Tracings Vol 3.2

Case

A 42-year-old man is conveyed to the ED via private vehicle with a 1-week history shortness of breath and bilateral leg swelling. Past medical history is negative; he takes no medications. He injects heroin, last 2 hours prior to arrival, and smokes tobacco.

On exam, blood pressure is 112/73 mm Hg, pulse 125 bpm, respirations 20, temperature 35.9. Chest is clear and heart sounds normal. Mild symmetrical pitting edema is noted in both legs up to the knees. Pulses are intact.

Pulse oximetry registers an oxygen saturation of 78% on 5 liters of oxygen per minute via nasal cannulae.

The attached ECG and CxR were obtained. (Click on image to enlarge)

ECG Vol 3.2CXR Vol 3.2

Questions:

1. Interpret the ECG?

2. List 3 of the most likely diagnoses?

3. What is the most appropriate management for this patient?

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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3 Responses

  1. 1. The EKG shows ST elevations in the most of the leads, most obvious the precordial leads. Also with right axis deviation.

    2. Endocarditis, pericarditis, myocarditis

    3. Antibiotics, airway management with agressive oxygenation, dialysis if signs of renal failure (uremia),

  2. 1. NSR, low voltageQRS, right atrial enlargment, right axis deviation

    2. PE/septic emboli, CHF(right sided) would check for pericardial fluid given low voltage QRS, maybe early pneumonia.

    3. anticoagulate/CT (a bed side US would be nice too) If CT does find emboli…I would think seriously about blood cx and abx cause they could be septic emboli.

  3. 1) Sinus rhythm, rate 75, axis difficult to determine, possibly normal. Intervals normal. Low voltage QRS in limb leads. No Q waves, deep S waves in precordial leads, abnormal T waves (flattened in limb leads). No ST elevations/depressions. Possible right heart strain?
    2) PE vs septic emboli, NSTEMI,
    3) Anticoagulation therapy should be started immediately

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