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Spontaneous Reperfusion and Re-occlusion - My Bad Thinking Contributes to a Death

Posted Aug 16 2012 3:36pm
This is a case I had about a decade ago.

This is a 51 year old who was playing cards with his friends when he started to have left hand numbness.  They were worried he was having a stroke and so called 911.  The medics had just learned to do ECGs, and so recorded one.  Here it is, at 1915
Diagnostic of Anterior STEMI.  It cannot be anything else.
I activated the cath lab at 1929 based on this ECG. 

Then, I questioned the patient at length and his only symptom was subjective left hand paresthesias.  He had no pain, discomfort, or tightness of any kind, no weakness, and no SOB.  So I had a hard time believing the ECG.  I thought perhaps it was recorded with lead misplacement.

So I did another ECG at 1931
STE is resolved (but there are de Winter's T-waves in V2 & V3 - hyperacute T-wave with depressed ST takeoff)        [previously published in:  Harrigan (Ed.). The ECG in Emergency Medicine.  Smith SW and Whitwam W.  The ECG in Acute Coronary Syndromes.   EM Clinics of N Am 24(1):53-89; Feb 2006]

With no more overt STEMI, and (through bad thinking and "Nah, couldn't be.") I thought that there must have been some mistake in recording the first ECG.  At worst, if it was a STEMI, I thought that it is reperfused.  I cancelled the cath lab activation for the team that would have to come in from home.   

(Today I would have unequivocally interpreted leads V2 and V3 as LAD occlusion).

At 1942, the patient started becoming hypotensive, so I recorded another ECG at 1946
                                                       Need I say more?  Obvious anterior STEMI.                                                              [previously published in:  Harrigan (Ed.). The ECG in Emergency Medicine.  Smith SW and Whitwam W. The ECG in Acute Coronary Syndromes.   EM Clinics of N Am 24(1):53-89; Feb 2006]

I activated the cath lab again at 1946, so that I had caused a 17 minute delay by cancelling.

He went to the cath lab, had an LAD occlusion, then died just before it could be opened.

I learned 2 major lessons from this
1. STEMI, even if it spontaneously resolves, is very high risk and must go to the cath lab.
2. A clearly diagnostic ECG is diagnostic even if it does not match the symptoms.
  (One cannot make the same conclusion about ECGs that are only highly suspicious - these are more likely to be false positives in the context of atypical symptoms.)

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