Monday, June 23, 2014

ED Bedside Echo for the last very subtle inferior MI case. Images obtained and interpreted by a novice.

This is from the last case of trapezius pain and syncope.  Here is the first ECG:
ST depression and T-wave inversion suggestive of inferior MI.  There is minimal ST elevatiion in inferior leads, and a T-wave in III that is large compared to a small QRS. But the ECG is nondiagnostic.


A pediatric MD who is learning bedside echo and had only performed 20 cardiac ultrasounds in his life was sent in to practice on this patient, not expecting to find anything, or even to be able to find anything.  He recorded this echo from the apical 4-chamber view:

Echo 1 done by newbie from Stephen Smith on Vimeo.


This 4 chamber view was recorded by an emergency echo expert:

Echo 13 from Stephen Smith on Vimeo.


Here is a still frame with a circle that shows the area of wall motion abnormality:
This is taken in systole.  The base of the septum (at the left of the circle) is not contracting as is the more apical portions of the septum.


Here is a two chamber view (LV and LA only, with the probe turned 90 degrees from the apical 4-chamber) which shows the infero-posterior wall on the left side of the image.

2 chamber view from Stephen Smith on Vimeo.

Here is a still frame in systole showing the wall motion abnormality at the base of the heart on the left side of the picture:


Here is a map of the echocardiographic wall motion abnormalities:
Reproduced with permission of Robert F. Reardon, from Ma, Mateer, Reardon, and Joing, Editors.  Emergency Ultrasound.  McGraw Hill 2014.  The chart shows the coronary supply of the segments of the heart as seen on various views.  The circle shows the area of wall motion abnormality in this patient's apical 4 chamber view.  The lavendar on the "long axis" 2 chamber view correlates with this patient's 2 chamber view.  Both are consistent with the RCA involvement, and thus correlates perfectly with the ECG.


This shows how even a novice may be a able to see wall motion abnormalities that, especially if they correlate with the subtle ECG findings, may help to make the diagnosis of ACS.

Warning:

I would warn that wall motion abnormalities may be very difficult to see, and that there are also false positives.

It frequently requires echo contrast, and an expert echocardiographer and interpreter to accurately obtain and read the images.

But there are times when those with less experience can provisionally identify wall motion abnormalities, and it may help in diagnosis of ACS.

6 comments:

  1. I cudnt appreciate any t wave inversion at EKG.. Neither did I she inferior wall hypokinesis...

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  2. its not uncommon to see subtle changes of early STEMI like this and QRS is of low voltage and probably STelevation is proportional to QRS. I had similar ECG yesterday of 37 year old man with typical chest pain, sweating whom i referred to cardiology as early STEMI but seems they were not convinved and admitted the patient as Unstable Angina. later troponin reached 12.
    https://www.dropbox.com/s/eqngrzqk5z4yr17/20141109_065701.jpg?dl=0

    ReplyDelete
    Replies
    1. Mateeq, The link did not work. I hope to see your interesting ECG!
      Steve

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    2. https://www.dropbox.com/s/3ngqm3bbl07wz7c/subtle%20inferiorSTEMI.jpg?dl=0

      Sorry this is the link again


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    3. Yes! Very nice sublte inferior MI!

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