EKG - what do you see?

[NightMedic1]

I hope I attached the image correctly - I'm doing this entirely from my phone! This is from a hospital. Pt is 20 yo female w cc of seizures. No pmhx of any sort. Been going on for the past month. After I saw this (5 lead for monitoring) I asked the Dr to put in orders for a 12-lead. I'm pretty new to this so I'm curious what you guys see here. Ill post my initial thoughts later and I should be able to obtain the 12-lead results overnight.

 

[chaz90]

Just a sinus arrhythmia. Probably completely normal for the patient as she breathes. If this were my patient, there's no way I'd even do a 12 lead.

 

[STXmedic]

Seconded on RSA. It can be pretty pronounced, too. When I'm in really good shape, my HR will float between 40 and 70 depending on what phase of respiration I'm on.

 

[Melclin]

I would have just said this was a sinus arrythmia with nothing else interesting or specific to seizures, but since this is a case study there is bound to be something involved.

If I was to clutch at straws....I suppose you could argue for hypokalaemia...flattened/inverted Ts, U waves...slightly downsloaping ST segments. Does she perhaps have some lifestyle/tox issue playing with her electrloytes. K+ for the ECG, Na+ for the seizures?

The only other thing I can think of is that you're maybe getting at HCM or something...inferior Q's.

Those are my best guesses, but I don't see anything too wrong with this ECG.

 

[VFlutter]

I would have just said this was a sinus arrythmia with nothing else interesting or specific to seizures, but since this is a case study there is bound to be something involved.

If I was to clutch at straws....I suppose you could argue for hypokalaemia...flattened/inverted Ts, U waves...slightly downsloaping ST segments. Does she perhaps have some lifestyle/tox issue playing with her electrloytes. K+ for the ECG, Na+ for the seizures?

The only other thing I can think of is that you're maybe getting at HCM or something...inferior Q's.

Those are my best guesses, but I don't see anything too wrong with this ECG.

I agree. HCM and HypoK came to mind but that is just hunting for Zebras.

Also, "Seizures" could be self-terminating arrhythmias.

 

[chaz90]

I don't even know if the OP was hinting at zebras though. Really, I wouldn't be thinking much of anything just based on this 3-lead and a 20 YOF w/ seizures.

 

[NightMedic1]

Learning moment for me. I saw the deep q waves and noted the large voltage of the qrs in II III and Avf. It looked to me like it could possibly meet lvh criteria. 12 lead showed short pri and was otherwise normal.

I am now curious why I was wrong, and why lead one has no amplitude and 2 and 3 are huge??

 

[Aprz]

If the mean vector QRS axis is -90 or +90 degrees, lead I is likely gonna be near isoelectric cause it's perpindicular to lead I (lead I is left to right, mean vector QRS axis is going up (-90 degrees) or down (+90 degrees). It's not going towards the positive electrode for lead I (left arm, black electrode), which would make it a positive QRS complex, nor away from the positive electrode for lead I (away would be towards right arm electrode, the white one), which would make a negative QRS complex (if the mean QRS complex would be going towards the right arm lead, the white one). I believe I saw it was +89 degree in the image yesterday, but I'm on my phone so I'm too lazy to actually load the image to look at it.

I believe it did meet one of the left ventricular hypertrophy (LVH) voltage criteria per Thomas Garcia's Art of Interpretation, which is aVF is greater than or equal to 20 mm I think? It's not a normal criterion I hear or seen used. To be honest, for LVH by itself, I would expect the mean QRS vector axis to be close to the left because of an obviously large left ventricle, but there are other things that could cause the axis to shift eg hypertrophic cardiomyopathy (HCM) or something electrical eg fascicular block/hemiblock.

I do not suspect hypokalemia. I think the p-wave is very visible. I don't recall seeing a second lump on the t-wave or in the TP segment that would make me think u-wave.

Interestingly I recall I think I saw retrograde T-wave and downsloping in III, a small q-wave in III, and small S-wave in I. S1Q3T3 I believe is a sign of right ventricular strain pattern including the downsloping in III looked like a strain pattern so maybe HCM, but to be honest, don't like thinking about these things without a 12-lead, and if you start to look too deeply in 12-leads, you gonna start seeing stuff that's not there (pareidolia, just read a yahoo article on this ) eg looking at the moon and seeing a face. I don't like to overthink ECGs.

To be honest, I see S1Q3T3 all the time for some reason now. I dislike it.

I would take a 12-lead just because they had a seizure. Electrolytes and arrhythmia are gonna be in my head for seizure patients.

 

[NightMedic1]

Thanks Aprz,
I appreciate the info! At least I saw what I thought I saw, and that's why I asked for a 12 lead because I didn't feel right seeing that and letting it go.

Looking at the actual 12-lead V2 is HUGE, about 3mm shy of 40mm. Lead I has a large amplitude and looks much more normal where AVL is very low amplitude and equiphasic. (I'm thinking lead placement has a lot to do with the difference between the 12 and 5 lead images.) There's no deep Q waves and several leads (II, V1, V5) are ~20mm give or take a little on each one. Axis is 67. Short PRI and otherwise everything looks totally normal. No strain pattern or anything.

I am puzzled over why lead placement would create such a thing, but I'm glad the 12-lead is a definitive answer.

Interpreted as normal ECG. What is a better/more modern LVH criteria I could study? Sounds like a lot of the sources are using the older ones that I'm apparently familiar with.

I see what you mean about pareidolia, for sure. I think separating out imaginary zebras is going to be a good challenge for me since I live and breath ECGs at work.

 

[Ecgg]

Pt is 20 yo female w cc of seizures. No pmhx of any sort.

Something tells me LVH is highly unlikely.

 

[Handsome Robb]

If we're arguing zebras it could be WPW with the shortened PRI but it doesn't look short enough and there are no delta waves anywhere.

Sinus arrhythmia, IMO.

 

[Aprz]

Also always gotta use the longest PRi. Doesn't matter if it's short in one lead. I am on my phone so I can't view it. What lawn ganong levine (LGL) syndrome if no delta wave, but short PRi? I'm just having fun by the way discussing this/shooting the wind.

 

[MSDeltaFlt]

Sinus arrhythmia with right axis deviation.