89 Year old female CC: Sick- Discussion

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:

  1. 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.
  2. 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.

5 Comments

  • i really appreciate this nuanced discussion. in particular the emphasis that symptoms of bradycardia is not "black and white." far too often we have crews who automatically declare a bradycardia is "symptomatic" based on some really soft criteria such as minor chest pain, instead of looking at the overall presentation and whether a patient is "tolerating the rhythm."

  • It's a lot like the "GCS less than 8: intubate" mantra. Stable versus unstable bradycardia is completely different if you have a 2 minute transport versus a 20 minute versus a 2 hour transport. A previous case presented here was of a 15 year old with a complete heart block and a junctional escape.

    If the escape rhythm is adequate, why on earth would you intervene?

  • Sergio says:

    I've had a patient very similar to this! She was feeling slightly ill, but refused any treatment until she fixed her hair and got all made up for the ER trip. She didn't appear sick AT ALL, but when we got her on the monitor, it was a 3rd deg heart block with a ventricular escape at a rate of 30-40. Her BP was fine, I couldnt find a reason to call her "symptomatic", so we just took her to the hospital ALS. Very strange.

  • CTMedic says:

    All to often we are blinded by our protocols and need to remember to step back and look at the big picture. Just because we CAN doesn’t always mean we SHOULD. Treat the patient not the monitor. Interesting case.

  • Ken Grauer says:

    Absolutely EXCELLENT case, supplemented by insightful comment by Steve Smith with provision of  classic Jacobson & Schrire 1966 BHJ article on, "Giant T Waves". Giant T waves are NOT common – but they ARE seen from time to time. Stokes-Adams is an excellent bet in this case as a cause (given patient's age and 3rd degree AV block) – though as reminded by the Jacobson/Schrire manuscript – there are other causes (coronary disease/acute MI; ventricular hypertrophy/cardiomyopathy; metabolic causes) – and this patient was retching for 2 days and did turn out to have positive troponins – so other factors (be they causative or secondary) may have contributed to her Giant T waves. The shift in axis is fascinating – and credit to Tom for providing us with a series of tracings to review. I believe this IS complete (3rd degree) AV block (very-close-to-regular ventricular escape rhythm and P waves occuring at all phases of the R-R interval with opportunity to conduct yet failure to do so). I believe the escape focus is fascicular/HIS – and that the reason for shifting of QRS axis is a change (sometimes from beat to beat) between the relative amount of left anterior hemifascicular (LAH) involvement vs left posterior hemifascicular (LPH) involvement. Supporting evidence is that the QRS is not that wide (which places the escape focus as either AV nodal, HIS, or fascicular). Thinking of the 3 major conduction fascicles, which are: – the RBB (right bundle branch) – the LAH (left anterior hemifascicle) and the LPH (left posterior hemifascicle) – you can surmise the site of of a fascicular escape focus because it is the one that is not "blocked". That is – when you see a pattern of RBBB/LAHB with a minimally widened QRS – the escape focus is in the LPH.  When you see RBBB/LPHB with minimally widened QRS – then the escape focus is in the LAH.  This is precisely what we see on the final (marked with red circles) tracing – in which there is RBBB/LAHB in leads I,II,II (positive in I; very negative in II,III) – and RBBB/LPHB in aVR,aVL,aVF (very deep negative S wave in aVL; qR in aVF). Against this truly being a "shift" in the site of the escape pacemaker is the fact that the rate of the ventricular escape focus remains virtually constant, and that despite this fairly constant R-R escape interval, there is relative change from beat-to-beat in QRS morphology in the lead II rhythm strip provided in Tom's original case. Alternatively (and what I propose is happening here) – is the possibility of HIS bundle escape with relative change in the degree of left anterior vs left posterior hemifascicular involvement (sometimes from beat-to-beat … ).  BOTTOM LINE – as Tom states, is whatever the reason for the fascinating change in QRS morphology of the escape focus, the treatment (need for pacer) doesn't change in this 89 yo woman who was remarkably stable despite Giant T waves and 3rd degree AV block.  GREAT CASE! – Ken Grauer, MD (ekgpress@mac.com)

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