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Vomiting Yesterday*

History: A man in his mid 60’s was sent to the urgent care by his PCP for 6 hours of vomiting that had occurred the day prior.  He has had no further vomiting today but occasionally still feels a bit nauseous.  He denies any fever, diarrhea, abdominal or chest discomfort, SOB, weakness other complaints.

Exam: Vital signs are normal.  Other than obesity his physical exam is normal including clear lungs, no edema and no abdominal tenderness

An EKG is done

Computer Read: NSR at 82, Normal ECG

 

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

  • A) Hyperkalemia
  • B) Hyponatremia
  • C) Acute coronary syndrome
  • D) Hypokalemia

“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) Hyperkalemia – findings not seen.  This is a normal EKG
  • B) Hyponatremia – he had some, but it doesn’t cause EKG changes
  • C) Acute coronary syndrome – EKG can be normal in 10% of ACS, especially after symptoms have resolved or in between episodes
  • D) Hypokalemia – findings not seen

2) EKG analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): This ECG is normal, but remember that one can have a normal ECG in ACS, especially if it is recorded when the patient is symptom free.  Do not convince yourself a patient doesn’t have ACS just because the EKG is normal or for that matter just because the troponin is normal.  Consider all aspects of the presentation and don’t over-focus on test results.  It is safest to enter a patient’s room expecting pitfalls and subtle presentations.  The first question I typically ask of a chest pain patient is if they are currently having pain.  If so I may need to repeat the EKG soon.  The second question is how many minutes the episodes have been lasting.  I go in assuming they last 5-15 minutes and my EKG and troponin will be normal so I don’t miss unstable angina.  If the patient tells me the episode or episodes last hours not minutes, then I use that information appropriately, but I never start off assuming they are having ongoing constant chest pain.

3) Case Conclusion:  Troponin-i was 0.12  (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  Lipase, LFT’s, abdominal US and CBC were normal.  Sodium was 127 likely due to medications.  Serial troponins were all elevated and had a rise and fall consistent with ACS but peaked at only 0.153.  An echo was essentially normal except for a trace pericardial effusion.  An outpatient stress test was recommended by cardiology who felt the troponin elevation was demand ischemia caused by vomiting.   I am skeptical of this since no other cause of vomiting was determined.  It is possible the hyponatremia was worse and was the cause of vomiting.  I think it was more likely that he had a tiny MI.

4) 1-Minute Consult from the Emergency Medicine 1-Minute Consult Website on the topic for this case

CLICK HERE AND SCROLL TO PAGE 25

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5) Case Lessons: You can have ACS with only GI symptoms and with a normal ECG

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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