EKG/ECG Practice

[ender18d]

Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.

[wook]

Originally Posted by ender18d

Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.

Nice!! Great case and very important diagnosis to catch (if it's what I think it is)!


Wook

[miclo18d]

All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?

[ender18d]

Originally Posted by miclo18d

All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?

Quick approach to transient loss of consciousness:

1. Is it syncope or is it seizure?
Convulsions (can be present for either but if prolonged more likely seizure)?
Post ictal period?
Incontinence?
Tongue biting?
Seizure history?

2. Is it syncope **AND?**
Syncope plus other symptoms can have a huge differential. In the right context, syncope AND abdominal pain could be AAA. Syncope AND dyspnea could be PE. Syncope AND headache could be SAH. Syncope and pregnant could be ectopic. Figure out if there are other concerning symptoms.

3. Red flags for syncope.
If you set aside syncope with significant and/or ongoing associated symptoms for a moment, almost all scary causes of syncope are cardiac. So some red flags that should scare you point to cardiac causes of syncope:
-Pain. Along the lines of #2, benign syncope should not hurt.
-“Lights out” with no prodrome. Suspect this if injured in fall esp.
-Syncope during exertion. Passing out after exertion is not uncommon, but during exrtion should scare you.
-history of cardiac disease
-family history of sudden cardiac or unexplained death
-Patient is elderly
-new/unexplained murmur

**So back to our patient:
1. No historical features to suggest seizure.
2. No associated symptoms not explained by ETOH. Neg HCG.
3. A few big red flags: she went out quickly with no prodrome and possibly (story fuzzy) while dancing. Her father died in his 30’s in his sleep and no one was ever sure why.

[ender18d]

So most of the MDs have PMd me and identified the rhythm, and I think no one else is going to wade in, so the answer:

This patient had Brugada Syndrome, a channelopathy that can predispose patients to arrhythmia and sudden cardiac death. Its an autosomal dominant genetic disorder, and this is likely what claimed her father's life. The EKG findings of Brugada are not always present (you can have a normal prior EKG) and Brugada "attacks" can be precipitated by alcohol use. This patient's EKG normalized when she sobered up.

She was admitted to Cardiology for an AICD placement.

Brugada has different forms, but should be considered in a syncopal patient with EKG findings of ST elevation in V1-3, especially if combined with T wave inversion as seen in this EKG.

If y'all want to keep going I have some other good real patient syncope scenarios for you.

[Trapper John]

As the namesake for my nomme de plume would say, "Finest Kind!"

Seriously, Thank you all for contributing to this discussion!

[miclo18d]

Way above my pay grade!

Put a GSW in front of me and I’ll make you proud!