Watch what happens when " pericarditis " and morphine cloud your judgment

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve SmithCaseA 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain “similar to his prior MI, but worse.” The pain initially started the daypriorto presentation. The pain roused him from sleep but subsided without intervention. Around 19 hours later, he experienced the same pain, which prompted his presentation to the ED. By this time, three hours had passed from the onset of the pain but it was no longer present. Here is his initial ECG:00:04What do you think? - Sinus rhythm at ~70 bpmSTE in lead V2 with a suspiciously large area under the ST segment and T-wave compared to the QRS complex - Borderline Terminal QRS distortion in V3. There is perhaps a tiny J-wave in several of the QRS complexes in V3, but it would not be enough to definitively say there is a J-wave. Lead aVL, for example, has a definite J-wave.With no other information other than the first ECG above, I texted this to Dr. Smith and he responded:“ST elevation in lead V2 and terminal QRS distortion in V3. LAD occlusion. Great case. Only viewed on my phone. "As an exercise, lets calculate the equation for differentiating the ST elevation between benign early repolarization and LAD occlusion. Recall that terminal QRS distortion was an exclusion criteria for this calculator (it was independently suggestive of LAD occlusion), so it cannot be truly applied to this case.Initial ECG wit...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs