Saturday, April 2, 2011

Answer: pulmonary embolism. Now another, with ultrasound....

This 18 year old presented with syncope and tachycardia.

Similar to the last case (the "quiz"), there is sinus tachycardia with precordial T-wave inversion with TW inversion in lead III also.  The morphology of these T inversions is highly suggestive, but unlike the previous case, not diagnostic.  There is also, arguably, S1Q3T3 depending on whether one considers the S-wave to be "prominent."  There is no right axis deviation, but there is a S-wave.  (Does anyone know of a definition of "prominent" S-wave in S1Q3T3?)

Immediately, a bedside echo was done.  Here is the video:

This shows a huge and poorly functional RV.

Here is a still picture from the video:

The RV is on the left, the LV on the right (thick-walled).  The RV is very enlarged and looks like a "D".  Accordingly, this is called the "D" sign.

  This is diagnostic for pulmonary embolism, which was subsequently proven. Thrombolytic therapy might have been given, but at least partly because of head trauma from syncope, it was not.


  1. I recently saw a patient with Q3T3 but there was no S1. How common is such a presentation?

  2. I don't know. I just spent the last hour trying to find a paper that I know exists that would probably answer your question. I couldn't find it, but emailed the author for a copy.

  3. Here is a great article. The answer is not in there, but worth a read anyway:

    Marchick MR, Courtney DM, Kabrhel C, et al. 12-lead ECG findings of pulmonary hypertension occur more frequently in emergency department patients with pulmonary embolism than in patients without pulmonary embolism. Ann Emerg Med;55(4):331-5.


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