Quick Case #04

the case.

An 85 year old female is bought to ED with right hip pain. She was found outside after unfortunately spending the night on the ground.

This is her ECG.Hypothermia (Osborne J waves)

[DDET Describe & interpret this ECG…]

  • Rate:
    • ~48-55 bpm
  • Rhythm:
    • Irregular
    • P:QRS = 1:1.
  • Axis:
    • Normal
  • Intervals:
    • PR ~ 240 msec
    • QRS 120 msec
    • QTc ~  495 msec
  • Extras:
    • Incomplete ECG [V6 missing]
    • Biphasic Inferior T-waves
    • J-point notching [V2-5]
    • Baseline wander and movement artefact

Interpretation Sinus bradycardia (sinus arrhythmia) with first degree heart block and prolonged QTc. Presence of Osborne J-waves & movement (shivering) artefact suggestive of hypothermia. Biphasic T-waves (inferiorly) raise concern about ischaemia.


[DDET What’s the diagnosis?]

This patient had a fracture neck of femur. Her temperature was 28*C.


[DDET My justification of rhythm…]

Hypothermia ECG annotated

Whilst I have called this sinus rhythm with 1st-degree AV block, I have considered the diagnosis of 2nd-degree AV block (2:1).

  • Morphology difference between P waves (blue circles) & those marked by red arrows.
  • Red arrows appear to coincide with end of T-wave (blue dotted-line).

I look forward to the suggestions of our #FOAM ECG gurus….


[DDET What other  ECG manifestations can occur…??]

There are no pathognomonic ECG changes in Hypothermia.

ECG Manifestations of Hypothermia.

  • Bradydysrhythmias
      • Sinus, junctional
      • AF
      • Varying AV blocks.
  • Prolongation of PR & QT interval
  • Osborne or J-wave.
      • Camel hump” sign.
      • A positive deflection at the junction between QRS & ST-segment.
        • Most prominent in precordial leads.
      • Consistently present with body-temperatures < 25*C.
  • Atrial fibrillation.
      • Occurs in 50-60% of patients w/ temperatures < 29*C.
      • Ventricular rate may be normal or slow.
  • Shivering artefact.
In severe hypothermia the following can be seen;
  • Bradycardia
  • Asystole
  • Ventricular fibrillation


[DDET References]

  1. Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

For more examples on these ECG changes take a look at “ECG changes in hypothermia” from LifeintheFastLane.com


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