Every Picture Tells A Story

This 96 year old man was taken to the Emergency Department (ED) after an unwitnessed fall at his Nursing Home. He sustained a lacerated scalp. He is not on any anticoagulant drugs. He suffers from moderate dementia, and has recurrent falls. There is a past history of coronary artery bypass surgery. A brain CT scan did not show any acute injury. The following three pictures tell his story.

Figure 1. Patient's cubicle in the ED showing the bed close to the floor (because of the risk of falls), blood on the pillow (from his un-sutured head laceration) and a wet patch on the bed (due to urine incontinence).

Figure 2 is a supine chest X-ray that shows cardiomegaly, pulmonary congestion and multiple surgical clips that have been placed to mark the course of his coronary artery grafts. This is no longer current practice.

Figure 3 shows the 12 lead ECG of this patient

+ Describe the main ECG findings

  • The atrial rhythm is atrial fibrillation with a ventricular rate of about 60 beats per minute
  • Right bundle branch block and a leftward axis deviation are present
  • There are Q waves in the inferior leads and marked T wave inversion in Lead III and Lead aVF
  • The T wave is upright in Lead V2, and there is a prominent U wave in Leads V2 and V3
  • The QT interval is prolonged (e.g. in Lead V2 it is about 520 msec)
  • There is a S1Q3T3 pattern but there are no other ECG features to suggest pulmonary embolism

Comment: Possible cardiac causes of the collapse in this case include heart block (given the presence of a bifasicular block) or a ventricular arrhythmia (there is a prolonged QT interval and inferior T wave inversion).

The patient had 12 hours of cardiac monitoring in the ED without any arrhythmia or heart block. The laceration was sutured and he went back to his Nursing Home.