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Near Syncope after a Jab

UnFiNiShEd CaSe CoMe BaCk LaTeR

History:  A man in his 20’s comes to the UCC for body aches and feeling light headed.  Symptoms started about 3 hours after his second COVID vaccine and are non-progressive at this point.  He was told he needs a doctor’s note to return to work.  He denies syncope, palpitations, chest pain, SOB, fever, cough or other complaints.

Exam: Vital signs are normal except slightly elevated BP.  He is not orthostatic.  Exam is normal

An EKG is done

Computer Read: NSR at 78, TWA consider inferior/anterolateral ischemia

 

What is the most likely cause of the EKG findings in this patient?

  • A) Cardiomyopathy
  • B) Myocarditis
  • C) Acute coronary syndrome
  • D) PE

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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QUIZ ANSWER, EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) Quiz Answer:

  • A) Cardiomyopathy – possible,
  • B) Myocarditis – possible, though unlikely due to no chest pain
  • C) Acute coronary syndrome – unlikely due to age, especially as no chest pain uncommon presentation in young patients
  • D) PE – unlikely because if large enough to cause near syncope would usually also cause at least soft vital signs

2) EKG/Echo analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): The differential of T-wave inversion may include the following:

  • Conduction:   ARVC, Brugada, WPW, BBB, LVH (in 1, AVL, V6 >V4: hockey-stick shape)
  • Ischemic:         Wellens reperfusion (terminal T-inversion then full T inversion), prior MI
  • Other bad:      Myocarditis/pericarditis, large PE, CNS catastrophe, ­high/low K+
  • Other benign: Hyperventilation, post-prandial, primary, pacer, MVP
  • Normal:           Juvenile T-inversion in V1-3 in young males or in women age <45

3) Case Conclusion:  Troponin-i was <0.03 x 2  (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  He felt he was improving.  Cardiology was consulted and recommended outpatient echo.

4) 1-Minute Consult from the Emergency Medicine 1-Minute Consult Pocketbook & Smartphone app on the topic for this case: See highlighted areas of sample page below.

5) Case Lessons: 

  1. Always
  2. Never

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should.  It’s long but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from emergent reperfusion and how you can pick up those patients and get them the care they need. for more information CLICK HERE

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