Rhythm Nation: July 2017

Faithful Bloggers!

Rhythm Nation is back from its brief hiatus for another installment of critical analysis of the ECGs seen at King’s County.

76M, past history of HTN, dyslipidemia, Stage III CKD, presents with headache and AMS.

Concerned family members bring this gentleman into your emergency department. At baseline, they note that their father is just “regular Dad goofy” but mention recently “his jokes have just been off”. In speaking to him, he mentions a worsening headache for the past day and says he “feels foggy”. When the headache worsened today, his family brought him to the ED over concern for his behavior change.

ROS: Denies recent illness, syncope, seizures, fevers, chills, chest pain or dyspnea in the last 2 weeks, abdominal pain, N/V/D, changes in BM, or urinary symptoms; rest of ROS unremarkable.

PMH: No history of coronary artery disease, no history of PE or DVT
PSH: Denies
SH: Lives with his family in Brooklyn, works as a carpenter
FH: Father died of MI at 51
Meds: Atorvastatin, Metformin, Lisinopril


Physical Exam:
Vitals: 97.8 (rectally), 79, 198/124, 18, 100% on RA, no orthostasis
Gen: Well-appearing, awake, alert, NAD, non-diaphoretic
HEENT: NCAT, EOMI, no conjunctival pallor
Neck: Supple
CV: RRR, no m/r/g, good pulses in b/l UE/LE
Resp: CTAB no w/r/r, good effort
Abd: Soft, NTND, +BS, no masses, no HSM
Ext: Nl ROM, no edema
Skin: No noted rashes or lesions
Neuro: AAOx3, GCS 15, pupils sluggish, CN intact, intact motor/sensation in b/l UE/LE, gait not tested

You obtain his first ECG (below) and after a look back in his chart, it seems consistent with his baseline right bundle branch block.

You draw labs, start fluids for the tachycardia and order urine studies, a chest X-Ray, and a head CT before you are called to the trauma bay for a pedestrian struck by a car. As you’re finishing up this next patient, radiology calls to inform you that the head CT shows a posterior mass with an accompanying bleed. As you’re considering intubation, the nurse hands you a repeat ECG.

Discuss the ECG findings. What is the pathophysiology? What complications may arise, and how would you manage this patient?

Yours Truly,

Rhythm Nation

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