Quote:
Originally Posted by Trapper John
Okay my gut is bringing me back to pulmonary function i.e. pulmonary hypertension/PE. Some of the highlighted changes in the ECG I think supports this differential - prominent S wave and lead I, invertedT lead III. TallR in VI. I will go out on a limb and suggest aRV MI.
So did you spin up the Cath Lab in time? I'm just guessing this patient dodged the bullet thanks to your attention and clear dDx  |
Yes the S1Q3T3 and also the right bundle branch block (which we must presume is new without comparison) suggests right heart strain and therefore in context of chest pain, dyspnea, and syncope concerning for pulmonary embolism.
Agree the ST changes suggest the possibility of right side MI.
So lets call that good for our differential and cap it at:
Differential:
Long QT (QTc = 652)
Acute Coronary Syndrome
Pulmonary Embolism
Hypertrophic Cardiomyopathy
Overdose, especially TCA
MVP -> Arrhythmia
Rejoining the action, you respond to the nurses call and find your patient unresponsive and apneic in the room. You quickly check a pulse and find an extremely rapid, weak and thready pulse. You perform a head tilt-jaw thurst and begin bagging the patient effectively as you transfer him to a resuscitation bay. On arrival in the bay you note that he now no longer has pulses and begin CPR. Your nurse cannot immediately get an IV so you get IO access. You start a full run of POC labs off the IO but remember that some labs are not reliable from IO. Your patient is connected to a Lifepack and on your first pulse check he is pulseless and the attached strip represents what you see on your monitor. (unfortunately I did not get a chance to copy the real strips, but this is a good approximation)
1. What is your interpretation of the strip?
2. Which item(s) on our differential are most likely now?
3. What are your next most important steps?