What Do You Think 63

Phillip sent me this ECG from the Royal Melbourne Hospital.

Thanks Phillip.

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22-year old unconscious inebriated male involved in a motorcycle accident.

Widespread trauma including cranium and sternum.  

Pre-operative ECG requested by anaesthetist, whilst awaiting urgent neurosurgery.

What do you think?

The poor R waves and ST elevation in the chest leads (red highlight) could be  interpreted as within normal limits or early repolarization in a young male. There is reciprocal ST depression in lead III(yellow highlight) which should alert the reporter to possible myocardial ischaemia/infarction. The most striking feature, however, is the prominent tall symmetrical peaked T waves in the same leads as the ST elevation (red highlight). These are hyperacute T waves seen very early with an acute myocardial infarction. This feature is rarely commented upon  because it is very transient and already resolving as other more visually apparent diagnostic features on the initialECG, such as ST elevation and Q waves, begin to emerge.

Those who report 12-lead ECGs are familiar with the auto-interpretive diagnosis regarding tall T waves as being “suggestive of acute ischaemia”. As an isolated feature, the diagnosis cannot be made unless there is a history of chest pain or at least other early changes as seen on our ECG and in particular, the reciprocal changes.

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Another example of hyperacute T waves (red highlight).

Smaller T waves can still be regarded as hyperacute, provided they are relatively large in relation to its accompanying R wave.

Two-days later, the 12-leadECG revealed extensive anterior transmural ST elevation myocardial infarction(yellow highlight) due to trauma to the left anterior descending coronary artery. The transient hyperacute T wave changes were localized to the site of the infarction

Did I hear someone suggest that these early changes may be related to intracranial trauma?

Marked changes on the 12-leadECG may occur as a result of severe acute cerebral trauma and in particular cerebrovascular accidents and cranial injuries. Reported ECG changes include:

• Wide spread marked T wave inversion called giant or cerebral T waves (red highlight).

• Prolonged QT interval.
• Increased U wave amplitude.
• Sinus bradycardia is one of the signs of the Cushing triad (also increased systolic blood pressure, reduced or erratic respiration) and is a warning of increasing intracerebral pressure and impending brainstem herniation.

The incidence of the ECG changes with severe cerebral trauma varies considerably in the literature with deep inverted T waves being the most common. ST elevation is very rare. Other rhythm disturbances include sinus tachycardia and ventricular ectopy. The findings are transient with the mechanism related to the sympathetic nervous system. Acute gall bladder and biliary disease can cause bradycardia and non-specific ST/T wave changes also related to heightened vagal tone.

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Harry Mond