EKG in PE, Fracture Mimics and Referred Scrotal Pain

April Fools Morning report (4/1/16)

3 case topics that will FOOL you

Case 1¹

A 45 year-old man presented to the hospital with chest pain and dyspnea. Exam was unremarkable. ECG showed T-wave inversions in leads II, III, aVF, V₁-V₄, and troponin was elevated. He was pale, diaphoretic, tachycardic, with a systolic blood pressure ranging from 85-110 mm Hg. He was taken urgently for cardiac catheterization which demonstrated no significant coronary artery disease. Later in the CCU, he got up to use the commode and then suffered a PEA arrest from which he expired. An autopsy revealed pulmonary embolism.

Discussion:
PEs (submassive and massive) are at times mistaken for MI (up to 3% of PEs are admitted for MI).² Generally there are 2 ECG patterns for PE that may suggest MI.

Pattern 1: RV strain pattern

• T-wave inversion in V₁ and V₂
  
• At least one of the following:
  
  • T-wave inversion in lead III
    
  • The precordial lead with deepest T-wave inversion is V₁ or V₂
    

• The most common MI-suggestive ECG finding in PE may look like Wellen’s pattern and is seen in 40% of patients with PE³
  
• Differentiating PE from MI:
  
  • PE more often T-wave inversion in the inferior leads and V₁-V₂
    
  • MI more often T-wave inversion in V₅-V₆

Pattern 2: RV injury pattern

• ST-elevation in aVR and ST depression in lead I
  
• ST-elevation in V₁-V₃ and/or ST depression in V₄-V₆
  
• The direction of RV injury will decide which of these findings is seen
  

• Differentiating from MI
  
  • In PE with RV injury, RV conduction is delayed. The terminal portion of the QRS complex reflects conduction of the right ventricle. Thus, when there is delayed RV conduction, the terminal portion of the QRS complex will produce a terminal S-wave in lead I and a terminal R-wave in lead III.

• Overall, when there is uncertainty regarding whether the patient has PE or MI, there should be a low threshold to obtain immediate bedside echocardiography to more accurately look for sonographic findings that may indicate RV strain.
  

Case 2: Fracture mimics⁴

a. b. c.

a. Bipartite Patella – Bipartite patella almost always involves the upper outer pole of patella; 57% are bilateral

b. Limbus Vertebra – Most commonly affects antero-superior border of single vertebra in lumbar spine

c. Multiple Ossification Centers – The calcaneal apophysis frequently has multiple centers of ossification and appears denser than rest

d. e. f.

d. Apophysis – The greater and lesser trochanters are apophyses which fuse at 15 – 20 years of age.

e. Skin Laceration – Air deep to lacerations may superimpose on the bone simulating fractures; one should look at multiple projections.

f. Apophysis – Apophysis of the 5th MT runs in a longitudinal direction; fractures are usually transverse

Case 3⁵

A 52 year-old man came to the emergency department with progressive left groin and testicular pain for two weeks which was severe, constant, and throbbing. The pain worsened with walking and urination and improved with rest. He was afebrile. Examination of the chest, abdomen, genitalia, rectum, and femoral pulses was unremarkable. Urinalysis, chemistries, complete blood count, and abdominal x-rays were normal. The patient went home with plans for outpatient abdominal ultrasonography but returned the next day with progressive left groin, testicle, and now inner thigh pain. Abdominal computed tomography (CT) revealed a leaking abdominal aortic aneurysm. The patient was taken to the OR and did well after surgical repair.

• Scrotal pain has 2 causes
  
  • Intrascrotal disease
    
    • Signs: Look for local erythema, warmth, or mass 
    • Examples:
      
      • Most common: Acute epididymitis, torsion of the spermatic cord, or torsion of testicular appendage
        
      • Less common: Orchitis, testicular tumors, polyarteritis nodosa, post-vasectomy sperm granulomas.
        
  • Referred pain
    
    • Symptoms: Scrotal pain without local inflammatory signs
    • Nerves involved:
      
      • Genitofemoral, Ilioinguinal, and posterior scrotal nerves
        

• Conditions with associated nerve involvement
  

  
  

References:

1: Farkas J Two EKG patterns of pulmonary embolism which mimic MI. http://emcrit.org/pulmcrit/two-ekg-patterns-of-pulmonary-embolism-which-mimic-mi. Posted July 30, 2014

2:
Kukla P, Długopolski R, Krupa E, Furtak R, Mirek-Bryniarska E, Szełemej R, Jastrzębski M, Nowak J, Kulak L, Hybel J, Wrabec K, Kawecka-Jaszcz K, Bryniarski L. How often pulmonary embolism mimics acute coronary syndrome?
Kardiol Pol. 2011;69(3):235-40.

3: Kukla P, McIntyre WF, Fijorek K, Mirek-Bryniarska E, Bryniarski L, Krupa E^, Jastrzębski M, Bryniarski KL, Zhong-qun Z, Baranchuk A. Electrocardiographic abnormalities in patients with acute pulmonary embolism complicated by cardiogenic shock.
Am J Emerg Med. 2014 Jun;32(6):507-10. doi: 10.1016/j.ajem.2014.01.043. Epub 2014 Feb 3.

4: Learning Radiology: 21 Imaging Findings Simulating Fractures. http://learningradiology.com/ archives2013/COW%20586-Fx%20or%20Not/fxornotcorrect.html

5: McGee SR. Referred scrotal pain: case reports and review. J Gen Intern Med. 1993 Dec;8(12):694-70

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