***Abnormal EKG Unconfirmed*** CONSIDER BRUGADA SYNDROME, Consider Ischemia

EMS crews respond to the report of a sick 70 year old male. An ECG is obtained. As your crew performs patient assessment and works on obtaining IV access, your astute EMT obtains a 12 lead ECG.

1) What's your interpretation ?
2) What is an emergency-focused differential that is consistent with this ECG?
3) Why NOT Brugada ?

12 LEAD ELECTROCARDIOGRAM

First, there is a wavy baseline that interferes with rhythm interpretation. The rhythm is obviously bradycardic and the rate is consistent with a ventricular etiology. The complexes are wide, bizarre, and irregular. There is evidence of ST segment elevation in (possibly) V1 and V2. ST elevation may also be present in Lead II. Diffuse ST segment depression is present in leads I, III, aVF, V5-V6. 

Interpretation

Ventricular rhythm, diffuse ST-T segment depression

Differential diagnosis

Ischemia
Hyperkalemia
Myocardial infarction

Therapy
As this ECG arrived in my inbox without any clinical context, it seems reasonable to consider calcium. In the late stages of hyperkalemia, the QRS can widen considerably and the p waves simply disappear. If the patient presented with a story concerning for ischemia, transport to a cath capable hospital would comprise an excellent treatment plan!

WHY NOT BRUGADA?
The ECG software seems a bit confused by the wandering baseline and the presence of atypical ST segment elevation. Brugada, however, is a curious interpretation because it is a clinically distinct entity that involves specific clinical and electrocardiographic findings. Brugada syndrome was first described in the 1990's. It is the result of an abnormality in the cardiac sodium channel gene. It iis associated with sudden cardiac death in certain patients. The Life in the Fast Lane blog has an excellent (and succint) review of this syndrome.

Brugada syndrome presents commonly following a syncopal episode. The patient may not complain of any chest pain or shortness of breath. The syncope is usually caused by a transient ventricular dysrhythmia. It is most commonly diagnosed in younger aged Asian males.

EKG Findings in The Brugada Syndrome
Atypical ST segment elevation is the hallmark of Brugada syndrome. Typically, there is a "coved" type of ST segment elevation present in leads V1-V3 .Another type of ST segment abnormality seen in the syndrome include a "saddle-back" deformity:

Treatment
Treatment is directed at correction of the underlying defect. Because these patients are at increased risk for death, they will usually benefit from a cardiology referral and consideration of AICD insertion.

Key Brugada points for the EMS provider:

• Brugada syndrome is a clinical entity consisting of distinct ECG and clinical characteristics
• Perform an ECG in ALL patients following a syncopal episode
• Scrutinize the ECG for atypical, "coved" or "saddle back" ST segment abnormalities, especially in the precordial leads

Does this young man really need to go to the hospital?!

Case Study

You are dispatched to a 32-year-old male who experienced a syncopal episode while grocery shopping. Upon arrival, you find an awake, alert, and oriented adult male. He apologizes profusely for disturbing you and tells you he is fine. He denies having chest pain, shortness of breath, or unexplained sweating. He states that he skipped breakfast earlier in the day and had quite a bit of alcohol the night before. You explain the importance of checking his vital signs and blood sugar and he agrees to let you check them. His vital signs are: blood pressure 124/74, pulse 62, respirations 18, SpO₂ 99%, blood sugar 90 mg/dL. His lung sounds are clear, skin cool, dry and pink, abdomen soft and non-tender. Your partner explains the importance of acquiring an ECG and the patient agrees.

12-Lead ECG

§  What is your interpretation?

§  Do you see anything life-threatening?

§  What is your next course of action?

§  Does this patient need to be transported to the hospital?

Case Study Summary

The ECG reveals a sinus rhythm. There are no signs of chamber enlargement, axis deviation, or myocardial ischemia. Close inspection of leads V₁-V₂ reveals an incomplete right bundle branch block (rSR’ pattern), ST segment elevation, and T wave inversion, consistent with Brugada Syndrome.

Brugada Syndrome is a genetic condition involving a sodium channel abnormality in the heart’s cells. The disease causes ventricular tachydysrhythmias that may lead to syncope or sudden death. The disease primarily affects males and is most commonly discovered in the third or fourth decade of life. Brugada Syndrome is reported to cause 5% of all sudden cardiac arrest cases.

This patient should be transported to the emergency department for further evaluation. Treatment for Brugada Syndrome includes electrophysiologic testing and placement of an automated implantable cardioverter-defibrillator.

Clinical Pearls

§  Never dismiss syncope in the prehospital setting.

§  Acquire a 12-Lead ECG on all patients presenting with presyncope or syncope and scrutinize the tracing for changes consistent with life-threatening diseases.

§  Brugada Syndrome is characterized by:

§  An incomplete right bundle branch block (rSR’ pattern in leads V₁-V₂).

§  ST segment elevation in leads V₁-V_2.

§  T wave inversion in leads V₁-V_2.

Suggested Readings

Syncope–http://emedicine.medscape.com/article/811669-overview

Brugada Syndrome–http://emedicine.medscape.com/article/163751-overview