ECG Case 088

Rate:

• 42 bpm

Rhythm:

• Irregular
• Nil visible p waves

Axis:

• Normal

Intervals:

• QRS – Prolonged (200ms)
• QT – 760ms (QTc Bazett 640 ms)

Segments:

• ST Elevation lead aVR
• ST Depression leads II, III, aVF, V2-6

Additional:

• Deep T wave inversion leads II, III, aVF, V1, V3-5
• Osborn wave (J wave) best seen infero-lateral leads
• ST morphology in lead V1 has ‘Brugada‘ appearance

Interpretation:

Main differentials for these ECG features include

• Hyperkalaemia – known T1DM altered conscious level could be associated with DKA
• Metabolic disturbance – severe acidaemia
• Hypothermia – slow AF, J waves
• Drug toxicity – ? sodium channel blocker – ‘Brugada’ pattern in V1

The patient was found obtunded and further history suggested a drug ingestion including a tricyclic antidepressant and paracetamol. He was severely hypothermic, core temp 25oC, with a  significant metabolic disturbance:

• pH 6.9
• K 7.2 
• HCO3 7 
• U 10.6 
• Creat 267
• Lactate 26

For the patient’s full set of clinical results see our lab case of the week here.

The patient was successfully resuscitated but unfortunately following his ICU admission he developed multi-organ failure and failed to respond to organ replacement and increasing vasopressor administration.

• ECG Library – Hypothermia
• ECG Library – Hyperkalaemia
• ECG Library – Osborn wave (J wave)
• ECG Library – Brugada Syndrome