79 year old female CC: Unresponsive

Here's a very interesting and unusual case submitted by a long-time reader of the Prehospital 12-Lead ECG blog named Christopher Linke (aka SoCalMedic).

I'll warn you up front that the patient insisted on being transported to a hospital without specialty services so we have no information about diagnostic testing that might confirm the diagnosis.

EMS is called to the scene of an "unresponsive" patient.

Upon arrival, paramedics find a 79 year old female with no complaints. The patient's family states that the patient's eyes rolled back into her head and she became unresponsive.

More disturbingly, the family states that she was not breathing and did not have a pulse prior to EMS arrival. CPR was performed.

At the time of EMS evaluation the patient is oriented to person and place but not time or event.

Vital signs:

  • Resp: 26
  • Pulse: 112
  • BP: 125/77
  • SpO2: 84 RA

Patient is resting in her right side.

Skin is pink, moist, and hot to the touch with no cyanosis.

No accessory muscle usage. No JVD, tracheal deviation or pitting edema.

The family states that the patient was diagnosed with ventricular tachycardia within the past week for which she takes amiodarone.

No known drug allergies.

Patient was placed on the cardiac monitor (this rhythm strip was captured later in the call).

A 12-lead ECG was captured.

Serial ECGs were performed en route to the hospital

Do you see anything unusual that is cause for concern?

*** UPDATE ***

Here are some additional 12-lead ECGs.

26 Comments

  • Meeghan says:

    “the family states that she was not breathing and did not have a pulse.

    They performed CPR until EMS arrival.

    The patient is oriented to person and place, but not time or event.”

    Please review and edit.

  • Tom B says:

    Meeghan –

    It wasn’t a misprint. I added the words “At the time of EMS evaluaton….”

    Does that clarify the way it went down?

    Tom

  • Baker says:

    As far as the pt. not breathing or having a pulse prior to EMS arrival goes its a guessing game, but without a doubt i would be concerned with the 12-Leads. The presence of the multiple PVC’s and then the absence there of in the later 12-leads shows that there has been some change in the irritation of the ventricles, and im saying this with no knowledge of any treatments, they may have been relieved with O2. The changes in V2 and V4 raise some concern to me mainly because they happened in a fairly short time frame, and they are somewhat drastic. Lead III appears to have some changes as well and possible elevation in V3 but this could just appear this way due to movement. The only other thing i see is the possibly new onset LBBB, I would like to know if the pt. ever became symptomatic at all, or if she remained complaint and pain free.

  • James says:

    LBBB masking AMI?

  • Anonymous says:

    James –

    QRS duration is too short for LBBB. Besides, we can use Sgarbossa’s criteria to identify acute STEMI in the presence of LBBB! 🙂

    Tom

  • RM says:

    Could be imagining it but looks like elevation in avr and depression in lateral leads. Also qt interval looks like it’s getting long too.

    Brugada syndrome popped into my head because of the hx and morphology of v2 on the first 12 lead but the t wave isn’t inverted and I believe you need the criteria in two leads. Interesting case.

  • Anonymous says:

    Is that you Mr. Noonan?

  • RM says:

    No actually I’m a long time reader, first time poster. Really enjoy your blog it’s a great resource and place to learn and practice. Hope I wasn’t too far off in left field with my post below 🙂

  • It looks like Brugada to me as well.

  • Gapacw says:

    They are hard to see but at one point she was in quadgemeny……She obviously has alot of aberant fireing and most likely went into or had a run of V Tach and needs either a ICD or a pacemaker……Its difficult not being able to physically put your eyes on the patient…..Ive been a paramedic for 21 years and still get surprises…..Lol

  • Terry says:

    It doesn’t appear to fit the criteria for Brugada’s syndrome. If it was Brugada’s you would think she would have more of a past medical cardiac hx. The twave is really long in V-2 and V-3 and there are alot of pvcs. She probably had an r on t and went in to a run of V-tach.

    I like the new layout Tom.

    Terry

  • Ralph3yr says:

    Taking the 12 lead out if the picture, this could have been a hypoxia induced dysrythmia that lead to cardiac arrest. This is based on her room saturation of 84% on room air. Possibly pneumonia if she was frebrile.

  • Christopher says:

    Am I seeing a short PR or is that just this small phone screen. Accessory Pathway?

  • Baker says:

    I’m thinking of a PE?

  • Anonymous says:

    (Cross-posted to the FB fan page): Thanks for all the comments, guys! As I indicated in the beginning, we don’t have a definitive diagnosis for this case. All I can tell you is that the ER docs suspected the possibility of Brugada’s and transferred the patient out for specialty care. I agree with many of you who expressed surprise or skepticism that an abnormality like Brugada’s could go so long without being diagnosed. This was certainly a strange case, particularly the ST/T morphology in leads V2 and V3 at 17:19:22. Compare to this case from TOTWTOTR’s blog in May 2010: http://tooldtowork.com/2010/05/an-unusual-ekg/

  • Bortolo Martini says:

    please forget brugada syndrome!!

  • Tom B says:

    Okay, Bortolo Martini. Why should we forget Brugada Syndrome?

    Tom

  • Josè says:

    LBBB is incomplete or perhaps it’s an amiodarone effect and it can masquerade NSTEMI. But I think that this EKG must to be confronted with one in the past. Elevation J point only in V2 suggest (new criteria!) Brugada but at this age with this history it’s very difficult for me.

  • BCMedic says:

    She has a right ventricular strain pattern, although the S wave in lead 1 is only slight. I would say PE.

  • JOHN SAMUEL says:

    sinus tachycardia with PVC, and Right ventricular ischemia. culprit ? likely the right marginal artery.

  • Matt says:

    "ventricular tachycardia within the past week for which she takes amiodarone." 

    Drugs preferably avoided by Brugada syndrome patients
     

  • Matt says:

    I have a very good friend, late 30's, trained and ran the Columbus Half Marathon. As he approached the finish line, he collasped. CPR was preformed and later he was dx'd with Brugada Syndrome. He had no family hx or the hx associated with Brugada Syndrome. Like Tom states above, we don't know how this particular case played out. But I definitely wouldn't count out Brugada here. You can read about my good friends story here. He did complete the Columbus Half Marathon the following year.  http://www.dispatch.com/content/stories/sports/2012/05/03/runner-returns-to-half-marathon-year-after-near-fatal-collapse.html
      

  • Brian Behn says:

    Her pr interval is less than 0.12 in some of the 12 leads but not all of them.  In some of the precordial leads you could make a case for delta waves being noted. But…. This seems unlikely to cause transient…uh..death. If she was dx with VT last week, and the family is accurate in saying she had no pulse then there is an extremely high chance that this was VT, probably as high as >95%*.  In some of her ECGs the QTc cmes in longer than 450 which is long and she is on a drug known to prolong the QT interval, ( but at the same time prevent arrythmia)  so the possibility of an R-on-T event is possible…..but as others have mentioned a lot of the precordial segments look Brugada-esque to me.  Most likely -brugada syndrome, second most likely R-onT, and the long shot is WPW or possibly LGL

  • Brian Behn says:

    "Rise from the dead"
    oops, didn't look at the dates on this one. 

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