Monday, March 21, 2011

LBBB with acute STEMI due to ruptured obtuse marginal, diagnosed with bedside ultrasound

This 74 yo male had just returned to his unit bed after successful PTCA of tight lesions of the first diagonal and obtuse marginal coronaries. He complained of chest pain. This ECG was recorded. The previous is below.

There is LBBB with concordant ST elevation in II and aVF (inferior STEMI) and V6 (lateral STEMI); also concordant ST depression in V2 and V3 (Posterior STEMI). There is also excessively discordant ST elevation in V5 (ST/S ratio 2:5 = 40%; excessive is > 20%). Compare with baseline ECG below.

Here, all ST segment are appropriately discordant; none excessively so. Maximum discordant ST elevation is in lead V2, (at 4 mm; but this is only 7% of a 60 mm S-wave)

Suddenly, the patient became hypotensive. The physician (one of our fine EM residents) caring for the patient did an immediate bedside ultrasound. This showed a loculated hyperechoic pericardial fluid (blood with clot).



Patient returned immediately to cath and this confirmed a ruptured coronary artery with pericardial bleeding. A balloon pump was placed and the patient went for immediate CABG.

The circumflex was dissected and will be bypassed any moment now.
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11 comments:

  1. ChristopherMarch 21, 2011 at 10:36 PM

    In the first ECG is that artifact or an atrial pacer?

    ReplyDelete
  2. Steve SmithMarch 21, 2011 at 10:40 PM

    Good eyes! It's an atrial pacer.

    ReplyDelete
  3. Hadik March 22, 2011 at 12:51 PM

    kindly tell me wer is artifact?

    ReplyDelete
  4. Steve SmithMarch 22, 2011 at 6:25 PM

    It's not an artifact; each p-wave is preceded by a spike that is an atrial pacer.

    ReplyDelete
  5. AnonymousMarch 22, 2011 at 8:18 PM

    theres alot of voltage going away from anterior leads, transition at v5 , do we excpect to see posterior axis in transverse plane if we do posterior leads? and why so ? was the fluid posterior?
    thanks
    NidalIsmail@LinkedIn

    ReplyDelete
  6. Steve SmithMarch 23, 2011 at 7:40 AM

    LBBB transition may be at V4-V5 or V5-V6 depending on a lot factors, including but not limited to lead placement and anatomic variation.

    ReplyDelete
  7. ChristopherMarch 27, 2011 at 8:26 PM

    Are those a look of the LV/LA in the parasternal long axis view?

    ReplyDelete
  8. Nguyen Chí TínhMay 14, 2017 at 11:33 PM

    Very interesting cases sir, very informative. I learned a lot from these 2 cases. But I just have a query and I need your help, sir. In typical LBBB, the morphology of QRS complexes in D1 and aVL are monophasic R waves, but in the 2nd case the QRS complexes in D1, aVL are negative, So how do you explain , sir Steve Smith. Thank you.

    ReplyDelete
    Replies
    1. Steve SmithMay 15, 2017 at 10:11 AM

      It is a matter of lead placement, heart orientation in the chest, and variability of the conducting system.

      Delete
    2. Nguyen Chí TínhMay 15, 2017 at 10:02 PM

      Thank you , sir! Can we identify this ECG as IVCD sir?

      Delete
    3. Steve SmithMay 19, 2017 at 6:57 AM

      Yes, it is IVCD that approaches LBBB

      Delete

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