An Unusual EKG

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This is an interesting case, something a bit on the unusual side even.

Here is the known history, actually it’s a pretty complete history, very straightforward.

Complaint; 37 year old male with a syncope.
History of Present Illness; One week of “sore throat” with “neck sniffness”. He was drinking tea with his wife when he felt light headed. She helped him to the bathroom where he lost consciousness and she called 9-1-1. Fire department first responders found him conscious, with a small head laceration.
ALS and BLS crews arrive simultaneously and find the patient sitting in a dining room chair.
PMH; None
Medications; OTC for his minor illness.
Allergies; Seasonal only.
PE; Conscious, alert, oriented x 3, skin cool, pale, non diaphoretic. No dyspnea, breath sounds clear, BP 124/72, HR 72, RR 20.
Before ECG leads are applied, the patient complains of feeling faint, loses radial pulses, has a syncopal episode. He is placed on the floor and rapidly regains consciousness. BP is now 118/P, HR unchanged.

EKG leads are applied, EKG shows sinus rhythm at 68. Blood Glucose is 138. O2 saturation is 100% on Oxygen 4L via nasal cannula. IV of warmed Normal Saline started, 250 ml bolus infused.

This is the 12 Lead ECG obtained. Serial 12 Leads were done, but all were the same as this.

Patient remains unchanged during transport.

What’s going on with this patient?

Please answer in the comments. I’ll provide the answer in a few days. I have no doubt that a couple of my frequent EMS readers will figure it out. I’ll probably hold any comments of anyone who does get it a few days to give everyone a chance to look at it.

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

21 COMMENTS

  1. I'm going with Brugada Syndrome. Nice catch if it is.Did the interpretation suggest it, or are they still not programming them to recognize it?

  2. Very cool, TOTWTYTR! I was just arguing on the NAEMSP Dialog list that all syncope patients should be screened for Brugada's Syndrome, prolonged QT-interval, and hypertrophic cardiomyopathy! Often syncope patients don't want to be transported. In this case it could certainly be life-saving!Tom

  3. it looks like Brugada syndrome. It would be interesting to look at ecg when he had the syncopal episode, probably ha had an arrhytmia like a v-tach.

  4. one DDX is Brugada syndrome. He goes into an arhythmia which causes the syncope and then probably converts back

  5. I'm using a rather small screen to view the 12, but do I see a possible WPW slope, with a possible area of ischemia in V1 V2 V3? Maybe even a borderline 1st deg? (Sorry, small screen = very pixellated on zoom 🙂 )With similar serial 12 leads being the same, might account for syncopal episodes. Could also be that the OTC med is preventing / delaying his bodies normal compensation, allowing for the WPW to actually show symptoms. ?? Just a guess 🙂

  6. I believe this is BRUGADA SYNDROME..Ihad a similar pt, where the call came in as a seizure. Family stated pt has no hx of seizures, but had one today. We did a 12 lead EKG, and found saddle like ST elevations in V1 V2..by the time we got downstairs, the elevations had resolved itself. The hospital ED advised us that because of our 12lead, which was brugada syndrome, this pt will get a pacemaker.Brugada Syndrome effects young patients, where they go into a brief Vfib or Vtach, lose consciousness or seize, then Vfib or Vtach resolves itself. Its may cause sudden death in the young patients.. its a genetic disorder

  7. sinus regular rhythm with ST changes in lead v1,v2this is the ECG interpretation ..ABOUT OUR PATIENT HE IS MOST PRPAPLEY Subarachnoid haemorrhage PLEASE CONSIDER G.C.S HOURLY AND CHECK HIS PUPILS SIZE AND REACTION TO LIGHTthe ECG didnt shows any Brugada syndrome cause there is no ST elevation…

  8. Brugada syndrome. He goes into an arhythmia which causes the syncope and then probably converts back

  9. It's not right, but I can't figure it out… (of course my training/field experience is 20+ years ago)

  10. Things that my partner and I considered but ruled out were, Posterior AMI, WPW, and IMI.I've not heard of a Subarachnoid bleed without a terrific headache before hand, but I suppose it could happen. Sometimes it resolves itself, but when it doesn't sudden cardiac death is often the result. The sore throat and sore neck were completely unrelated to the problem, purely coincidental. Thanks to everyone for stopping by to take a look.

  11. Divemedic, we did check orthostatic VS, and they weren't different. Well, actually his BP was a bit lower lying down, but not that much. We thought of a V4R, but decided against it as the ECG didn't really suggest an IMI.

  12. I was guessing a potassium problem. Because of the pqrs below the base line. Guessing was the key word.

  13. Amazing case ..I couldn't resist from sharing the discussion, thu i will not say anything new !! ..Yes, i do agree with the rest the history and ECG is highly suggestive of prugada syndrome with ST elevation in the anterior leads .. Thank you..

  14. TOTWTYTR,I'm sorry if I missed it, did Brugada enter your differential? Not that it would have changed your treatment, maybe your destination. Maybe you would have got a wink from a good ED Doc or a confused scowl from an ignorant one. I haven't done a whole lot of research on Brugada syndrome, but I believe these classic findings are circumstantial and not always present in patients that do exhibit them. So it is possible that without this capture, it may have gone undetected. Good job anyhow. Not a whole lot of us will ever get to see this in the field.

  15. Adam, Brugada didn't enter the differential because neither I nor my partner had ever heard of it before. Which is pretty surprising as we as a service are pretty good at ECGs and are frequently updated in new trends. My medical director picked up the Dx when I showed him the 12 Lead as did the associate medical director. Now that we've caught one "in the wild" so to speak I expect that we'll get an update during the next rounds. It was entirely possible that the ECG could have normalized before we got the 12Lead, in which case this would have been just another case of a young adult male with syncope. He might have refused transport, he might have been seen at the hospital without Dx, and he might have had a recurrence at home without recovering. So yes, I'm very proud that we picked this one up.

  16. Very interesting. I think most haven't heard of Brugada, but this post/call can now educate so many, including those great ECG interpreters at your agency. Thanks for sharing.

  17. I believe it is more common and almost exclusive to south East Asian males. It is a genetic abnormality. I had a 25 year old Asian male V-Fib arrest found by his friend. We got pulses back with one shock and his post arrest 12 lead was similar to this one. He now has a pacemaker and made a full recovery

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