ECG of the Week – 20th February 2017 – Interpretation

The following ECG is from a 20 yr old male who was brought to the Emergency Department following a motorbike accident in which he sustained a head injury. 
He has a GCS of 3, BP 160 systolic and divergent pupils.



Click to enlarge


Rate:

  • 96 bpm

Rhythm:

  • Regular
  • Sinus rhythm

Axis:

  • Right axis deviation

Intervals:

  • PR – Normal
  • QRS – Normal

Segments:

  • ST Depression leads II, III, aVL, V3-6
  • ST Elevation aVR & aVL
Additional:
  • Biphasic T wave in leads V3-4

Interpretation:

Remember the ECG is a test that must be taken to the bedside

In a young trauma patient with significant ST segment and T wave changes there are three main considerations:

  • Traumatic Brain Injury causing ECG changes
  • Blunt chest injury causing ECG changes
  • Cardiac event precipitating accident
    • ? Drug ingestion / vasospasm
    • ? Coronary dissection

In this patient there was no suspicion of a proceeding medical event precipitating the event and no evidence of blunt chest injury including clinical features, plain imaging and bedside USS assessment. The patient had sustained an isolated catastrophic head injury which was unfortunately unsurvivable.

Blunt Cardiac Injury

The American Association for the Surgery of Trauma has a very nice overview of blunt cardiac injury here:

ECG Changes Associated with Neurological Pathology

ECG changes are well described in the setting of neurological pathology, especially subarachnoid haemorrhage. but can occur in traumatic brain injury. There following is a nice overview of pathophysiology and outcome effects of cardiovascular abnormalities associated with brain injury:


References / Further Reading

Life in the Fast Lane

Textbook

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

ECG of the Week – 20th February 2017 – Interpretation

The following ECG is from a 20 yr old male who was brought to the Emergency Department following a motorbike accident in which he sustained a head injury. 
He has a GCS of 3, BP 160 systolic and divergent pupils.



Click to enlarge


Rate:

  • 96 bpm

Rhythm:

  • Regular
  • Sinus rhythm

Axis:

  • Right axis deviation

Intervals:

  • PR – Normal
  • QRS – Normal

Segments:

  • ST Depression leads II, III, aVL, V3-6
  • ST Elevation aVR & aVL
Additional:
  • Biphasic T wave in leads V3-4

Interpretation:

Remember the ECG is a test that must be taken to the bedside

In a young trauma patient with significant ST segment and T wave changes there are three main considerations:

  • Traumatic Brain Injury causing ECG changes
  • Blunt chest injury causing ECG changes
  • Cardiac event precipitating accident
    • ? Drug ingestion / vasospasm
    • ? Coronary dissection

In this patient there was no suspicion of a proceeding medical event precipitating the event and no evidence of blunt chest injury including clinical features, plain imaging and bedside USS assessment. The patient had sustained an isolated catastrophic head injury which was unfortunately unsurvivable.

Blunt Cardiac Injury

The American Association for the Surgery of Trauma has a very nice overview of blunt cardiac injury here:

ECG Changes Associated with Neurological Pathology

ECG changes are well described in the setting of neurological pathology, especially subarachnoid haemorrhage. but can occur in traumatic brain injury. There following is a nice overview of pathophysiology and outcome effects of cardiovascular abnormalities associated with brain injury:


References / Further Reading

Life in the Fast Lane

Textbook

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

ECG of the Week – 20th February 2017 – Interpretation

The following ECG is from a 20 yr old male who was brought to the Emergency Department following a motorbike accident in which he sustained a head injury. 
He has a GCS of 3, BP 160 systolic and divergent pupils.



Click to enlarge



Rate:
  • 96 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Right axis deviation
Intervals:
  • PR - Normal
  • QRS - Normal
Segments:
  • ST Depression leads II, III, aVL, V3-6
  • ST Elevation aVR & aVL
Additional:
  • Biphasic T wave in leads V3-4
Interpretation:

Remember the ECG is a test that must be taken to the bedside

In a young trauma patient with significant ST segment and T wave changes there are three main considerations:

  • Traumatic Brain Injury causing ECG changes
  • Blunt chest injury causing ECG changes
  • Cardiac event precipitating accident
    • ? Drug ingestion / vasospasm
    • ? Coronary dissection

In this patient there was no suspicion of a proceeding medical event precipitating the event and no evidence of blunt chest injury including clinical features, plain imaging and bedside USS assessment. The patient had sustained an isolated catastrophic head injury which was unfortunately unsurvivable.

Blunt Cardiac Injury

The American Association for the Surgery of Trauma has a very nice overview of blunt cardiac injury here:


ECG Changes Associated with Neurological Pathology

ECG changes are well described in the setting of neurological pathology, especially subarachnoid haemorrhage. but can occur in traumatic brain injury. There following is a nice overview of pathophysiology and outcome effects of cardiovascular abnormalities associated with brain injury:



References / Further Reading

Life in the Fast Lane

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

REMI 2200. Control estricto de la glucemia en niños en estado crítico

ARTÍCULO ORIGINAL: Tight Glycemic Control in Critically Ill Children. Agus MS, Wypij D, Hirshberg EL, Srinivasan V, Faustino EV, Luckett PM, Alexander JL, Asaro LA, Curley MA, Steil GM, Nadkarni VM; HALF-PINT Study Investigators and the PALISI Network. N Engl J Med. 2017 Jan 24. doi: 10.1056/NEJMoa1612348. [Resumen] [Artículos relacionados] [Texto completo]
   
INTRODUCCIÓN: La presencia de hiperglucemia sobre todo si es mantenida se asocia a un peor pronóstico en el paciente crítico, tanto en adultos como en niños. Un estudio en adultos encontró que un tratamiento intensivo dirigido a mantener cifras normales de la glucemia se asociaba a un mejor pronóstico. Sin embargo, estudios posteriores no confirmaron estos hallazgos y encontraron una mayor incidencia de hipoglucemia en los pacientes con tratamiento intensivo. Existen pocos estudios que hayan analizado el efecto del tratamiento intensivo de la glucemia en niños en estado crítico [1, 2].
  
RESUMEN: Se realizó un estudio prospectivo multicéntrico aleatorizado en el que se incluyeron 713 niños en estado crítico de edades entre 15 días y 17 años con hiperglucemia mayor de 130 mg/dl (excluyendo el postoperatorio de cirugía cardiaca). 360 pacientes fueron aleatorizados al grupo de glucemia baja, cuyo objetivo era mantener unos valores de glucemia entre 80 y 110 mg/dl y 353 al grupo de glucemia alta, cuyo objetivo era mantener unos valores entre 150 a 180 mg/dl. Los pacientes recibieron tratamiento con perfusión de insulina y se realizó un control continuo de la glucemia. No existieron diferencias en la mortalidad, la duración del ingreso en la UCIP, la duración de la ventilación mecánica ni el fallo de órganos entre los dos grupos. La glucemia fue significativamente menor en el grupo de bajo valor de glucemia. En el grupo de glucemia baja la incidencia de infecciones fue significativamente más alta 3,4% frente a 1,1% (P = 0,04) y también la incidencia de hipoglucemia grave (menor de 40 mg/dl): 5,2 % frente a 2 % (P = 0,03).
   
COMENTARIO: Los resultados de este estudio en niños confirman los de los estudios en adultos y muestran que el tratamiento intensivo con insulina no mejora el pronóstico de los pacientes críticos y aumenta el riesgo de complicaciones. Por tanto, una cosa es que la presencia de una hiperglucemia mantenida sea un indicador de gravedad y de mal pronóstico en el paciente crítico y otra que el tratamiento intensivo con objetivo de alcanzar la normoglucemia sea beneficiosa. No sabemos cuál es el objetivo más adecuado de glucemia en el paciente crítico. Para averiguarlo serían necesarios estudios que compararan el tratamiento con objetivos moderados (150 a 180 mg/dl) frente al no tratamiento, pero ese tipo de estudios son complicados de realizar porque pocos profesionales sanitarios estarían de acuerdo en no tratar a los pacientes con valores muy elevados de glucemia. 
   
Jesús López-Herce Cid
Hospital Universitario Gregorio Marañón, Madrid.
© REMI, http://medicina-intensiva.com. Febrero 2017.
      
ENLACES:
  1. A randomized trial of hyperglycemic control in pediatric intensive care. Macrae D, Grieve R, Allen E, Sadique Z, Morris K, Pappachan J, Parslow R, Tasker RC, Elbourne D; CHiP Investigators. N Engl J Med. 2014 Jan 9;370(2):107-18. [PubMed]
  2. Tight glycemic control versus standard care after pediatric cardiac surgery. Agus MS, Steil GM, Wypij D, Costello JM, Laussen PC, Langer M, Alexander JL, Scoppettuolo LA, Pigula FA, Charpie JR, Ohye RG, Gaies MG; SPECS Study Investigators. N Engl J Med. 2012 Sep 27;367(13):1208-19. [PubMed]

BÚSQUEDA EN PUBMED:
  • Enunciado: Control de la glucemia en niños en estado crítico
  • Sintaxis: Glycemic Control Critically Ill Children
  • [Resultados]