Noisy, low amplitude ECG in a patient with chest pain

Written by Colin Jenkins. Colin is an emergency medicine resident beginning his critical care fellowship in the summer with a strong interest in the role of ECG in critical care and OMI. Edits by Willy Frick.A patient in their 40s with type 1 diabetes mellitus and hyperlipidemia presented to the emergency department with 5 days of “flu-like” illness. They had difficulty describing their symptoms, but complained of severe weakness, nausea, vomiting, headache, and chest pain. They denied fever, cough, dyspnea, and sick contacts. They described the chest pain as severe, crushing, and non-radiating. It was not worse with exer tion or relieved by rest. The patient was tremulous and severely hypoglycemic by point-of-care testing. An ECG was obtained shortly after arrival:ECG 1What do you think?The ECG has a lot of artifact, and the amplitude is very small, making interpretation challenging. We can see enough to make out that the rhythm is sinus tachycardia. Tachycardia is unusual for OMI, unless the patient is in cardiogenic shock (or getting close). The lack of anterior R waves suggests age indeterminate anterior MI, but there does not appear to be active anterior OMI.Sometimes when the amplitude is this small and the signal to noise ratio is this poor, it can be difficult to be sure what is the QRS, the ST segment, the T wave, etc. It is often helpful to find a lead where the distinction is obvious, for example the V1 rhythm strip. You can then compare the...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs