Tracings Vol 3.1

HPI

A 15 y.o. girl was transported by EMS to the ED. She had just experienced her second syncopal episode in 8 days. This morning while in the bathroom at her family’s home getting ready for school, she felt nauseous and then passed out. When she awoke, EMS was on the scene. She had had a previous syncopal episode 8 days prior while at school. On that occasion she had gone into the girls’ bathroom and then woke up lying on the floor. “Possible” seizure activity was observed. Since that time she has had a throbbing headache involving the entire head. Neither episode had associated chest pain, shortness of breath, faintness or focal neurologic symptoms. Her last menstrual period had been 3 weeks prior.

Past medical history was significant for a congenital single kidney and appendectomy. She was taking no medications. There was no history of drug, alcohol or tobacco use.

Physical Exam

On exam the patient appeared alert and generally well. BP was 116/66, pulse 73, respirations 20, and temperature 36.5C. General, cardiopulmonary, neurologic and extremity exams were all normal. Pulse oximetry registered a 100% saturation on room air.

Review of the EMR revealed that a brain CT performed during the ED visit 8 days prior had been normal. UDS and SDS had both been negative. The patient had been discharged from the ED and referred to her primary care physician. He had obtained a neurology consult which found no abnormalities and an EEG which was normal.

During the present visit, a 12-lead ECG was normal and initial laboratory evaluation was unremarkable. After conferring with the patient’s physician, a decision was made to obtain an echocardiogram.

While the patient was awaiting this study, the cardiac monitor alarm activated and a rhythm strip was recorded. The patient remained asymptomatic and the abnormality which had triggered the alarm resolved before any action could be contemplated.

Repeat VS and a directed exam were unremarkable.

Questions

1.  What rhythm does this strip reflect?

2.  What should be done next?

Case ECG ACase ECG B

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics are derived from the EM Model for Resident Education. Cases are prepared by Dr. William Berk.

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8 Responses

  1. Torsades de Pointe
    Magnesium

  2. 1- RSR’
    Brugada syndrome
    2-placement of an ICD

  3. shows artifact, can dc if echo ok, or get echo as outpatient

  4. 1.) Sinus rhythm progressing to ventricular tachycardia

    2.) Pt. is well perfused and asymptomatic. Cards consult, while considering underlying causes (included labs), and close monitoring with considering antiarrythmic agents.

  5. 1. Torsades des Pointes
    2. give 2 gms of IV Mg Sulfate over 1-2 min, continue to observe the patient

  6. 1. NSR with a run of VT
    2. The patient should be given O2, an IV, and the pacer pads placed on her chest (in case of a symptomatic episode that needs to be cardioverted). She should be monitored for a reoccurance of the dysryhmia.

  7. The rhythm strip shows a run of ventricular tachycardia. There seems to be fusion beats suggesting that there might be an ectopic node in the ventricle beating along with sinus node.
    Order electrolytes level with Mg and Phosphorous. Ask in detail elicit drug use and medications. Ask family history to see if there is a history of sudden cardiac death. Admit to cardiac care unit of hospital for further work up of abnormal rhythm.

  8. 1) It appears to be ventricular tachycardia, but considering patient was asymptomatic and sitting quietly, could this be artifact?
    2) Maybe perform a complete EKG to see rhythm noted. Patient may need to be transferred to peds cardiologist for further work up and investigation

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