Thursday, February 19, 2015

How are these cases related?

I saw these two cases on the same day.


This patient had a GI bleed and a massive transfusion:
What is it?


This patient had a history of "frozen shoulders," and had been treated for this elsewhere for quite a while.  He had been seen in the ED 6 days prior for increased shoulder pain, and was referred back to his orthopedic clinic.  He had this ECG recorded because shoulder pain can be a symptom of ACS:
What do you notice?
















The first case has a very long ST segment and thus long QT.  This is classic for hypocalcemia; the ionized calcium was 3.0 mEq/L.  This is a common complication of massive transfusion.  One must be vigilant for hypocalcemia.

The second case shows a very short QT with short ST segment.  The computer measured it at 354 ms.   This was a tipoff to hypercalcemia and so we suspected that this patient had cancer as the etiology of his pain.  A chest x-ray (which we were going to get anyway) confirmed a chest mass.  A chest CT confirmed this and also showed otherwise occult spread to the shoulders.  The ionized calcium was 7.32 mg/dL and the total calcium was 15 mg/dL.


Here was the ECG after normalization of Ca in the second (hypercalcemia) case:
The QTc is now 384 ms


8 comments:

  1. Hypocalcemia typically produces the "tent sign" at the end of the desert (ie, relatively normal but prolonged ST segment followed by an otherwise unaffected T wave) - which is precisely what the TOP ECG shows. Hypocalcemia often accompanies hyperkalemia - so that T wave at the end of the long ST may be peaked in renal failure patients with both abnormalities.

    ECG-2 is a beautiful example of that short-Q-to-peak-of-T interval seen with hypercalcemia. Having looked for examples of Hypercalcemia on ECG over a period of ~ 3 decades while I was attending (and religiously checking serum Ca++ levels whenever I suspected this finding) - it is not common to see (and be able to recognize) hypercalcemia on ECG in my experience. In those cases in which I could - serum Ca++ levels were almost always quite elevated (ie, ≥13 mg/dL range) - as they were for the above example.

    NICE case!

    ReplyDelete
  2. The T wave is bizarre in the first one like there was a hidden P wave. AVblock?

    ReplyDelete
    Replies
    1. Olivier,
      My inclination is to attribute it to artifact, of which there is quite a bit on this ECG.
      Steve

      Delete
  3. Okay, I am stumped but very curious on how these two cases are related. Can you give any tips, Dr. Smith?

    ReplyDelete
    Replies
    1. Only that both are related to calcium: hyper- and hypocalcemia.

      Delete
  4. Thanks for this, very interesting. I got the long QT but not the short.

    At what point would you say QTc is pathologically short and check the calcium?

    I also thought there are some additional p waves in top tracing, possibly 2:1, but as you say difficult to see with the artifact and no rhythm strip.

    ReplyDelete
    Replies
    1. The ACC says that any corrected QT less than 390 is short.
      http://content.onlinejacc.org/article.aspx?articleid=%201139533
      I would guesstimate that one should be particularly worried if less than 375

      Steve

      Delete

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