Case # 4: Palpitations
A 25 year old woman presents with palpitations, sweating, and shortness of breath since this morning. 6 days ago she had syncopized, was shocked out of V-tach by EMS, and eventually had a defibrillator placed for an unknown arrhythmia. Now, she feels her heart beating in her chest, looks diaphoretic, is tachypnic, but her pulse is 58 and regular.
I looked on the monitor and she was beating away at about 60 bpm and it looked normal sinus rhythm. An EKG showed this:
I opened the Paucis Verbis card about Brugada by Michelle Lin on Academic Life in EM on my iPad and saw this:
I called the electrophysiologist, and I sent the EKG to his phone. I told him that I thought she had Brugada syndrome, and he told me it was something close, but not quite – because in V2 the J-point is not > 2mm. The patient would be fine because she already had the AICD placed. Some ativan, reassurance, and encouragment to call her insurance company to inquire about her outpatient mental health benefits fixed the problem. You’d be anxious too if you literally died earlier that week.
I went home after the shift and opened Dr. Smith’s EKG Blog, searched Brugada and learned that the pattern could be unmasked by common occurances like fever, cocaine, propofol, and lidocaine. “Get this patient some Tylenol. We need to break his fever, STAT” I imagined myself saying next time I had a saddle-back with fever.
Brugada has a high incidence of sudden cardiac death. Although this was not a true Brugada, this patient who had an EKG that sure looked a lot like Brugada had suffered from sudden cardiac death. I’ll leave the specific rules of diagnosing Brugada to the cardiologists – the saddleback is my can’t miss diagnosis.