Comments on: I sent a guy with a normal EKG to the cath lab (Updated)

By: Parcho, MD

Parcho, MD — Tue, 25 May 2010 22:54:08 +0000

And apparently I like repeating myself myself.

Keep up the good blogging!

By: Parcho, MD

Parcho, MD — Tue, 25 May 2010 21:00:26 +0000

Sent a guy to the lab with a 100% circ to the lab with a normal EKG just two days ago.

Go figure.

And sorry to be pedantic. Or something. ;-)

By: Rick

Rick — Mon, 24 May 2010 14:40:08 +0000

Give me enough time and a cath report of 100% LAD, I could probably find a MI in a Laerdal simulator. I’m more surprised the cardiologist chose to stent a proximal LAD instead of going for a CABG.

That EKG is just as normal as 99% of the folks who get discharged from the ED every day. Based on the information available to you AT THE TIME it was a heck of a good call.

By: GruntDoc

GruntDoc — Sun, 23 May 2010 19:00:52 +0000

Dear Pedants:
Yes, I know this EKG isn’t “Normal”; what it’s not is normal for a guy with a 100% LAD lesion who’s visibly having a heart attack in front of you.

Jeez.

By: Parcho, MD

Parcho, MD — Sun, 23 May 2010 03:37:38 +0000

The guy was having a “stuttering” MI, if you will. At least that’s the possibility. It’s not a “normal” ecg–but not an obvious STEMI either.

I had this happen the other night. Initial ekg negative but then on a repeat the guy’s got just about 1mm elevation in 2, 3, AVF with some chest pain. The next minute his pain is gone and the ekg is normal. Cath the next AM–after some more chest pain shows clot in the circ. Not a true “stemi” for more than the 2 minutes it took to get ONE ekg in between 3 normal ekgs.

It’s possible your guy was alternating between perfused and not-perfused. ST’s can come and go. Perhaps in the lab his STs were up.

Of course, the alternative is he simply had no major electrical abnormalities. ;-)

Good case.

By: Abed

Abed — Thu, 20 May 2010 03:08:49 +0000

The EKG was Abnormal but good call!

By: Holly

Holly — Fri, 30 Apr 2010 01:29:46 +0000

I think I cathed this guy last night!

By: Jim Dougherty

Jim Dougherty — Sat, 10 Apr 2010 14:30:29 +0000

My lucky day: 52yo WM comes in about 11PM, onset that evening of low cervical neck pain. Agitated, keeps walking up and down the hall, rubbing his neck. Hx neg, Exam neg. No sweaty, clammy, etc… Nagging thought: people with disks/strain don’t move around a lot, do they?

OK, so you know the bottom line. But everybody looked at me funny when I ordered the EKG. Bingo.

So, I had seen patients with mid-back pain and MI, and patients with anterior neck pain and MI. But not focal cervical pain.

Yeah, yeah, not unheard of…but, index of suspicion needed.

Cardiologist came around in the morning: “what made you suspicious?”

By: Howard Luks

Howard Luks — Tue, 02 Mar 2010 13:45:17 +0000

Great case…. Reminds me of a minor leaguer i saw a few years ago as a second opinion prior to a procedure to stabilize his ankle. He denied any precipitating trauma, or any prior history of ankle sprains. Something didn’t make sense. A very focused physical showed what I thought to be slight, asymmetric peroneal weakness. I decided to order an MRI of the spine… the patient, his dad and coach thought I was nuts, until we found a schwanoma wrapped around one little rootlet. Sometimes it just pays to listen to that little voice.

By: Kam

Kam — Tue, 23 Feb 2010 21:57:11 +0000

The ECG isn’t normal (poor R-progression, old anteroseptal MI, Q in aVL). There is some J-point elevation in V1 and V2 as well. If the LAD was 100% occluded it raises the possibility of a prior anterior MI with a chronic total occlusion. The Troponin elevation could be PCI related in that case.