89 Year Old Female CC: "Sick"

It's a snowy afternoon, when you and your partner are called to a local doctor's office for an 89 year old female with "flu-like symptoms", including nausea and vomiting over the past two days.

You walk into Room 2, and find a sick looking woman lying back on the exam bed…She is alert and oriented, and denies any chest pain or shortness of breath…but her color appears grey.  She is not diaphoretic, and also denies any numbness or tingling anywhere. She tells you that as long as she lays still, she feels ok, but every time she gets up to walk even a few feet she gets dizzy, short of breath, and nauseous.

She says " I didn't want to go to the doctor, but my friends forced me to because they said I looked ill."

She tells you she's generally in good health, her only hx being very bad hypertension, for which she takes Cozaar and Atenolol.  Because of the nausea and "retching", she has not been able to take her meds for the couple of days.

you obtain the following vital signs:

  • HR:   44 and regular
  • BP:   160/74
  • RR:   26 and regular
  • Lungs:   clear bilaterally
  • skin:   warm and dry

The PA hands you the following ECG they acquired 30 minutes ago:

 

You apply your cardiac monitor and acquire the following 12 lead:

Enroute to the hospital, you acquire one more 12 lead:

*** UPDATE***

By request, here are the computerized numbers from the last ECG:

  • Vent. rate:   43
  • PRI:   0
  • QRS:   92 ms
  • QTc:   639
  • P-R-T axes:   0   -63   -172

 

How do you interpret these ECG's?

is there anything else you'd like to know?

How will you treat this patient and why?

46 Comments

  • Baker says:

    Looks like maybe a Complete heart block but we really need a longer strip of a single lead with a little less artifact.

  • Troy says:

    Id call it a 3rd degree HB with a ventricular escape with what appears to be multiple ectopic pacemakers. The inverted T-waves with that width would make me want to know if she’s had any falls lately because they look like neurogenic symmetrical T-waves. Also could be do to Dig? Anyways treatment is mostly supportive at this time. I would mix an epi infusion just in case and have the TCP in place for my benefit.

    On a side note I’m starting to do more axis studying. I put both of them around +120.

  • Will says:

    Im with everyone else on 3rd degree.

    (Editor’s note: The problem is resolved. Thanks, Tom B.)

    Cheers

    Will

  • Will says:

    What do I need to know about this patient? Does the patient have a pacemaker. Past cardiac Hx, medications. It would be nice to know the baseline but unlikely in our setting.
    Treatment would involve TCP and transport to the closest appropriate facility that can treat her condition.
    Prognosis with pacemaker probably good unless the good lord says "mam you have just had too many birthdays" then well its in his hands 🙂
     
    Cheers
    Will

  • Elliott Gordon says:

    I have to go with the 3rd degree av block and I could be full of cr*p on this but it appears she has a conduction delay on both branches.

  • thiaga says:

    could be 3rd degree heart block

  • David Baumrind says:

    @Troy:

    good ddx question… the patient had no history of recent falls, and no s/s of any head injury.. also, pt was not on Dig.

  • David Baumrind says:

    @ Will:

    no cardiac hx.  Only hypertension.

  • Gary says:

    Dumb question from a basic – Can someone explain the link between a fall and the inverted T waves?

  • probie says:

    Good question, Gary. As far as I know, Intracranial bleeds (e.g., subarachnoids or the more ominous subtle chronic subdural hematoma) can manifest with EKG changes — one theory is that it is due to catecholamine surge and remodeling associated with these pathologies. A common EKG presentation is diffuse T-wave inversions not fitting a vascular distribution (e.g., inferior + septal + anterior in her case).
     

  • Troy says:

    @ David,

    What’s her normal pressures? A decrease in 20% of normal MAP can cause detrimental effects to the CNS and perfusion. You said “extreme hypertension” so in that case it could be a possibility. Skin turgor? Also id give a fluid bolus for dehydration if lungs are clear

  • Troy says:

    @ Gary,

    No question is stupid! That’s how we learn things. If you aren’t asking questions then you’re doing yourself and the patient a disservice. I’ve been doing ECG studying for the past 2.5 years and am still learning new things every day!

  • VinceD says:

    gah! I had a nice explination typed up and then lost it. Third degree AV block, junctional escape, global T-wave inversions, prolonged QT, tall R-wave in V1, and intermittent conduction delay (including, at least, LPFB), but I can't tell exactly what's going on there. The conduction changes do not seem to be due to cycle length or fusion beats, so I'm at a loss for why the axis keeps wandering.

    My first thought was a neuro cause for the giant inverted t-waves, CHB, and dizziness, but her presentation just isn't screaming "brainstem insult" to me. So I'm leaning more towards her Sx being due to the CHB and slow escape rate, but then have to worry about a cause. Maybe she just has an old conduction system, but MI is a real possibility and that tall R in V1 could be due to a posterior infarct, although I don't see any inferior or lateral involvement. Those giant t-waves don't necessarily have to have a neurologic cause as well, and the exact same picture can be seen with high grade heart blocks, which is what I'm thinking is the case here.

    From me, she'll get O2 at 15 Lpm, IV access with a 500mL fluid bolus, a highly scrutinized neuro exam, and pacer pads in place but not turned on.

  • karen says:

    As a UK para, it would just be supportive care with 02, possible aspirin, Incase of silent MI, iv access but no fluids or Atropine as Bp stable. I would put the ECGs as 3rd degree block and take straight to ccu. Sounds like pt needs pacemaker but would love to know the outcome if possible.

  • nunya says:

    Intranodal 3rd degree block. Hx of “extreme HTN”. She’s prescribed a beta blocker, I’m gonna go with beta blocker overdose. Initially QRS is narrow, so its not a ventricular escape, but junctional, even though the last 12 lead the QRS is borderline wide but not quite. Plus the rate is within junctional limits meaning the origin of the block is Intranodal. The most common cause of Intranodal blocks is med overdose. Especially beta blockers. Patient is stable, no need for TCP at this time but prepare to if needed. Otherwise 4-5mg glucagon IV.

  • nunya says:

    Then again she couldn’t keep her meds down. So who knows. Id consider atropine because their narrow complexes. There’s always the possibility of MI.

  • Philip says:

     
    I am going to just toss some questions out till I get a chance to finish my coffee and get my brain awake…
     
    Looks like a pretty obvious 3rd degree HB, if the electrical activity present  was ventricular in origin, then would we expect more of an extreme right axis? 
    I know that bradycardia is typically a contraindication to NTG, could we expect a devastating drop in BP if it was administered due to her lower HR if her rate did not increase? 
    On that same token, could her BP increase excessively if she was paced? She is remaining hypertensive despite a bradycardic rate (HTN may like be caused by not taking her beta blockers). 
    Also.. If she has been nauseated and ill for a few days and not taken her medicine, then it would seem less likely that this rhythm is caused by a digitalis toxicity if she has not been able to take her dig. 
    Anyhow, just a few thoughts I wanted to toss out. This is the first time I posted here, so go easy on me! 
     

  • Robert (Las Vegas) says:

    12 lead interpretation: Sinus bradycardia, 3rd degree heart block/av dissociation, WPW with repolarization abnormality, peaked t waves suggestive of Hyperkalemia vs Acute ischemia 
    Person has upright p waves in leads I, II, III, AvF with inverted P wave in AvR showing sinus in origin. Regular qrs, Regular P wave activity, with dissociated PR Interval showing 3rd degree block. Delta waves in numerous leads with prolongation of QT Interval. Peaked T waves, especially in the precordial leads v3-v6 give Hyperkalemia VS Acute Ischemia.
    Person has history of "Bad Hypertension," which is the most common cause of End Stage Renal Disease. In addition, she has had nausea/vomiting x 2 days leading to electrolyte imbalance, on top of that she appears to be severely dehydrated. I'm leaning towards Hyperkalemia, but still possible for Acute Ischemia.
    Treatment: All preventive care, Oxygen only if 02 sats low, 2 iv's, pacer pads ready, EtCO2, send in the 12 lead via blue tooth. Consult physician. Wait to get to hospital for lab work… If persons vitals became unstable then I would begin pacing as well as treat for hyperkalemia.
    Cheers,
    Robert

  • EMT says:

    Interesting.
    There's definitely a 3rd degree AVB w/ junctional escape. Consistent R-R, but the QRS is constantly changing directions…query electrical alternans, possibly from an accesory pathway or tamponade? 
    Possible pericardial effusion? How are heart sounds? Any hx of fever? Is there any signs of pulsus paradoxus?
    O2, IV, Continuous monitoring, Chest X-Ray, bloodwork, and prepare for pacing. 

  • Christine says:

    3rd degree AV block. Still nedd to know what is she being treated with for her HTN, this may help with explaining the T wave inversion.

  • BryanL says:

     
    EKG shows a very clear CHB, with very strange changing axis. Other than inverted T waves I do not see anything of concern for ACS.
    Vomiting x 2 days in an elderly female? Might consider a metabolic derangement, maybe a mixed acid base disorder. RR of 26 compensating for volume depletion? No evident hypoxia but gets SOB and dizzy on standing. Kidneys excreting more bicarb to retain H+, K+ and Na+?
    I would really like to know:
    – sidestream ETCO2 and BGL and temp?
    – fluid input and output?
    – previous renal insufficiency?
    – ABGs, electrolytes and biochem panel (esp bicarb PCO2, anion gap, K+, Na+ and Cl-)
    Tx: O2 NC, IV access with fluid bolus of RL, antiemetic, transport and monitor vitals
     

  • David Baumrind says:

    By request, the computerized numbers for the last ECG have been added.

    any thoughts?

  • BryanL says:

    IIRC excessive vomiting can cause Long QT syndrome due to the loss of Na+ and/or K+ ions

  • Christopher says:

    Haven't seen it mentioned yet, but the change in axis could be intermittant fusion/capture of the atrial impulses. The PR-intervals prior to most of them are pseudo-normal.

  • CallahanNY says:

    General impression: Pt is sick.
    EKG Interpretation: Ventricular and Atrial rates appear regular but asynchronous (40 and 100 BPM respectively from MD's EKG). Rhythm is 3rd deg AV block. Axis is variable… 107 deg on 1st EKG (RAD) , to Pathologic LAD on 2nd, to  -63 deg on last (Normal).  Suggests intermittent Anterior and Posterior Hemiblocks.  QRS in V1 is >120 ms and shows RBB.  Combined with 3rd deg AV block, I think this gal has some conduction issues. But I don't know why.  Symmetric broad inverted T-waves in II, III, aVF & V3-6,indicates ischemia to me which could simply be consistent with atrial/ventricular decoupling. (-) ST elevation in 12 lead views.
    Treatment: Transport would be 40 min to PCI facility in our region.  Check on DNR status. O2 12 LPM by NRB if SpO2<95%, large bore IV with NS at KVO. Antiemetic if currently vomiting.  Prep for pacing/defib, CPR if needed (extra hands?). Go back through Pt Rx's for some clues re: working diagnosis. 15 Lead. I want to view RV (V4R) and Posterior leads (V8&9). Call medical control at receiving facility for consult and to alert of Pt status.
    So is ischemia causing conduction issues or vice versa?
    Could this be a calcium channel blocker OD?
    Interesting case. Thanks.

  • VinceD says:

    Christopher – I gave that consideration but, at a glance, I couldn't identify any association between the plausible PRis and the following QRS complexes. Maybe your eyes are better than mine though.

  • alex says:

    3rd degree block, very strange T waves, varied QRS morphology.

    There are signs of circulatey compromise (her pallor and general illness) so I’d be very tempted to give atropine. Probably 100% O2 as well.

    I realise atropine is cautioned in an MI…

  • alex says:

    oh, and some metaclopromide / maxalon

  • saraswathi thangavel says:

    first ecg looks like wenckebach's with dropped beat.. last one s complete heart block.. as she feels shortness of breath and chest discomfort she definitely needs permanent pacemaker insertion.. even though her BP is stable because of her TIA LIKE SYMPTOMS and cyanosis  itself indicates she needs to be treated by temporary pm either transcutaneous or trasvenouss..

  • Eff Dogg says:

    so feel the vommiting caused hyperkalemia/hypokalemia which cause the heart probs. Others say the heart probs caused the vommiting. I agree with the 2nd group/ I also would be hesitant to treat hyperkalemia here in case we later find out it was hypokalemia. I don't think we can localise an MI as it is likely the T wave changes might be from global cardiac hypoperfusion due to bradycardia. I also would consider the possibilty that the CHB is organic and not related to BB's or dig. Ignore the BP telling you she is fine- the pale skin and the dizzyness reveal more about perfusion than the BP. Tx: saline bolus, prophelactic ASA, would have considered atropine if I had caught it while it was junctional escape. Now the QRS has widened would be hesitant. pacer pads on and ready to pace if she crumped. 🙂 Thanks. F.

  • Rose says:

    I am reading the strips as a 3rd degree heart block.  The pt is symptomatic and requires pacing. The patient would be able to tolerate mild sedation to help during the pacing.

  • David Baumrind says:

    Great comments so far…

    i can clarify for some: 

       -there was no sign of AMS at all… pt remained A/O with no neurologic deficits…

       -patient had no prior cardiac hx… only hx was hypertension

       -patient had not been compliant with her meds x2 days

       -there was no fever or signs of infection

  • saraswathi thangavel says:

    expecting the appropriate management  protocol from david soon. thank you sir …

  • David Baumrind says:

    Now there seems to be some difference of opinions…

    Is this patient stable?

    Do we treat this patient with meds? pacing? supportive care?

    What do you guys think?

  • Rose says:

    If the patient looks sick while laying down, has poor skin color and not able to walk with out symptoms, then she is unstable and needs pacing.

  • BryanL says:

    I would consider dizzy and SOB with no AMS and no hypotension as stable and symptomatic, however the "grey" skin does pain a picture of hypoperfusion…..
     

  • BryanL says:

    paint a picture

  • Milhouse says:

    I would call it proximal 3rd degree block and look closer at it later. I would have to decide whether that bp is working for her or not. What’s her baseline pressure? I would do a neuro exam and ask questions in that department. I don’t like those twaves.

  • VinceD says:

    Symptomatic, not unstable, in my opinion. She's been feeling unwell for two days, and in most cases I like to fall back on the tenet; "If a disease comes on slowly, treat it slowely, and if it arrives quickly, treat quickly." Like all rules, there's always exceptions (i.e. sepsis), but for this young lady I think it's a useful aid to avoid doing harm.

  • Shalom says:

    Stokes-Adam Syndrome? Slow rate causing syncope and giant T wave inversions…
    Get em pacer pads out

  • Robert (Las Vegas) says:

    Relatively stable… 5/10. Supportive care.

  • AW says:

    She is presenting stable at rest but her colour and her lack of any excersize tolorance makes me hold her right on the line of unstable.   The ECG is a 3rd degree block with varing QRS morphology which could be simply that no lower pacemaker site is reliable and thus the job is shifting around.  Pacer pads are a priority here I think, I'd want to be set up to use them but so far in the discription of her presentation I'm not going to begin proactively.  The T waves are obviously not normal and with the history of vomiting I'd be very concerned about electrolyte imbalance.  I want to know her medications that she is non-compliant with and anything that she may have tried taking for this 'flu', including electrolyte containing beverages such as Gatoraid (been burned on that one) as well as her urine output/colour and comfort of urination/ back or flank pain.  With the possibility of this ECG presentation being cardiac depression due to electrolytes I'd be very conservative and not move to Atropine or Pacing unless she became symptomatic at rest on oxygen.  Flogging a sick or toxic heart never goes well for me.  🙂

  • Medikate says:

    As a medic of only 2 years I definitely see a 3rd degree HB, but alot of other information here is lost on me and I am heading to Amazon after I post this to update some ECG reference books.
     
    But Im interested to hear what the outcome of this case is from David.
     

  • Colten says:

    Maybe it's just me, but I feel the last 12 lead has similar morphological to a RBBB, but it's not consistent in the other tracings. Slurred S wave in V6 and RSr' pattern in V3 and possible slurred S wave in Lead 1. Just an observation I thought was weird.

  • Colten says:

    Morphology that is… Not morphological…

  • Colten says:

    And some of the QRS's looked bigger than the 92 it was measured out to be.

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