ECG of the Week – 8th June 2015 – Interpretation

Two ECG's for this week's case. They are from a 59 yr old female with a history of IHD, prior stents to LAD and non-compliance with anti-platelet therapy. She presented following a bee sting with dysponea, urticaria and a brief episode of chest pain. The ECG's below were performed 20 minutes apart.
Check out the comments on our original post here.

ECG 1 At presentation
Click to enlarge

ECG 2 20 Minutes following 1st ECG
Click to enlarge
Features similar on both ECG's

  • ECG 1 42 bpm
  • ECG 2 60 bpm
  • Sinus Rhythm
  • Sinus Arrhythmia
  • Normal
  • PR - Normal (~180ms)
  • QRS - Normal (100ms)
Key differences between ECG's


  • ECG 1 Flat ST segment elevation leads V2 & V3
  • ECG 1 ST Depression leads II, III
  • ECG 2 Flattening of J point in leads V2 & V3
  • ECG 2 Positive T wave in lead V1 with ST elevation in V1


  • Dynamic ST segment changes
  • DDx:
    • ACS in the setting of physiological stress
    • Kounis Syndrome

What is Kounis Syndrome ?

First described in 1991 by Dr N Kounis, Kounis syndrome is characterized by a group of symptoms that manifest as unstable vasospastic or non-vasospastic angina secondary to a hypersensitivity reaction and was initially termed 'allergic angina'.

There are three types of Kounis syndrome:

  • Type I: Chest pain secondary to coronary artery vasospasm in patients with no previous history of coronary artery disease
  • Type II: Patients with culprit but quiescent pre-existing atheromatous disease in whom the acute release of inflammatory mediators can induce either coronary artery spasm with normal cardiac enzymes and troponins or plaque erosion or rupture manifesting as acute myocardial infarction
  • Type III: Patients with coronary thrombosis (including stent thrombosis) in whom aspirated thrombus demonstrate the presence of eosinophils and mast cells respectively 

Further reading on Kounis Syndrome here:

Thanks to Dr Prathibha Shenoy who educated me about Kounis Syndrome, you can check out Dr Shenoy's Imaging Case of the Week at our sister site Emergucate here.

References / Further Reading
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.


Currently the RAGE Podcast site is recovering from a cold, so here are the show notes for the pre-SMACC mini RAGE episode released June 2015. Here is the podcast And here are the references: SMACC Conference It’s a knockout GoodSAM GoodSAM App Oxygen therapy AVOID: Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction. HOT or […]

How lipid rescue therapy works: it’s more than just a sink

intralipid-161x3003.5 out of 5 stars

Multi-modal contributions to detoxification of acute pharmacotoxicity by a triglyceride micro-emulsion. Fettiplace MR et al. J Control Release 2015 Jan 28;198:62-70


This study, from Guy Weinberg’s lab at the University of Illinois, used a rat model of bupivacaine toxicity, along with and computational analysis, to investigate the mechanisms by which lipid rescue therapy (LRT) might act in treating overdose from local anesthetics and other cardiotoxic drugs.

This is a very complex paper, and I have to admit that I found reading through the experimental protocol rough going. However, the authors findings are important and convincing. The results suggest that — as the title of the paper indicates — there are several modalities that provide benefit:

  1. LRT accelerated removal of drug from cardiac tissue within the first several minutes of administration.
  2. Once the concentration of drug in cardiac tissue was reduced below a certain threshold, lipid emulsion provided a direct inotropic effect.
  3. LRT slowed redistribution of drug from the vascular space into tissues.

In summary, LRT works through both a partitioning phenomenon and cardiotonic activity. The implications for this model on use of LRT — especially at what stage of toxicity it should be administered for optimal effect — remain to be seen.

Related posts:

Intravenous lipid emulsion in oral overdoses: what is the optimal dosing?

Excellent review of lipid rescue therapy

TPR Podcast #7: Interview with Guy Weinberg about lipid rescue therapy

Acute respiratory distress syndrome following intralipid emulsion therapy 

Complications associated with lipid emulsion therapy

Lipid rescue therapy can interfere with critical lab values

Case report: cocaine cardiotoxicity treated with intravenous lipid infusion

Lipid emulsion therapy for poisonings: a review

Lipid emulsion overdose