The 4 Physiologic Etiologies of Shock, and the 3 Etiologies of Cardiogenic Shock

A 60-something presented with hypotension, bradycardia, chest pain and back pain.She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension.  She had a mechanical aortic valve.  She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing.  BP was 70/49, pulse 60.A bedside echo showed good ejection fraction and normal right ventricle and no pericardial fluid. Here is the initial ECG:What do you think?This ECG actually looks like a left main occlusion (which rarely presents to the ED alive):  ST Elevation in aVR, but also in V1, and what appears to be " coving " of the ST segment in aVL, which suggests ST Elevation in that lead as well.There is bradycardia, which is ominous in such a sick patient.  This may be due to atenolol, but could simply be a sign of severe illness.Whereas ST elevation in aVR is usuallyreciprocal to the the ST depression of subendocardial ischemia, with a negative ST vector towards leads II and V5, and may be accompanied by STE in V1 (which is in the same direction as aVR),when there is also STE in aVLit implies a more directly superior ST axis (supported by ST depression in all of II, III, aVF).When the ST axis is directly superior, there may actually be transmural ischemia of the " base " of the heart (the base is actually the top of the heart, which really does not have a wall -- the ventricles have openings to...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs

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