65 year old male who was brought to the Emergency Department following an out-of-hospital cardiac arrest. ROSC was achieved prehospital following an episode of VT.

On arrival GCS 3, intubated with sats 98%, BP 75 systolic.

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Rate:

Rhythm:

Axis:

Intervals:

  • PR – Prolonged(~220ms)
  • QRS – Normal (80-100ms)
  • QT – 400ms (QTc Bazette 470-480 ms)

Segments:

  • ST Elevation leads II, III, aVF, V4, V6
    • Unusual ST morphology in inferior leads
  • ST depression lead aVL, V1-3

Additional:

  • Note complete lead inversion leads I, aVL – negative P/QRS/T

Interpretation:

  • STEMI
  • Lead malposition
    • Likely V4 & V5 reversed
    • RA / LA limb lead reversal resultant inversion lead I, II/III switched and aVR/aVL switched

CLINICAL OUTCOME

What happened?

The patient was taken for urgent PCI which was normal!

He subsequently went on to have a CT brain which showed an extensive subarachnoid haemorrhage.

There are a number of cases in the literature where subarachnoid haemorrhage has been associated with significant ST changes:

Further Reading

Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |