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Syncope & SOB

UnFiNiShEd CaSe CoMe BaCk LaTeR

History:  A woman in her mid twenties presents to the ER with dyspnea and palpitations followed by a syncopal episode.  She denies chest pain, fever, cough or other complaints.  She denies any significant past medical history.

Exam: Vital signs are normal except for a pulse around 130 and a BP around 105.

An EKG is done

What is the most likely cause of the EKG findings?

  • A) SVT
  • B) Pulmonary embolism
  • C) Anxiety
  • D) Hypocalcemia

“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) SVT: the rate is close to 150 but there appear to be P waves although they are harder to see due to the tachycardia.
  • B) Pulmonary embolism: CORRECT.  PE is painless in about 20% of cases and is even more common in larger PE’s likely due to their more central location.  This EKG shows tachycardia, S1Q3 and nonspecific ST changes.
  • C) Anxiety: can cause SOB but less likely to cause syncope or a BP this low.  In the ED population, diagnose anxiety only after you are confident that nothing more serious could be going on, if ever.
  • D) Hypocalcemia: not likely to present this way

2) EKG/Echo analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog):

3) Case Conclusion:  CT angio was positive for saddle PE

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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