An Ischemic ECG and Bedside Echo shows diffuse dysfunction but with Apical Sparing

An approximately 40 y.o. male was in jail when he reported dyspnea.  He was brought to a small local ED where a chest x-ray showed pulmonary infiltrates.  He was hypotensive and hypoxic, and a provisional diagnosis of sepsis from pneumonia was made.  He had CT pulmonary angiogram which was read as " no PE. "  His lactate was 4.6 mEq/L and WBC count 20,000.  He was given levofloxacin, thentransferred to a tertiary care center.Upon arrival, his vitals were HR 115, BP 87/53, RR 30, T 37.3, and O2 sat 91% on room air. Breathing was labored, tachypneic.  He had cool extremities. He had this chest X-ray:There certainly are pulmonary infiltrates, but it looks more like pulmonary edema. There was no fever. His troponin I returned at 6.8 ng/mL, at which point this ECG was recorded: There is ST depression maximal in V3 and V4, and a large R/S ratio in V2 and V3.There is a suggestion of ST elevation in aVL, with reciprocal ST depression in II, III, and aVF.In a patient with chest pain, one might diagnose posterolateral infarction with probable OMI.  And you would say it is probably subacute MI given the presence of high R/S ratio, suggesting some degree of completion of the posterior infarct.But this is not a chest pain patient, so it is more difficult to interpret.  He was given aspirin. An ED echo was recorded:This shows good contraction ONLY of the apex.Again, good contraction ONLY of the apex.These are t...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs