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Altered Mental Status, Bradycardia == MY Comment , by K EN G RAUER, MD ( 2/2 /2024 ): == Dr. Meyers began today’s case with the clinical challenge of asking you to identify the underlying cause of ECG #2. -- Read this ECG -- Osborn Waves and Hypothermia (this is the "Figure" above) What does LBBB look like in severe hypothermia?
The ECG shows sinus tachycardia with RBBB and LAFB, without clear additional superimposed signs of ischemia. Massive Transfusion for Motorcycle Collision with Hemorrhage, Troponin Elevated. Other Arrhythmias ( PACs, PVCs, AFib, Bradycardia and AV conduction disorders — potentially lethal VT/VFib ).
Osborn waves have been reported with hypercalcemia, brain injury, subarachnoid hemorrhage, Brugada syndrome, cardiac arrest from VFib — and — severe, acute ischemia resulting in acute MI ( See My Comment in the November 22, 2019 post on Dr. Smith’s Blog ). Rituparna et al — as well as Chauhan and Brahma ( Int.
lidocaine) can result in severe bradycardia or asystole (Weinberg, Sedowski and Alexander, below) The presence of accelerated idioventricular rhythm does not affect prognosis, and there is no definitive evidence that, if left untreated, the incidence of VF or death is increased. Do not treat AIVR. In fact, use of antidyrhythimcs (e.g.,
A man in his 40s with multitrauma from motor vehicle collision Massive Transfusion for Motorcycle Collision with Hemorrhage, Troponin Elevated. These include ( among others ) — acute febrile illness — variations in autonomic tone — hypothermia — ischemia-infarction — malignant arrhythmias — cardiac arrest — and especially Hyperkalemia.
This ECG shows a sinus bradycardia with a normal conduction pattern (normal PR, normal QRS, and normal QTc), normal axis, normal R-wave progression, normal voltages. Hypothermia can also produce bradycardia and J waves, with a pseudo-STEMI pattern. ECG met STEMI criteria and was labeled STEMI by computer interpretation.
Also consider non-hemorrhagic volume depletion, dehydration : orthostatic vitals may uncover this [see Mendu et al. (3)]. Evidence of acute ischemia (may be subtle) vii. Thus, if there is documented sinus bradycardia, and no suspicion of high grade AV block, at the time of the syncope, this is very useful. Left BBB vi.
Moreover, if you know that catastrophic intracranial hemorrhage can result in an ECG that mimics STEMI, then you know that this patient probably has a severe intracranial hemorrhage. Put it all together, and this is a sudden severe spontaneous intracranial hemorrhage, probably a ruptured cerebral aneuyrms (subarachnoid hemorrhage).
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