Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.

 Written by Pendell Meyers with edits by SmithA man in his 60s called EMS apparently for shortness of breath. EMS found him in distress and hypoxemic requiring 4 L nasal cannula to maintain oxygen saturation greater than 93%.Here is his triage ECG:What do you think?An old ECG was available on file, from 2 years ago:RBBB, otherwise normal.The triage ECG is diagnostic of life threatening hyperkalemia (sodium channel blockade would also produce this pattern, but the patient was not known to be on any sodium blocking medications). There is the very common brugada pattern STEMI mimic seen in V1 and partially in V3 and aVR. There is also STE in III with reciprocal STD in I and aVL which is due to the hyperkalemia.When hyperkalemia causes STEMI mimics, in my experience, the most common areas where the false positive STE morphology is located are, in this order: right precordial leads (due to brugada morphology), inferior leads (as seen here), and then the high lateral leads. We have many such cases on the blog, see links below. This ECG is easy for those who have been taught this hyperkalemia pattern, and almost impossible to understand for those who haven ' t. Unfortunately, the providers interpreted this ECG as a " STEMI " and activated the cath lab. The interventionalist called the ED provider and completely agreed that the ECG represented STEMI. However, they informed the ED team that the patient ' s size was not physically compatible with the cath lab table, and ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs