38: She Fell

A 70-year-old female presents to the ED for a wrist injury after a fall.  She states she fell because she lost her balance.  She felt woozy after she fell, but currently she denies any symptoms other than right wrist pain.

Her exam is unremarkable except for a systolic murmur and a mild deformity and tenderness to her right wrist.   Her skin is intact, her compartments soft and distal neurovascular status is within normal limits.  You administer 4mg of morphine IV for pain and initiate a mini-syncope work up because of her age just in case something else is going on.

Her labs including a CBC, metabolic panel and cardiac enzymes are normal except for a white count of 12.3.  A wrist X-ray shows a distal radius fracture, which you splint and sling.  Her EKG is shown below.  What condition or conditions should you be worried about?

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Answer: Lateral ST-Elevation MI

Note the ST-elevation in V4-V6, which was markedly changed from the baseline EKG.  Troponins became positive after 10 hours.

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EXCERPT ON EKG’s & ISCHEMIA

from

CORNUCOPIA EMERGENCY MEDICINE

ISCHEMIA:   delay repol>flip/tall T; Injury>partial depol>ST^; Infarct=silent zone>Q wave
MI Timing:     Peak T(min-hours) > ST^ (<1mm)(reciprocal in 80%)(h-days)(measure 1mm from J) > Q(2h-14h Onset.  U developed by 9h.  Last days.  Permanent in 85%)
(Abnormal Q >=0.04 sec.  Q=>1 box, >25% x in V1, III, R & ?L) > T inversion
Frequency:    ST^-40%, or ST down-75%; or old MI-85%, or NSSTWC-90%, Nl-10%
Pseudo MI:    LVH(strain, poor R, QS), RVH, COPD(Q, poor R progress), PTX(T), PE(inferior or anterior), ICH(ST up/down+large T up or down), HyperK(ST up V1V2 u c short QT), pericarditis
Prinzmental: recurrent & transient ST^ at rest during chest pain w/o ^Trop
LV Aneurysm: leads to: ST^ >1mo, CHF, VT
Badness:     ST^ > dynamic change > ST down > LBBB > paced > old MI > deep/peak T > LVH
Reperfusion:    CP & ST improve/resolve by >70% in <30-90 min (IF NOT NEED RESCUE PTCA)
T wave inversion <4h.  AIVR:90%, PVC, VT:20%, Bradycardia

PITFALLS: Other than a normal EKG, here are some frequent misses  Wellen’s syndrome = Critical LAD stenosis.  EKG: biphasic or deep T waves in V2-V3

T-V1:        A large upright T-wave in V1 is suggestive of acute ischemia, especially if new
Lead AVR:    ST^ can be LAD or Left main disease or PULMONARY EMBOLISM
Inverted T:    A new inverted T-wave may be the earliest or only sign of acute ischemia.
Posterior MI: V1-V3: tall R/rR’/rSR’ or ST depression, peaked upright T waveV6:Q.                   MI & RBBB:   RBBB masks only posterior MI b/c all other MI change mostly initial QRS forces.
MI & LBBB:    Masks b/c it affects initial QRS; 1:Q in I, V5, V6;  2:reversal of R wave progression
(+)EKG:    ST elevation >1mm that is inappropriately concordant with end of QRS: 18/94
ST depression in V1-V3 that is inappropriately concordant with end of QRS: 18/94
ST elevation that is appropriately discordant with end of QRS but is >5mm: 53/88
MI & Pacer:    Most pacers in RV so normal pattern is a LBBB.
Same as LBBB and MI: Beta Blockers are underused (Pacer does not prevent V-Tach)
(Patients with pacers benefit from but are under Rx’d with: ASA, BB, cath)

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