tag:blogger.com,1999:blog-549949223388475481.post3374146035384982537..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A Child with Blunt TraumaUnknownnoreply@blogger.comBlogger6125tag:blogger.com,1999:blog-549949223388475481.post-30476193089685396022012-11-12T08:47:16.502-06:002012-11-12T08:47:16.502-06:00Thanks, Ken.Thanks, Ken.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-28973555685541832892012-11-11T16:12:57.645-06:002012-11-11T16:12:57.645-06:00THANK YOU Steve for this excellent, soul-searching...THANK YOU Steve for this excellent, soul-searching post with the tragic outcome you report in this unfortunate 6yo girl. Credit to you for extracting the teaching points, with suggestion of how a future approach might be improved. I don't know that anything could have prevented the ultimate tragic outcome. That said - I do agree that this ECG is not normal - and support your emphasis that complete RBBB is not an expected usual "normal baseline" in a 6yo child suffering significant trauma from MVC.<br /><br />I'd ADD one suggestion to the 4 you listed re potential future approach:<br />5) Repeat the ECG (more than once) to see if baseline abnormalities resolve or evolve.<br /><br />Hindsight is admittedly 100% in the "retrospectoscope" - but to me - there are a few additional abnormalities I see on this initial (and only) ECG:<br />i) Not only is the ST segment elevated in lead aVL - but it is coved, and there is a hint of T wave inversion. There is also a Q wave (though I'm not sure what that means in this lead ...).<br />ii) There appears to also be ST elevation in lead I (the J point is clearly elevated in lead I).<br />iii) I think there is reciprocal ST depression in lead III and probably also in aVF. This is challenging to assess, given the unusual terminal shape of the QRS complex in these leads - but I think the ST depression is real.<br />iv) The angled step-off between the end of the S wave and beginning of the ST segment in leads V4 and V5 (and possibly V6) may also reflect ST depression ....<br />v) I agree that lead V2 looks to be mislabeled. It makes no sense appearing between V1 and V3 as it does here. IF this lead is in fact mislabeled - then perhaps IF leads had been correctly mounted there would have been precordial ST elevation in MORE than just a single precordial lead ...<br /><br />As stated - I make the above observations AFTER learning the outcome you describe. I'm not sure I would have called all of this had I been "on the scene" - but like you, I would be concerned that this RBBB tracing is not "the usual" for a 6yo trauma patient. Some ECG abnormalities may have been increased by the tachycardia. In any event - a few REPEAT ECGs would clearly have been helpful.<br /><br />Thank you again for your soul-searching and insightful review of the highly challenging entity of myocardial contusion.<br />ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-824714676638636102012-07-25T08:11:59.040-05:002012-07-25T08:11:59.040-05:00Thanks, David. It may be one of them, anyway.Thanks, David. It may be one of them, anyway.Steve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-26884360126846923302012-07-24T17:11:56.383-05:002012-07-24T17:11:56.383-05:00I believe this is the article you were referencing...I believe this is the article you were referencing:<br /><br />The electrocardiographic and clinical diagnosis of myocardial contusion <br /><br />Intensive Care Medicine <br />Volume 4, Number 2 (1978), 99-102, DOI: 10.1007/BF01684393<br /><br /><br />R. D. Cane and N. Buchanan<br /><br />My college's library article database only goes back to 1980 for this journal. I found a preview of the article, the link is listed below.<br /><br />http://www.deepdyve.com/lp/springer-journals/the-electrocardiographic-and-clinical-diagnosis-of-myocardial-xffjuQQNI8Anonymoushttps://www.blogger.com/profile/04814543249032406874noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-40945619043554734512012-07-23T08:05:38.724-05:002012-07-23T08:05:38.724-05:00Thanks for the great reference. Unfortunately, it...Thanks for the great reference. Unfortunately, it does not specifically comment on ST elevation (or depression) or echocardiographic wall motion abnormalities. Does your pile contain any papers on these? <br /><br />Thanks, Steve SmithSteve Smithhttps://www.blogger.com/profile/08027289511840815536noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-87434959993650623222012-07-22T21:23:55.606-05:002012-07-22T21:23:55.606-05:00I'm hoping that it is a rare entity, whatever ...I'm hoping that it is a rare entity, whatever occurred.<br /><br />I have a virtual pile of papers on the topic from a review I did during residency. Perhaps the reference you were looking for was: <br />"Suspected myocardial contusion. Triage and indications for monitoring." (http://www.ncbi.nlm.nih.gov/pubmed/2363607)<br /><br />"Conduction abnormalities on admission electrocardiogram predicted serious arrhythmias. Echocardiography and creatine phosphokinase isoenzyme levels, although frequently positive, did not predict morbidity."Brooks Walshhttps://www.blogger.com/profile/16108633682893762401noreply@blogger.com