GCS 16
  • home page
  • Paediatrics
    • Paediatric fracture management
    • Procedural sedation
  • fellowship examination
  • study tips

Acutely short of breath at 2am - raised troponin but no chest pain......

28/9/2016

6 Comments

 
Posted by Dan Crompton
This 72 year old man presented by ambulance, to a regional hospital at 4am, acutely short of breath. He complained of having had a cough and increasing dyspnoea for the last 3 days but suddenly worse at 2am. He had recently been diagnosed with COPD after a hospital admission for pneumonia and the paramedics had given him a total of 15mg salbutamol and 1.5mg ipratropium. His initial sats were 77% and he had widespread wheeze but no crackles. He hadn't improved much on the way.

PMH
COPD
- recently diagnosed following similar presentation
HT
recent ex-smoker
abdominal surgery - uncertain what

DH
Salbutamol
Tiotropium 
Atorvastatin
Bromhexine (bisolvon)

First set of Obs in ED
P   123     BP  160/110         RR   35       SaO2  86%         GCS  15     Temp 36.5

This is his ECG.
Picture
What are the major abnormalities on this ECG?
What additional assessment would you perform?
6 Comments
J
7/10/2016 09:05:36 pm

1. ECG shows a wide complex tachyarrythmia. It looks to be a LBBB, given the rate and that there are appreciable PWs preceding each QRS. I wonder whether it's atrial flutter with a 2:1 block, as there appears to be PWs hidden in the ST segments. There is nothing that really meets the sgarbossa criteria. Should compare this to the patient's previous ECGs.

2. A bedside USS would be very useful in this patient. A predominance of B-lines (over A-lines) on chest USS would point this towards interstitial syndrome, which in the setting of a raised troponin would suggest APO. A quick POC-TTE would also allow us to assess the gross RV/LV size and function. Being able to differentiate between obstructive airways disease and APO is vital, as unnecessary beta-agonists can exacerbate demand-related ischemia from the induced tachycardia.

Reply
George
23/11/2016 10:32:30 pm

1) Sinus tachycardia. Wide QRS with picture of LBBB. Discordant STE elevation 5mm in aVR. Discordant STDs in I, II, aVF and V3 to V6, with horizontal segments, indicating ischemia

2) CXR, Bloods (FBE, Electrolytes, Troponine, Renal function) and POC ECHO

ps. So finally pt had elevated Trop? What about other clinical features, eg JVP, murmurs? What about other history, eg coryza, productive cough? Furthermore, as pt hadn't improved after bronchodilators (had he had steroids?), could it be "cardiac asthma", precipitated by ischemia given most likely severe underlying IHD?

Reply
George
23/11/2016 10:32:47 pm

1) Sinus tachycardia. Wide QRS with picture of LBBB. Discordant STE elevation 5mm in aVR. Discordant STDs in I, II, aVF and V3 to V6, with horizontal segments, indicating ischemia

2) CXR, Bloods (FBE, Electrolytes, Troponine, Renal function) and POC ECHO

ps. So finally pt had elevated Trop? What about other clinical features, eg JVP, murmurs? What about other history, eg coryza, productive cough? Furthermore, as pt hadn't improved after bronchodilators (had he had steroids?), could it be "cardiac asthma", precipitated by ischemia given most likely severe underlying IHD?

Reply
George
23/11/2016 10:32:56 pm

1) Sinus tachycardia. Wide QRS with picture of LBBB. Discordant STE elevation 5mm in aVR. Discordant STDs in I, II, aVF and V3 to V6, with horizontal segments, indicating ischemia

2) CXR, Bloods (FBE, Electrolytes, Troponine, Renal function) and POC ECHO

ps. So finally pt had elevated Trop? What about other clinical features, eg JVP, murmurs? What about other history, eg coryza, productive cough? Furthermore, as pt hadn't improved after bronchodilators (had he had steroids?), could it be "cardiac asthma", precipitated by ischemia given most likely severe underlying IHD?

Reply
George
23/11/2016 10:33:22 pm

1) Sinus tachycardia. Wide QRS with picture of LBBB. Discordant STE elevation 5mm in aVR. Discordant STDs in I, II, aVF and V3 to V6, with horizontal segments, indicating ischemia

2) CXR, Bloods (FBE, Electrolytes, Troponine, Renal function) and POC ECHO

ps. So finally pt had elevated Trop? What about other clinical features, eg JVP, murmurs? What about other history, eg coryza, productive cough? Furthermore, as pt hadn't improved after bronchodilators (had he had steroids?), could it be "cardiac asthma", precipitated by ischemia given most likely severe underlying IHD?

Reply
George
23/11/2016 10:34:04 pm

1) Sinus tachycardia. Wide QRS with picture of LBBB. Discordant STE elevation 5mm in aVR. Discordant STDs in I, II, aVF and V3 to V6, with horizontal segments, indicating ischemia

2) CXR, Bloods (FBE, Electrolytes, Troponine, Renal function) and POC ECHO

ps. So finally pt had elevated Trop? What about other clinical features, eg JVP, murmurs? What about other history, eg coryza, productive cough? Furthermore, as pt hadn't improved after bronchodilators (had he had steroids?), could it be "cardiac asthma", precipitated by ischemia given most likely severe underlying IHD?

Reply



Leave a Reply.

    Archives

    October 2017
    September 2016
    August 2016
    March 2016
    November 2015
    August 2015
    January 2014
    November 2013
    October 2013

    Categories

    All
    Diagnostic Imaging
    Ecgs

    Author

    Rachel Rosler - DEMT Casey

    RSS Feed

Proudly powered by Weebly