EKG of the Week – Week 6
This week’s write up comes from an EKG Dr. Sean Griffiths saw during his thrilling month on medicine. He wrote up the case and sent it to me. I’d encourage you to look at the EKGs first and then read his solution to each of them. It’s really interesting case with a solution that I had never heard of before! Enjoy!
-Lloyd
Had an interesting EKG case that I saw on the wards and thought it would be good to share with everyone.
Brief Hx: 72 year old male PMHx of CVA with severe personality changes, dementia, AV pacer, HRrEF, aortic stenosis, and Afib who was admitted from the ED for possible pneumonia after infiltrate seen on CXR. To give you a better idea he was the patient screaming in B Pod a few days ago and had to be put down with Haldol, Ativan, and Benadryl.
Overnight, the night float team was paged on him several times with strange rhythms on EKG and agitation requiring more haldol. In these rhythms he would go from paced left bundle pattern, to RBBB, then SVT and then convert back to regular pacing. In the morning, the tele tech and nurse paged me several times to come look at his monitor for “weird rhythms”.
ECG 1: 30 Oct 0827 – irregular AV paced rhythm, with LBBB pattern no concerns for ischemia by Sgarbossa criteria
ECG 2: 0828 – irregular paced rhythm with RBBB pattern, PVCs – weird but not quite sure what to think. Machine saying ****ACUTE MI*****. Patient asymptomatic.
ECG 3: 0829 – irregular paced rhythm with what looks like paced beats of LBBB then PVCs that look RBBB to me. Again very weird, by this point I’ve already decided to call cards and have them come interrogate the pacer. No signs of acute ischemia and patient asymptomatic. Machine saying ****ACUTE MI**** but neg Sgarbossa
ECG 4: 0838 – at the end of the tracing he goes into SVT with what looks like a strain pattern at a rate of slightly less than 150. This stopped after a few seconds and patient remained asymptomatic.
Ok all that was very weird, not sure what’s going on. I called the electrophysiology fellow and told him what’s up and he agreed to go check out the pacer and call me back; which of course he didn’t call after. A few hours later I get a page about his rhythm again so I have them do an ECG and go down there to check it out.
ECG 5 (Rhythm Strip): on this ECG there are new T wave inversions in II, III, AvF, V3-V6. At this point now I am very concerned. The patient is asymptomatic but then I started thinking about Wellens Syndrome and T wave inversions in V2-V3 in a pain free patient could be indicative of proximal LAD lesion that is in imminent need for cath. I immediately walk down to the CCU work room and ask some people there who were useless and told me this is a fellow level ECG. So I went back upstairs, paged the cards fellow, and ordered a right sided ECG for the inferior changes I saw.
Cards calls me back and I filled them in on the findings. So what happened? He informed me that he had adjusted settings on the patient’s pacemaker and that yes these findings would be concerning in a normal person but in this person they were not concerning.
So what was going on with this patient?
Interesting answers to follow with answers next week