28-year-old obese man presents after syncope and with this EKG. He is hypotensive at 78/46. Thoughts and plans?
His level of hypotension seemed unusual for an acute septal MI, especially in an otherwise fairly healthy young man. He had no chest pain, just some shortness of breath.
78/46 110 28 O2sat 92% on RA afebrile
lungs – clear bilaterally
cor – regular, no murmur appreciated
extremities – no edema, diminished distal pulses
RUSH (Rapid US in Shock) exam revealed a massively dilated right ventricle. When asked about leg pain, he described significant pain in his right calf for 2 days. Ultrasound of the right popliteal area revealed a non-compressible vein with intramural clot. STAT CT angiogram revealed large bilateral pulmonary emboli. This patient received TPA in the ED and has done well.
While PE has no definite EKG findings, it is a great masquerader…it can present with T-wave inversion anteriorly (small or giant T-wave inversion) and with ST-segment elevation on occasion. Keep PE on many differentials, especially when the EKG findings don’t quite fit with the clinical presentation.