I saw these two cases on the same day.
This patient had a GI bleed and a massive transfusion:
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| 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:
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| 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:
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| The QTc is now 384 ms |
Hypocalcemia typically produces the "tent sign" at the end of the desert (ie, relatively normal but prolonged ST segment followed by an otherwise unaffected T wave) – which is precisely what the TOP ECG shows. Hypocalcemia often accompanies hyperkalemia – so that T wave at the end of the long ST may be peaked in renal failure patients with both abnormalities.
ECG-2 is a beautiful example of that short-Q-to-peak-of-T interval seen with hypercalcemia. Having looked for examples of Hypercalcemia on ECG over a period of ~ 3 decades while I was attending (and religiously checking serum Ca++ levels whenever I suspected this finding) – it is not common to see (and be able to recognize) hypercalcemia on ECG in my experience. In those cases in which I could – serum Ca++ levels were almost always quite elevated (ie, ≥13 mg/dL range) – as they were for the above example.
NICE case!
Thanks, Ken!
The T wave is bizarre in the first one like there was a hidden P wave. AVblock?
Olivier,
My inclination is to attribute it to artifact, of which there is quite a bit on this ECG.
Steve
Okay, I am stumped but very curious on how these two cases are related. Can you give any tips, Dr. Smith?
Only that both are related to calcium: hyper- and hypocalcemia.
Thanks for this, very interesting. I got the long QT but not the short.
At what point would you say QTc is pathologically short and check the calcium?
I also thought there are some additional p waves in top tracing, possibly 2:1, but as you say difficult to see with the artifact and no rhythm strip.
The ACC says that any corrected QT less than 390 is short.
http://content.onlinejacc.org/article.aspx?articleid=%201139533
I would guesstimate that one should be particularly worried if less than 375
Steve