I visited the patient in the ICU today, he was sitting up in bed chatting on the phone.

He went to the cath lab about 10 minutes after that EKG was taken.
They stented his LAD.

I take it he has left dominant circulation? , thus the LAD wrapped down and around and supplied the inferior portion (thus the STE in II, III & aVF).

I couldn't find out anymore, sorry.

Regards
Dave

---

From: "PMATERAMD@aol. com" <PMATERAMD@aol. com>

To: ekg_club@yahoogroup s.com

Sent: Thursday, 2 April, 2009 11:26:38 AM

Subject: Re: [ekg_club] Please tell me what's happening here

yeah for klaus, like I keep repeating that refractory, automaticity, excitability nature of cardiac muscle comes in handy when you are trying to figure out physiologically what is happening, obviously this is "the big one", classic angina pectoris onset and AMI, huge amounts of muscle at risk, vitals are c/w cardiogenic shock, my copy of the strip wasn't really clear but looks like fixed coupling which is more frequently non-ischemic (not in this case), in the old days some cardios would have called this an "echo" meaning the depol wave did not depol that area of myocardium(refracto ry) but rather allowed that area to fire (excitability) without a longer strip or one with clear onset and break it is sometimes difficult to determine abberant from ventricular, and in bigeminy ?? compensatory from non-compensatory, I think in this case if it were SVB with abb (or reentrant) at that coupling rate they would all be abberant because the focus is anterior wall and probably is taking out the left anterior fascicle(bundle) , this is the type of patient you don't want to mess with as far as b-blockade or even Ca blockade because right now it looks like his intrinsic rate is high enough to keep the ectopic focus from taking over (VT/VF/Vf), let us know what the cath or follow up ecgs showed, nice case, btw he should also have rales, jvd filling from below, no pedal edema, an AI and/or MR murmer, on ecg without ectopy may see electrical alternans and in this case due to the large area of myocardium dys/atonic may even get to experience mechanical alternans and significant respiratory changes in pulse volume (CO) due to increased preload after inspiration (Starling Law), isn't medicine fun !...,

(my my record length of response for Nick, but close to my longest run-on sentence for Paul (PB) )

Paul  (PM)

Paul Matera, MD, FAEP, FAAIM, EMTP


-----Original Message-----
From: Klaus Skrudland <lapsklaus@gmail. com>

To: ekg_club@yahoogroup s.com
Sent: Wed, 1 Apr 2009 6:19 am
Subject: Re: [ekg_club] Please tell me what's happening here

Looks like anterioseptal STEMI with reciprocal changes and ventricular bigeminy.

Although, the configuration of those extrasystolic beats look a bit weird. I'm not sure whether they are ventricular or junctional with aberrancy. I'd like to think they are aberrantly conducted PJCs, because the initial QRS vector is similar (best seen in V3) to the sinus beats. They also end a long-short cycle, which favors aberrancy as the premature impulse will find the conduction system refractory to impulse transmission.

Great EKG..!

klaus

On Wed, Apr 1, 2009 at 11:50 AM, David Thomas <tazambo@yahoo. com.au> wrote:

Hi Guys,

Patient was a male, 53 years old, smoker with no cardiac history (he later stated his dad had heart problems).  He was chopping wood when acute onset of L sided chest pain, radiating into L shoulder.

Blood pressure was 100/70 and remained 100/palp during transport

Recieved fluid,  Aspirin and 8 mg IV Morphine.
No GTN due to BP (must be >100)


Initial pre-hospital 12 lead (and subsequent serial 12 lead) was sinus with multiple PJC's and the occasional PVC at a rate of 100
He had massive STE in V2, V3 & V4
Smaller STE in II, III & aVF
Depression in I & avL


This bigeminal ? ryhthm only presented on arrival at hospital.

I'm after the knowledgeable ones to tell me what is happening here ?


Regards
Dave

---

Yahoo!7 recommends that you update your browser to the new Internet Explorer 8. Get it now..

--
Mvh,
Klaus Nilsen Skrudland

http://www.lapsklau s.com

http://ecgblog. wordpress. com
+ 47 99 38 67 55

---

Get there faster with the MapQuest Toolbar. Try it now.

---

Enjoy a better web experience. Upgrade to the new Internet Explorer 8 optimised for Yahoo!7. Get it now..