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When it comes to ECGs, you know that we highly recommend them for pretty much every single patient. It can be done on any patient from anywhere. You just need to learn how to increase your knowledge on squiggles on a piece of paper. In emergency situations, we may not think that an ECG is important for our TBI or stroke changes, but let me change your mind.
What if I told you that these two 12 leads were caused by a TBI or increased ICP and were not STEMIs or STEMI equivalents?
Increased ICP Changes on an ECG
- Prolonged QT interval
- ST elevation
- T wave inversions
Back To the Case
Now obviously if we had a patient who had a traumatic brain injury, we are going to do a good thorough neurological exam on them and definitely get a CT of their head. But what happens in a non-traumatic patient with the chief complaint of a headache or syncope? Well obviously we always obtain a 12 lead ECG on these kinds of patients. But unfortunately, if you are not familiar with these findings, you could harm your patient.
After seeing these 12 leads, your first knee-jerk reaction is to obtain an angiogram, perform an echocardiogram, and test the troponin to rule out an MI. On the echocardiogram, you may even notice some hypokinesis on the left ventricle. But what if you took a step back and started critically thinking?
Critical Thinking Time!
So if these two examples are caused by a TBI or increased ICP, then why does it present this way on a 12 lead? This comes down to catecholamines. When your brain is extremely stressed out, it may start dumping catecholamines (hormones such as dopamine, epinephrine, and norepinephrine). This may not seem like a big deal but an increased amount of catecholamines can actually cause neurogenic-stunned myocardium. This quite literally means that a neurological issue caused some form of cardiac abnormality. As more catecholamines are dumped onto the heart, the more stressed it becomes (in simple terms). These stressors can cause damage in the subendocardial cells.
If you have read about Takotsubo cardiomyopathy (Broken Heart Syndrome) then you should see a similarity here. The pathos on both of these are pretty similar. Lesions or damage in the brain to certain parts of the brain (especially the insular cortex) can lead to a massive release of norepinephrine which can cause left ventricular dysfunction which might explain why when you obtain an echocardiogram on these patients, hypokinesia can be seen in the septal or left ventricular regions.
So Why is This Important?
We have had “time is brain” drilled into our heads since school. So when a patient comes in with a headache or loss of consciousness, and you obtain a 12 lead, maybe think before administering antiplatelet and anticoagulant medications. Because a brain bleed isn’t exactly the kind of patient you would want to give these to right? And the longer it takes to obtain a CT of the patient, the more damage has been done. This all comes down to obtaining a thorough history and assessment. Most of the myocardial infarctions will present in your stereotypical ways such as chest pain, diaphoresis, shoulder pain, neck pain, etc. Yes I understand that majority of our patients do not read the medical literature, so their symptoms might not be spot on (especially in our female patients).
The decision to send a patient to obtain a CT or immediately start anticoagulants/antiplatelet medications and sending them to the cath lab is quite difficult. But when you do your thorough history and exam, it should help you favor one of the possible diagnosis over the other one. I love playing blackjack which is obviously a gambling game which kind of goes perfectly for this analogy. You are taking a gamble on if the patient is having a bleed or having a myocardial infarction so a 50/50 chance. But what makes a good black jack player/ provider is gathering all of the information and making an educated guess on what move to do next. The collection of all the information will help sway your decision on whether to stand/hit or obtain a CT or an angiogram.
This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place.
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–Scopeducation Team (Matt)
Ali, A., Ahmad, M., Malik, M., Alvi, Z., Iftikhar, W., Kumar, D., . . . Cheema, A. (2018, August 10). Neurogenic Stunned Myocardium: A Literature Review. Retrieved October 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181249/
Hashemian, A., Ahmadi, K., Taherinia, A., Sharifi, M., Ramezani, J., Jazayeri, S., . . . Rahimi-Movaghar, V. (2015, December 13). ECG changes of cardiac origin in elderly patients with traumatic brain injury. Retrieved October 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4764264/
Heo, W., Kang, J., Jeong, W., Jeong, M., Lee, S., Seo, J., & Jo, S. (2012, March). Subarachnoid Hemorrhage Misdiagnosed as an Acute ST Elevation Myocardial Infarction. Retrieved October 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3318097/
Hersch, C. (n.d.). Electrocardiographic Changes in Head Injuries. Retrieved October 12, 2020, from https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.23.6.853