I saw these two cases on the same day.

This patient had a GI bleed and a massive transfusion:

What is it?

This patient had a history of “frozen shoulders,” and had been treated for this elsewhere for quite a while.  He had been seen in the ED 6 days prior for increased shoulder pain, and was referred back to his orthopedic clinic.  He had this ECG recorded because shoulder pain can be a symptom of ACS:

What do you notice?

The first case has a very long ST segment and thus long QT.  This is classic for hypocalcemia; the ionized calcium was 3.0 mEq/L.  This is a common complication of massive transfusion.  One must be vigilant for hypocalcemia.

The second case shows a very short QT with short ST segment.  The computer measured it at 354 ms.   This was a tipoff to hypercalcemia and so we suspected that this patient had cancer as the etiology of his pain.  A chest x-ray (which we were going to get anyway) confirmed a chest mass.  A chest CT confirmed this and also showed otherwise occult spread to the shoulders.  The ionized calcium was 7.32 mg/dL and the total calcium was 15 mg/dL.

Here was the ECG after normalization of Ca in the second (hypercalcemia) case:

The QTc is now 384 ms