A 42-year-old man is conveyed to the ED via private vehicle with a 1-week history shortness of breath and bilateral leg swelling. Past medical history is negative; he takes no medications. He injects heroin, last 2 hours prior to arrival, and smokes tobacco.
On exam, blood pressure is 112/73 mm Hg, pulse 125 bpm, respirations 20, temperature 35.9. Chest is clear and heart sounds normal. Mild symmetrical pitting edema is noted in both legs up to the knees. Pulses are intact.
Pulse oximetry registers an oxygen saturation of 78% on 5 liters of oxygen per minute via nasal cannulae.
The attached ECG and CxR were obtained. (Click on image to enlarge)
1. Interpret the ECG?
2. List 3 of the most likely diagnoses?
3. What is the most appropriate management for this patient?
The Chest x-ray reflects cardiomegaly. Pulmonary arteries are enlarged and pulmonary vasculature is prominent without cephalization.
ECG shows normal sinus rhythm at a rate of 68bpm. There is low voltage in the QRS of the limb leads (<5 mm in each lead). Right axis deviation is present and that along with a nearly equipotentialed QRS in V1 suggests RV strain or hypertrophy.
Low voltage on the ECG combined with cardiomegaly on chest x-ray should strongly suggest pericardial effusion. The presence of right heart strain and right axis deviation on ECG combined with a low pulse ox and no chest x-ray finding that can explain a large A-a gradient should suggest pulmonary embolism.
Bedside ultrasound confirmed pericardial fluid. CT with contrast showed bilateral segmental PE’s, pericardial effusion, and a large heterogeneous posterior mediastinal mass with areas of necrosis, possibly an esophageal leiomyona.
Heparin and antibiotics were started. The patient was admitted to the MICU. Troponins were 1.13 and 1.24. On the 2nd hospital day, leg doppler ultrasound showed a right common femoral vein non-occlusive thrombus. Blood cultures were negative.
On the 3rd hospital day, the patient signed out AMA. Three months later he has no further medical records at the institution the initially carded for him.
Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department. Topics chosesn are dervied from the EM Model for Resident Education. Cases are prepared by Dr. William Berk.
Filed under: Tracings |