SSmith-DRAFT-Regular WCT (3-22.23-2024)-ME_TO_DO

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MY Comment, by KEN GRAUER, MD (3/22/2024):

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Figure 1: The initial ECG in today's case.

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For additional examples of this phenomenon whereby automatic truncation of an EMS ECG may mistakenly result in LVH serving to mimic ischemia — Check out My Comment at the bottom of the page of the following posts in Dr. Smith's ECG Blog — the November 29, 2023 post — June 20, 2020 — March 31, 2019 — March 29, 2019 — and the December 27, 2018 post.

69 y.o. male with pertinent past medical history including Afib, aflutter, cardiomyopathy, PE, HTN who presents to the stabilization room via ambulance for respiratory distress and tachycardia. Per EMS report, patient has been in afib for 5 days, since coming down with flu-like illness with rhinorrhea, productive cough, SOB. Patient is on xarelto, coreg, and dofetilide, says he maybe missed a dose or two during recent illness. On EMS arrival, patient satting high 80s, improved on 4L O2 via NC. Noted to have irregular heart rhythm with rates 120-170s. BG 248. 

First ED ECG

1. · Patient hemodynamically stable, discussed options with patient, would prefer medications before attempting cardioversion
2. · Patient given metoprolol 5 mg IV with improvement in HR to 110-120s, repeated ~q5 mins x3. Patient also given metoprolol PO 50 mg. 
3. · Mag 2g administered 
4. · Appeared mildly hypovolemic on US, LV function grossly preserved, reports decreased PO intake, given gentle 500 cc bolus
5. · CXR with likely infiltrates vs edema, blood cultures collected, started ceftriaxone and azithromycin
6. · Given patient reports not having taken home meds today, given home dofetilide, coreg and xarelto
7. · Labs notable for mild Acute Kidney Injury (Cr 1.5). pH 7.4. 
8. · CT noncon prelim consistent with pneumonia, final read pending
9. · Patient's HR 110s, respiratory effort improved, reported symptomatic improvement

1. · Patient was transferred to the ED team center while in stable condition.  Their care was signed out face-to-face with the ED team center provider.  Please see their note for the remainder of patient's care while in the emergency department.

Previous ECG

t = 14 minutes, after metoprolol

t = 16 minutes

Later in afternoon