This 18 year old presented with syncope and tachycardia.
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| Similar to the last case (the “quiz”), there is sinus tachycardia with precordial T-wave inversion with TW inversion in lead III also. The morphology of these T inversions is highly suggestive, but unlike the previous case, not diagnostic. There is also, arguably, S1Q3T3 depending on whether one considers the S-wave to be “prominent.” There is no right axis deviation, but there is a S-wave. (Does anyone know of a definition of “prominent” S-wave in S1Q3T3?) |
Immediately, a bedside echo was done. Here is the video:
This shows a huge and poorly functional RV.
Here is a still picture from the video:
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| The RV is on the left, the LV on the right (thick-walled). The RV is very enlarged and looks like a “D”. Accordingly, this is called the “D” sign. |
This is diagnostic for pulmonary embolism, which was subsequently proven. Thrombolytic therapy might have been given, but at least partly because of head trauma from syncope, it was not.
I recently saw a patient with Q3T3 but there was no S1. How common is such a presentation?
I don't know. I just spent the last hour trying to find a paper that I know exists that would probably answer your question. I couldn't find it, but emailed the author for a copy.
Here is a great article. The answer is not in there, but worth a read anyway:
Marchick MR, Courtney DM, Kabrhel C, et al. 12-lead ECG findings of pulmonary hypertension occur more frequently in emergency department patients with pulmonary embolism than in patients without pulmonary embolism. Ann Emerg Med;55(4):331-5.