Anaphylaxis, chest pain, and ST elevation in aVR

 Sent by anonymous, written by Pendell MeyersA man in his late 40s presented to the ED with concern for allergic reaction after accidentally eating a potential allergen, then developing an itchy full body rash and diarrhea. In the ED he received methylprednisolone, diphenhydramine, and epinephrine for possible anaphylaxis. Shortly after receiving epinephrine, the patient developed new leg cramps and chest pain. The chest pain was described as sharp and radiated to both arms.During active chest pain an ECG was recorded:Meyers ECG interpretation: Sinus tachycardia, normal QRS complex, STD in V2-V6, I, II, III and aVF. Reciprocal STE in aVR, and a touch in V1 (closest lead to aVR). The precordial STD persists in severity from V4-V6, rather than being maximal in V1-V4 (as in posterior OMI), and so the ECG overall best fits the subendocardial ischemia pattern (diffuse supply/demand mismatch). This pattern occurs regardless of whether the cause is ACS (decreased supply) or any other cause of decreased supply or increased demand. There is a tiny hint of STE in aVL, but overall I do not think this looks like high lateral OMI.A " STEMI alert " was called and soon cancelled. His vitals are unfortunately unavailable during the chest pain episode.Pain lasted for approximately 45 minutes.Initial high sensitivity troponin I returned within normal limits at 10 ng/L (less than 20 is reference range for men for this assay).After pain had resolved, another ECG was performed:Almost resolve...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs