This great case was submitted by Vince DiGiulio, EMT-CC; we highly recommend you read his wonderful blog The Medial Approach to Emergency Medicine. As usual, the case has been altered to protect patient and provider privacy.
You're working triage in a busy urban ED when an 88 year old female is brought in by her family. She is in a wheelchair and appears lethargic.
When you introduce yourself she comes around and is able to answer your questions, albeit with some hesitation. Her family reports that she is independent and lively at baseline and are concerned she is having a stroke.
You move her into a triage room and grab a set of vitals. Her breathing appears unlabored with an irregularly irregular pulse at her radials. You ask an ED tech to join you to help with acquiring an ECG.
- Pulse: 80-100, irregularly irregular
- BP: 122/83, auto-cuff
- Resps: 22, unlabored, clear bilaterally
- SpO2: 92% r/a
- GCS: 14 (E3 V5 M6)
- LAPSS: Negative
The ED tech runs a strip from the monitor after switching to Lead I as Lead II had small complexes.
You call back to the charge nurse and ask for a bed assignment and wheel the patient back with the help of the ED tech. In the room a 12-Lead ECG is acquired while a complete history is gathered.
- PMHx: hypertension, hypercholesterolemia, Type II diabetes
- Meds: lisinopril, Lipitor, glipizide, ASA, and a multivitamin
- Allergies: PCN and Sulfa
- Last In's/Out's: normal lunch, vomiting during the afternoon
- Events: progressive lethargy and weakness after vomiting in the afternoon
The RN hands you a copy of the 12-Lead while she updates the electronic chart.
Given the 12-Lead you decide that a Lewis Lead should be acquired, as it may give additional insight into the underlying rhythm:
The ED physician walks into the room and asks you one question, "does she has a history of atrial fibrillation?"
- What is this patient's rhythm?
- What are some potential causes of our patient's rhythm?
- Does the Lewis Lead offer any potential insights into our pateint's rhythm?
- Would this information change your treatment decision?