Not just S1Q3T3: Look at the other 10 leads!

It was a slow morning in the ED, so I was able to catch the medic as she came in with the patient. “Hey Leigh, what do you have for us? Got an interesting ECG?”

“Well, maybe,” she replied as she wheeled by with a comfortable looking middle-aged male, “here, take a look at it while I give report to the nurse.” She handed me the 12-lead:


After leaving the patient with the RN, Leigh came back. “This is a guy with a history of CHF, with an AICD placement. He’s had shortness of breath for 4 days, worse when he walks. He passed out today when he was walking, so his family called us. He looked fine when we got to him, just needed 2 liters of O2 to keep him at 98%. No chest pain.”

“Yeah,” I said, “he certainly looked fine when you rolled past. Okay, so probably just a CHF admission. I’ll go see him right now.”

“Yeah, it’s probably just his CHF,” she continued, “but I expected worse. His lungs sound just fine, totally clear. Plus, he says it doesn’t get worse when he lays flat. Seems funny for CHF… Plus, I didn’t like my ECG – did you notice the S1Q3T3?”

“Well, I pulled his old ECG, just done a few weeks ago in fact, and I see it looks like there’s a S1Q3T3 too. So, probably doesn’t mean much.” I showed her the ECG I had dug up:

“Okay, Dr Walsh, maybe the S1Q3T3 is old, but I still see…” She paused, and appeared to be looking for a diplomatic way to phrase her thoughts. “How about using the ultrasound, checking to see if there’s any CHF?”

“Good idea Leigh! I’ll go show you how we do those, especially since some EMS systems are using this these days.”

After introducing myself to the patient, gathering a history, and finding that the lungs were, indeed, completely clear, I wheeled over the ultrasound. A quick check of the lungs confirmed that there was no edema in the lungs. I then took a look at the heart. (The image quality is not great, I realize.)

Just so you know what is what:

Legend for Dil RV clip-1

I then turned to Leigh and asked her “What else did you see on your ECG that you were too polite to point out to me?”


  • Kyle He says:

    New inverted T waves in the anterior leads as well as leads III, and aVF = new pulmonary HTN caused by PE until proven otherwise.

  • Andy says:

    I don’t know much about cardiac ultrasound, but it looks like the Left Ventricle is not moving much. That in addition to the titular right ventricular dilation makes me think of a left side MI or at the least some ischemia. V1-3 shows a right ventricle strain pattern, and V4-6 seems to show a ischemic changes and possibly an evolving MI. The ST segments in those leads (V4-6) seem much flatter compared to the old ECG and the T-wave is almost biphasic in V4.

  • John Gray says:

    I agree with Kyle the new t wave inversions should be treated as a PE until proven otherwise.

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