A 33 year old male with acute back pain radiating to the chest

Written by Pendell Meyers, with edits by Steve SmithCaseI was called to the EMS control room to answer an RMA (Refusal of Medical Advice). After the call was over, just before I was about to go back to the grind in our acute emergency department, my fantastic EMS colleague paramedic Jess Boyle asked me for an opinion on these 2 ECGs from a single patient, one done immediately after the other, without any other clinical information:What do you think?Both of the ECGs show sinus rhythm with normal QRS complex morphology. There is ST segment depression in leads III and aVF with inappropriate large " volume " T-wave inversion. This is reciprocal to a small amount of ST elevation in lead aVL, with suspiciously large amount of area underneath the ST segment and T-wave, suspicious for hyperacute T-waves. In the context of the inappropriate (inappropriate for the QRS) STE in aVL with reciprocal inferior STD, these T-wave must be considered truly diagnostic for hyperacute T-waves. In the first ECG, take a close look at the PVC that occurs in leads aVR, aVL, and aVF just before the precordial leads start. What do you notice?There is concordant ST elevation in that PVC in lead aVL. PVCs, like any other form of abnormal conduction (LBBB, ventricular paced rhythm, etc) generally follow the rule of appropriate discordance (which states that the ST segment and T wave will deviate away from the majority of the abnormally conducted QRS complex). So in the absence of superimposed ST elevat...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs