ECG of the Week - 6th July 2015 - Interpretation

The following ECG is from a 65 year old male who was brought to the Emergency Department following an out-of-hospital cardiac arrest. ROSC was achieved pre-hospital following an episode of VT. ON arrival GCS 3, intubated with sats 98%, BP 75 systolic.
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Rate:

• ~84 bpm

Rhythm:

• Regular

Axis:

• RAD

Intervals:

• PR - Prolonged(~220ms)
• QRS - Normal (80-100ms)
• QT - 400ms (QTc Bazette 470-480 ms)

Segments:

• ST Elevation leads II, III, aVF, V4, V6
• Unusual ST morphology in inferior leads
• ST depression lead aVL, V1-3

Additional:

• Note complete lead inversion leads I, aVL - negative P/QRS/T

Interpretation:

• STEMI
• Lead malposition
• Likely V4 & V5 reversed
• RA / LA limb lead reversal resultant inversion lead I, II/III switched and aVR/aVL switched

What happened ?

The patient was taken for urgent PCI which was normal !
He subsequently went on to have a CT brain which showed an extensive sub-arachnoid haemorrhage.

There are a number of cases in the literature were sub-arachnoid hemorrhage has been associated with significant ST changes:

• Van der Velden LBJ,Otterspoor LC,Schultze Kool LJ,Biessels GJ, Verheugt FWA. Acute myocardial infarction complicating subarachnoid haemorrhage. Neth Heart J. 2009 Aug; 17(7-8): 284–287.
• I Beydilli, I Korkmaz, F Yilmaz,Eren, C Kavalci, M Yilmaz. Subarachnoid Hemorrhage Mimicking Myocardial Infarction. The Internet Journal of Emergency Medicine. 2012 Volume 7 Number 2.
• S Chatterjeec.ECG Changes in Subarachnoid Haemorrhage: A Synopsis.Neth Heart J. 2011 Jan; 19(1): 31–34.

References / Further Reading

Life in the Fast Lane

• ECG in Raised ICP
• STEMI - Posterior
• STEMI - Inferior
• STEMI - Lateral

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.