ECG Case 088

44 year old male with a history of non-complaint Type 1 diabetes. He has been found at home in a semi-conscious state.


Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

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

OUTCOME

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.


FURTHER READING

TOP 150 ECG SERIES



Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |

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