Quick Case #02
the case.
It’s 3am in your typical ED. The waiting list has hit 25. Your resus-bay is full of patients awaiting beds in the ICU. You are having a chat with your intern about the PERC rule and avoidance of D-Dimer testing in young patients…
…meanwhile, a 27 year old male presents to ED with “loss of consciousness”. He has moderate developmental delay and a history of epilepsy. His carers report multiple episodes of transient loss of consciousness over the past 12 hours, which self-resolve without intervention. There is no associated tonic-clonic, jerking movements with these episodes and he returns to his normal self quickly afterwards.
As the nurse connects him for this 12-lead, he quickly loses consciousness without warning…
… by the time you are called to the bedside to review the ECG; the patient is again back to his normal self.
[DDET What’s your interpretation??]
Uh oh !! It’s broad, fast & regular. It looks monomorphic…
Is it VT ? Is it Torsades ??
Is he losing consciousness due to ventricular dysrhythmias ??
[/DDET]
[DDET Take a deep breath…]
Before we get too carried away, lets take a step back & look at it closely…
Firstly – Yes, there are broad ‘complexes’ marching through the page at a rate close to 300/min. But look at lead I. Here, there are narrow complex, regular, sinus beats at a rate of ~100 bpm. On further inspection, these complexes can be seen throughout the remainder of cardiograph (see the annotated ECG below).
So this is sinus rhythm… The remainder of the ECG is essentially uninterpretable however due these broad monstrosities getting in the way !! So what is causing them ??
Well, when you turn to the patient you notice a fine, rhythmic tremor. His carer strongly assures you that this is a long-standing problem. They are movement artefacts…
[/DDET]
[DDET The Take-home…]
The ED can be an intimidating environment & it is easy to get distracted.
Patients of horrendous trauma, blood gases from a patients with DKA & markedly abnormal ECGs can all be complex and tricky.
Having a standardised approach to each of these can help us in times when we are already stressed, tired and under the pump. Knowing how to take a step back and look at things systematically will more than likely ensure we reach the correct decision/diagnosis.
[/DDET]
