amanda says:

    Agree w/ Bryan L re. difficulty getting reliable field dx though would still want hx from daughter if possible.Would be interesting to find out what hsp labs show esp electrolytes & Glucose as well as results of CT.

  • Pete says:

    hypothermic !

  • Chris says:

    Can you tell me where everyone is getting the Hypothermia from, she was found on her kitchen floor not in a ice lake. Looks like A.fib with LBBB, possible ST eleveation but hard to confirm with a left bundle. I say PCI.
     

  • Jeff says:

    Chris:

    Shes elderly. She doesn’t need to be in a lake to be hypothermic.

  • Gabriel says:

    Left bundle branch block?
     
    @gfcaveda

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EMS 12-Lead

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