51 year old female CC: Near Syncopal Episode – Conclusion

This is the conclusion to a 51 year old female CC: Near Syncopal Episode. If you haven't read the first part we highly recommend it!

When we left off, our crew was attending to a 51 year old female who had almost passed out in a stadium tunnel during a college football game. We received a few questions as to the type of football, which could be important to the diagnosis, so we will clarify that this was an American Football game.

Our crew had found her to be hypotensive, first bradycardic and then tachycardic, with concerning changes on the 12-Lead.  A nasal cannula at 4 L/min was initiated and they established bilateral IV's and were rapidly infusing nomal saline to restore perfusion.

Let's take a look at the initial rhythm strip:

Wouldn't Want to Miss the Big Game - Initial Rhythm

The initial rhythm strip shows a narrow complex tachycardia at ~130 bpm, without clear P-waves. Retrograde P-waves can be seen in numerous complexes T-waves, leading to a presumptive diagnosis of a junctional tachycardia.

Wouldn't Want to Miss the Big Game - Long Rhythm Strip

The longer rhythm strip shows sinus complexes followed by runs of junctional tachycardia. Astute readers will note Wenckebach conduction of the retrograde P-waves!

This finding alone would be highly concerning given our patient's present condition and history, however, when we move onto the 12-Lead her diagnosis is clinched:

Wouldn't Want to Miss the Big Game - Initial 12-Lead

The initial 12-Lead ECG again shows a junctional tachycardia, with markedly hyperacute T-waves and ST-elevation in the anterior precordials with downsloping ST-depression in the inferior leads. The degree of which the T-waves tower over the R-waves in V4 is truely impressive!

The crew immediately recognized the extensive anterior wall infarct with cardiogenic shock, and given the concurrent finding of a junctional tachycardia presumed there to be gross insult to the AV nodal tissue. They placed defibrillation pads on the patient and helped the arriving crew package the patient. The patient was able to follow commands and 324 mg aspirin was given PO. After 1 liter of fluid the patient remained hypotensive and another bolus was started. Oxygen was titrated to maintain an SpO2 of >96%.

Eventually the patient stated she had some dull pressure in her chest, but otherwise denied pain or shortness of breath. An early STEMI notification was given and while enroute to a STEMI receiving center the crew ran multiple 12-Leads, capturing the evolution of the myocardial infarction.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 1

In this 12-Lead we can clearly see periods of alternating tachycardia and bradycardia, an ominous sign given the evolving MI. V5 and V6 were removed and adjusted closer to V4 and V7 so that defibrillation pads could be placed.

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 2

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 3

Wouldn't Want to Miss the Big Game - Subsequent 12-Lead 4

The patient was taken directly to a cath lab suite and found to have a 100% occlusion of the LAD and after the placement of a stent the patient's ECG normalized and her hypotension resolved.

This case illustrates the amazing evolution of an extensive anterior myocardial infarction and highlights the role the LAD can play in AV nodal function. We hope you enjoyed these ECG's as much as we did!

7 Comments

  • Alex says:

    Did this lady ever have any chest pain?

  • Alex,

    I asked the crew and they said eventually she said she had "dull pressure" in her chest, but otherwise she did not initially present w/ C/P.

    Thank you!

  • lyndon jones says:

    did the crew do a right sided ekg? did the crew check for JVD and confirm clear lung sounds before dumping fluids? and finally was the patient place in the legs elevated position for txp?

  • Lyndon,

    Given an extensive anterior MI the crew did not feel it was necessary to check a Right Sided ECG. No adventitious lung sounds were noted. And as far as I can tell, no Trendelenberg positioning was used.

  • Firebird71 says:

    agree with the extensive anterior dx.  ST elevation in almost all precordial leads along with AvL.  ST depression inferiorly.  not sure i would've done a right sided set, but it couldn't have hurt.  ST elevation inferiorly and I would definitely do a right sided tracing.  Sounds like she made out ok, but I hope some collateral circulation kicked in for the areas affected. That'll keep her from being a cardiac cripple.

  • Casey Cardwell says:

    I am not an astute reader ;)  Could someone help me understand the Wenckebach, retrograde p-wave pattern?  I don't know how to identify the Wenckebach from the rhythm strip.

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EMS 12-Lead

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Comments
Kevin
44 year old male CC: Palpitations
Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
2014-10-22 13:31:06
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56
Eric Strong
Axis Determination – Part VI
This is a great discussion of axis determination. One minor suggestion: I think it's potentially misleading to refer to an axis between 0 and -30 as "physiologic left axis deviation", since "axis devitation" implies deviation from normal, and axes between 0 and -30 are perfectly normal, (depending on age and body habitus). It may be…
2014-10-05 17:09:00

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