This is the discussion for 89 year old female CC: Sick. You may wish to go back and review the case.
To begin, lets review one of the 12 leads:
Many of you correctly identified this as a third degree block….however, the etiology of the block was at the time unknown, especially in light of the fact that the patient had no prior cardiac history.
Other confounding factors on her ECG were the huge and bizarre inverted T waves, and the very long QTc of 639!
So, we have a few decisions to make:
- Is the patient stable?
- Do we need to treat this patient with medicine, electricity, or just supportive care?
- Is there anything else we need to be very watchful of?
We would all agree that the patient is symptomatic, but is she stable? Clearly, under exertion, she is not. However, laying still on a gurney, is she?
While she is in your care, does she have:
- Chest pain? No.
- Hypotension? No.
- Altered mental status? No.
- Pulmonary edema? No.
- Shortness of breath? No.
What was notable right off the bat, was that the patient was mentating well and making a good pressure at 160/74. She was no doubt helped by at least two factors:
- The escape beats seemed to be junctional, with a narrow QRS, and a rate in the low 40's. Junctional rhythms perfuse much better than a ventricular rhythm would have.
- She had not taken her hypertension medications for at least a couple of days, which helped keep her pressure up.
In any ACLS classes I've taken the question of stability is usually black and white. However, out in the field it is often not clear at all!
One major concern is if this was due to an ischemic event. In the face of an adequate junctional escape, do we really want to speed up the heart and increase the workload of the heart and O2 consumption? Pacing would do this, as would atropine.
The other major concern here was the very prolonged QTc. Was she at risk for sudden VT? Possibly.
After all this was considered, the crew decided she was "tolerating the rhythm". They elected to place combi-pads, in anticipation of her condition deteriorating, and provide supportive care (O2, IV, monitor). Vitals were monitored every few minutes, as was mental status. Because of the fact that she was tolerating the rhythm, and the concern the crew had of an ischemic event going on, the decision was made not to increase the workload of the heart via medication or pacing unless her presentation started to change.
But wait, what about that bizarre ECG?!
Many of you pointed out, correctly, that a neurogenic cause of those bizarre inverted T waves had to be considered even without evidence that the cause was neurogenic.
So I asked Stephen Smith, M.D. of Dr. Smith's ECG Blog for his impression of these ECG's, and here is what he had to say:
As for the T-waves, you have a classic EKG here: this is what is called a Stokes Adams attack. I have no idea why it produces these T-waves but I have seen this several times and it is described in textbooks. 3rd degree heart block, often associated with syncope, and with bizarre wide inverted T-waves and a long QT.
For a more in-depth discussion of giant T wave inversions, visit here.
Here is an example of the giant inverted T waves of a Stokes-Adams attack from this article:
Stokes-Adams attacks are frequently the result of ischemia. For more information on Stokes-Adams attacks, visit here.
Also, some pointed out the issue of the axis changing from one ECG to the next…
It is possible that the focus of the escape was changing locations, and equally possible that it was due to something else. While this may be interesting to note, it will not likely change our treatment of this patient at all.
At the hospital, her troponin level came back elevated. She was diagnosed with NSTEMI, and in addition was sent for immediate pacemaker implantation.