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This case was posted on the [link] ultrasound site, of which this ECG blog is a part. I refer you to the video case presentation by one of my colleagues, Dr. Rob Reardon (who has, by the way, a fantastic collection of ED ultrasound cases). However, only the first ECG was shown, and it was recorded before the patient became ill.
The morphology of V2-V4 is very specific in my experience for acute right heart strain (which has many potential etiologies, but none more common and important in EM than acute pulmonary embolism). CT angiogram showed extensive saddle pulmonary embolism. Now another, with ultrasound. On epinephrine and norepinephrine drips."
This suggests that there is pulmonary hypertension and thus possibly RVH. So we did a bedside cardiac ultrasound. The estimated pulmonary artery systolic pressure is 31 mmHg + RA pressure. In a patient with RVH — the finding of a qR pattern has been closely correlated with pulmonary hypertension.
Smith comment: This patient did not have a bedside ultrasound. Had one been done, it would have shown a feature that is apparent on this ultrasound (however, this patient's LV function would not be as good as in this clip): This is recorded with the LV on the right. In fact, bedside ultrasound might even find severe aortic stenosis.
Check : [vitals, SOB, Chest Pain, Ultrasound] If the patient has Abdominal Pain, Chest Pain, Dyspnea or Hypoxemia, Headache, Hypotension , then these should be considered the primary chief complaint (not syncope). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events.
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