Right Ventricle? ECGs....

[fiznat]

The other night I had an 81 year old female complaining of general weakness times 2 days, nausea and vomiting for the same period. She's got a new onset of bilateral hand swelling, also.

History

HX: CABG X 4 (10 years ago), Angio + Stent in the RCA 1/07, IDDM

RX: Couple beta blockers, ASA, Plavix, Insulin and Metformin (both, I know)

NKDA

Assessment:

Lung sounds are clear bilateral, no JVD, no pedal edema but her hands are very swollen. Not quite the mickey mouse gloves but almost. Skin is warm/pale/dry, PEARRL, c-stroke scale is zero. Trauma assessment negative. BGL 210.

She is without complaints of SOB or pain at all. Her vomit has been without heme and she says she hasn't been "feeling like herself lately." "Something is wrong," she says, and she states that she feels "like I am about to leave this earth."

On the ECG is a sinus bradycardia at about 50-55. No ectopy. Here is the 12 lead:

Not too much except for the fancy block and some flipped T waves in some of the inferior leads.

I kind of wanted this lady to be cardiac. She had a fairly good story, she LOOKED cardiac (age, general presentation, etc), and the cardiac history was very significant.

After finding out that it was indeed the RCA that was stented (that she had problems with before), and the presentation of "distal edema in the absence of pulmonary edema," I elect to do a right sided ECG:

Now, it's nothing drastic, I know. ...But there are a lot of flipped T waves. I'm not going to fly off the handle and say that this lady is about to have an RVI and all that, but I bring the patient into the ED and show the ECGs to the doc right away. To be honest I was a little happy with myself for going the extra mile and finding a potential issue on the right side.

The doc pretty much blew it off... Did everything but crumple up the ECG right then and there. He tells me that the right sided ECG was not indicated because there was no ST elevation in the inferior leads, and that the T-wave inversions I did find are "meaningless."

Now, I KNOW that he is wrong about the indication of right sided ECGs based on inferior lead changes alone. No way there HAS to be ST elevations in the inferior leads before we consider doing a non invasive right sided exam. ...Especially in a patient with a history of right sided ACS and a presentation somewhat suggestive of it.

It did get me a little down that he blew off the right sided "ischemia" so quickly though. I was hoping I could get a little insight from the more experienced people here... I know that t-wave inversion isn't exactly cath-lab-activating emergency stuff, but sometimes it is a sign of distress, and I thought I did a good thing in both looking for it and identifying what I saw. ...Or maybe it really does mean nothing?

What do you guys think?

[paramedicmike]

I had a discussion with a couple of ER docs recently regarding right sided 12 leads and suspicion of right ventricular involvement. Basically, what I got from the discussion is that right sided imaging like this is purely academic. A normal 12 lead should give you enough of an image to tell you if there is right sided involvement. Because when you look at a normal 12 lead, those inferior leads are really the right side of the heart. Extra imaging isn't usually going to give you that different a picture than what you already have.

The inverted T waves could be something left over from a previous cardiac event or something else entirely. It's tough to say without having another recent EKG from the patient for comparison...or even without more information on the history provided to you (and then to us).

With all that said, I don't think you were wrong to do what you did. But don't take it personally that the doc dismissed you as readily as you described. It could've been just a bad day for the doc (even docs have a bad day occasionally).

You did what you thought needed to be done based on how the patient presented to you. You were thinking which is always a good thing. In the future maybe press the doc for a little more info? Tough to do at times given the situation in the ER and what else may be going on. But it never hurts to ask for clarification.

Hope this helps.

-be safe

[fiznat]

I had considered that the inverted t waves could be a symptom of her history and not an acute event, but like you said - without a previous ECG to confirm I have to assume it is a recent change.

I dont know, I would have pressed the doc for more info but I feel he probably would have just shut down on me. This doc especially is one of those types to say something and then not have the interest to really explain what he means. Not all that interested in teaching. Not to mention I was a little put off when he said that you should ONLY do a right sided ECG if there are ST elevations in the inferior leads. That is simply not true at all, and I thought that he was saying something like that just to blow me off so I let it be.

Because when you look at a normal 12 lead, those inferior leads are really the right side of the heart.

I dont know if that is completely true. I mean, I know that the inferior leads do look a little bit at the right side of the heart, but not completely by any means. I think that would be like saying that the septal and anterior leads give a complete look at the entire left side of the heart. ...Not exactly true, there is still a lot of muscle that you can't see without the more leftward, lateral leads. Right ventricular hypoperfusion often comes from an occlusion of the RCA, which starts fairly anterior but quickly hides around the right lateral and posterior portion of the heart... areas that you can't see with a left sided 12 lead. I dont know.... just cause it's rare doesn't mean it's academic to look for. Things like this are always "just academic" till you actually find something, then its like "oh shit, well.... good job finding that."

Anyways I do have a technical question actually haha... I was a little unsure about this when doing the ECG. When switching over to the right side from the left, I popped off the leads (leaving the stickers so they would be in the same place) and placed V3-V6 on the right side in the same manner as the left. I wasn't sure about V1 and V2 though-- are you supposed to reverse their positions from the left (so V1 is on the left side of the chest and V2 the right), or leave them be? I reversed them, but I wasn't sure about it. I guess you're still seeing the same views (just in different spots), but the order of them is sometimes important to see proper progression.

[paramedicmike]

Go back to how the heart actually sits in the body. It rests on the right ventricle. The right ventricle is what we see as the inferior wall when we do a standard 12 lead. If there is any right sided involvement you'll see it in the inferior leads on a standard 12 lead. I suppose then, if you were motivated, you could try the right sided image. But it would simply be for the sake of knowledge at that point (not entirely a bad thing, though).

But then that takes us back to the response you got from the ER doc. There was no right sided (i.e. inferior wall) involvement noted on the normal 12 lead so the right sided image probably wasn't indicated. Was it wrong to do? Eh...probably not. But it probably wasn't indicated either.

As for your technical question, to the best of my knowledge you had it right. Just move V3-V6 to their corresponding points on the left side of the chest and take your tracing from there.

Keep in mind, I'm not saying you're wrong. So long as completing the right side didn't detract from treating your patient then why not, right?

-be safe

[UMSTUDENT]

I would say that one thing indicates right-ventricular involvement:

1. R-wave equal to or greater in size than the S-wave in V1.

R/O Right Ventricular Hypertrophy. Bundle Branch Block too...

Pathologic Left Axis Deviation.

Did your patient have a history of Digoxin use?

[fiznat]

I think the RBBB does account for a lot of the R, R' business in V1. Not sure how much evidence there really is for right ventricular hypertrophy, especially when there is a left axis deviation. Normally the axis will deviate towards hypertrophy and away from infarct, no? The LAD probably has more to do with the BBB I think, although in this elderly patient with such a significant history who knows.

[UMSTUDENT]

I think the RBBB does account for a lot of the R, R' business in V1. Not sure how much evidence there really is for right ventricular hypertrophy, especially when there is a left axis deviation. Normally the axis will deviate towards hypertrophy and away from infarct, no? The LAD probably has more to do with the BBB I think, although in this elderly patient with such a significant history who knows.

I agree with your assessment on the R,R' in V1. Good point that I failed to think through.

I guess the next thing to do would be to look at the R-wave progression, which...ugh...I guess is fine. This is the problem with the 12-Lead ECG. So much of it may be irrelevant to your treatment of the patient. Physiologic finger prints...

Nothing substitutes a set of labs. 12-Lead is a good tool for early recognition of STEMI. It has also helped me make some other treatment decisions in the past, but in the end it is one diagnostic tool among many.

[ERDoc]

The only use I've found for a right sided EKG is with evidence of inferior ischemia. If I see ischemia in the inferior leads I will get a right sided EKG (my right sided EKG is with only V4 flipped). If there is elevation when you flip V4 you've got yourself a STEMI. I've picked up several STEMIs this way.

[Echo]

Forget about the Right sided ECG, it's not warranted in this patient. the 12-lead shows a trifascicular block (RBBB, left anterior fascicular block, and 1st degree AV block). The problem is in her conduction system which has three blocks in it. This patient is in need of a pacemker.

[fiznat]

Right.

I donno, like I said earlier, I decided to do a right sided ECG mostly because of the patient's presentation and history- both of which indicated potential red flags about the right side. The left sided ECG had some T wave inversions and (small) ST depressions in the inferior leads, so I thought I might as well do a right sided since I had the time.

I thought I had remembered from class or possibly elsewhere that there is a potential for a patient to have an isolated right sided failure that doesn't show or shows minimally in the inferior leads. This makes sense to me as I think about the anatomy and where the RCA goes. Everyone seems to be saying that this isn't true, so maybe not... In any case, though, I don't think there is anything wrong with doing a quick 2nd non-invasive exam as a zebra rule-out.

The bulk of the question was more about what the right sided ECG actually showed... T wave inversions all across the board. Is this really completely meaningless? Assume we had an old right sided ECG which indicated no t wave inversions and this was a new change. Still meaningless?