76 year old female CC: Diminished LOC – Discussion

Here’s the follow-up to 76 year old female CC: Diminished LOC.

Be sure to check out all the awesome comments on the case!

Let’s take another look at the 12-lead ECG.

There’s something very unusual about this heart rhythm.

It’s slow, there are no P-waves, and the QRS complexes are extremely wide (> 200 ms).

Could this be a ventricular rhythm?

Sure. It’s possible. But this is wide even for a ventricular rhythm.

The morphology is consistent with a nonspecific intraventricular conduction defect.

Whenever I see an ECG like this I immediately think, “Hyperkalemia!”

Other possibilities include:

  • Tricyclic anti-depressant overdose (note the tall R-wave in lead aVR)
  • Other sodium channel blockers (Class 1a antiarrhythmics, tramadol, diphenhydramine, etc.)
  • The effects of prolonged myocardial ischemia (end stage of big MI, PE, or respiratory arrest)

Special thanks to Dr. Smith from Dr. Smith’s ECG Blog for helping me refine this list of differentials.

Another interesting feature of this case is the multiple ecchymotic areas on the body and the pulseless R foot. This could suggest a coagulopathy or renal failure.

Additionally, I liked David’s theory about rhabdomyolysis contributing to hyperkalemia.

Would I have given this patient calcium? Absolutely!

It couldn’t hurt and it might help.

We often have to make decisions in the field based on incomplete information.

It’s the “fog of war”.

As Carl von Clausewitz wrote:

“The great uncertainty of all data in war is a peculiar difficulty, because all action must, to a certain extent, be planned in a mere twilight, which in addition not infrequently ó like the effect of a fog or moonshine ó gives to things exaggerated dimensions and unnatural appearance.”

So what was the outcome?

This patient went into cardiac arrest at the emergency department and was not successfully resuscitated.

If we find out the exact cause of death we’ll let you know.

*** UPDATE ***

The patient’s potassium level was 8.3 (Critical High).

Here’s the raw data.

Thanks again to Randy for the great case!

27 Comments

  • Christopher says:

    Our only concern with empiric calcium administration would be the patency of our IV/IO access. Don’t want any extravasation!

  • Mike Sherriff says:

    “Our only concern with empiric calcium administration would be the patency of our IV/IO access. Donít want any extravasation!”

    True. However, if it isn’t patent, find some other access! Break out the drill, or drill another hole if needed. This is a “right now baby cow” situation(conscious or unconscious)!

  • Christopher says:

    Well said, just sometimes these renal patients are loathesome for access. My last bad dialysis patient was a bilateral above the knee amputee and we’re not allowed to do humeral or iliac IO starts.

  • Brandon O says:

    Diphenhydramine can cause wide complex arrhythmias?

  • Maunay says:

    Looks like she was going into DIC…

  • Troy says:

    Diphen overdoses are notorious for wide complexes and Prolonged QT intervals. I admit I was wrong but I just wanted to put up a little bit of a fight. BTW with a lactate above 4, I’ve never seen anyone live very long.

  • Troy says:

    Maunay,

    DIC is not very probable due to the patient having thrombocytopenia and Macrototic Normocytic anemia. Plus there’s no elevation in WBC’s, Neutrophils, or banded neutrophils. Lactate elevation is caused by the muscle death which in turn throws myoglobin cells which destroys the kidneys, hence the elevated creatinine

  • Brandon O says:

    Hey guys, for those of us who slept through those four years of school, would anyone mind lending a hand with interpretation of those lab results? The general gist I’m getting is kidney failure, advanced hyperkalemia, elevated troponin (how elevated? is this consistent with STEMI?), and elevated lactate — maybe from the shock? And then nothing remarkable on the imaging. Is that in the right neighborhood?

  • Brandon O says:

    Sorry, unremarkable except for the ischemic bowel, that is.

  • Troy says:

    Brandon,

    The troponin is elevated but not enough to call it an AMI. There is some elevation but our hospitals use 1.5 or higher for a PCI activation. This could be caused by the build up of toxic chemicals causing some damage on the heart.

    The kidneys are failing. This is why they cannot filter properly which we see by excess creatinine (which is normally seen in healthy peoples blood draws) and BUN ( Blood Urea Nitrogen). Notice the UA analysis shows bacteria, RBC’s, and proteins which proteins are usually kept within the blood in those high of doses by an effectively working glomular filtration system in the kidney. BUN is extremely toxic to the body and usually is filtered out.

    Lactate is released by oxygen deprived necrotic tissue, in this case I imagine the leg. The increased PT/INR means this patient was on an anticoagulant and was on the higher end (usually that high with a heparin dose recent).

    The only thing that we’re missing is the ABG which I’m almost positive would show uncompensated metabolic acidosis. The hyperkalemia is caused because of the tissue death, but because of the kidneys being screwed, it can’t filter out well and builds up. Like I stated before, when rhabdomyolysis happens, K+, CK, and myoglobin are released. The kidney is mainly injured by the myoglobin (being a large protien) but doesn’t filter the CK and K+ out readily. CK is in all tissue, but don’t get it confused with CK-MB which is more cardiac specific. Let me know if this helps!

  • Troy says:

    And the ischemic bowel is a common cause of that high of lactate which is usually caused by poor end organ perfusion. At least that’s been the case with all the ones I’ve seen minus one guy who had a DVT and didn’t seek help for 2 days because he believed hospitals are for dying people. His lactate came back 4.6 and ended up dying 3 weeks later up in ICU

  • Troy says:

    On another note….. Does anyone carry one of the new istat portable labs? Ive heard mixed reviews… Please let me know! We wanna possibly switch to them but if its rubbish what’s the point. I love this blog! No offense Dr. Smith…. :/

  • Brandon O says:

    Is the ischemic bowel -> elevated lactate connection an infectious (septic) one?

  • Troy says:

    I would doubt sepsis in the absence of elevated WBC count

  • Brandon O says:

    So then the lactate is just from the local tissue damage in the bowel, plus perhaps the leg? (And the leg is from what — DVT? Or perhaps crush injury from being unable to change position, due to weakness and hemiparesis?) Then rhabdomyolysis shut down the kidneys and the potassium built up until it killed her from the arrhythmias?

  • Troy says:

    I didn’t even see the ischemic bowel. Yeah, that would be my hypothesis. Think about rhabdo like burn patients. They need copious amounts of fluid why? To keep the kidneys filtering and the concentration dilute.

    When cells don’t have oxygen to proceed with the Krebb cycle, glycolysis takes place. In Krebb cycle, each molecule of glucose yields 32 ATP and byproducts are CO2 and H20. In Glycolysis, each glucose instead of only yields 2 ATP and by product of pyruvic (which turns into lactic) acid. Its a biproduct of anearobic metabolism.

    And FYI if oxygen was restored during the pyruvic phase, the citric acid cycle and oxidation would convert an extra ATP and ADPH. But since this doesn’t happen, ADH attaches to the pyruvic acid which makes lactate (lactic acid) which is detrimental

  • Brandon O says:

    Thank you Troy! Very helpful.

  • Troy says:

    No problem Brandon. I might be new to 12 leads but I’m a bit of a nerd! Lol

  • Christopher says:

    We’ll help with the 12-leads if you help with the labs! Deal?

  • Tom B says:

    Seriously! Thanks, Troy!

  • Troy says:

    So reading over my past posts that I did when i was tired, I realized that i needed to clarify some stuff. I didn’t have much time to actually type due to me being at work and having to do it on my phone. So bare with me if you would.

    I believe that the lab values are indicative of ischemic bowel which caused the end result. The presence of ascites in this case is consistant with the increased hydrostatic pressure and failure of the vessels to maintain integrity.

    We all can agree on kidney failure but lets talk about why:1)creatinine is a common byproduct of muscle cells. The kidneys freely filter creatinine so the high levels in the body is always a concern. Don’t be fooled with dehydrated patients! 2)BUN (Blood Urea Nitrogen) is elevated also. This also is freely filtered out of the kidneys and is extremely toxic to the body, so when it’s elevated always be concerned. 3)the eGFR (glomular filtration rate) is 9. this is extremely low and means that the kidneys are filtering at only 9mL/min. According to the National Kidney Foundation normal is 60-90mL/min. Isn’t it exciting knowing what it means??!!!

    The RBC, HGB, and HCT test all are just telling you that the patient is anemic. The MCV (mean corpuscular volume) tells you that the patients average RBC size is large, but his MCH (Mean Corpuscular Hemaglobin) is normal. That means the average hemoglobin in the cells are normal concentration. Thank Professor Chugg for being a pathophysiology hemotology freak!! basically all it means is that the patient is deprived of folic acid.

    PT/INR is how long it takes to clot,PT, based against the world accepted time, INR. Its used often to titrate patients coumadin levels.

    I wanted to clarify on the Troponin level. Yes, it is elevated. But the fact that the patient has a high lactate, K+, BUN, and creatinine we can assume that the slight elevation is due to the toxic chemicals floating around in his blood injuring his heart muscles. Remember, free radicals are non-bias.

    everything else seemed to be clear. If you can get some labs with your future cases I’d love to help where i can (and be drooling over it). If I can clarify more let me know please. If you find an error in my documenting PLEASE let me know :)

  • Brandon O says:

    Thanks again Troy. What’s your background, if you don’t mind my asking? Are you a student?

  • Troy says:

    I’m a NREMT-P, EMS Instructor for Weber State University, Training Officer, and Pre-Med student. Plus I’m a CMN (Certified Medical Nerd) :D

  • Brandon O says:

    Cool! Everyone needs their own premed nerd! :D

  • Troy says:

    It sure can help! All my other pre-med buddies asked me why I got my paramedic if I was planning on going MD or PA anyways? I tell them because when I get those initials behind my name I want everyone to see the EMT-P with them so they know I actually know what I’m talking about. Lol

  • Kathy says:

    Reading posts like this make surfing such a paelsrue

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
David Baumrind
All that wiggles isn’t Wellens’
@Gary, by all means, nitpick all you like. I agree with your assessment, and the post has been modified. Thank you for the feedback!
2014-08-30 17:28:16
Gary Huntress
All that wiggles isn’t Wellens’
Not to nitpick but is this really a "slightly leftward axis"? I and AVF are both positive. I put it at about +20 degrees, not leftward.
2014-08-30 11:49:35
Handsome Robb
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2014-08-30 08:08:22
Christopher Watford
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Brooks, Firstly, thank you for the warm welcome to the club. Secondly, the Glasgow algorithm's only published sens/spec for AMI is 51.6%/97.6% respectively (Tuscon STEMI Database). I've not been able to find any other publications. The GE Marquette 12SL algorithm has been widely studied, but is much older, and ranges in sensitivity from 48% to…
2014-08-29 16:50:14
CB
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