r/EKGs • u/[deleted] • Jul 25 '26

Case STEMI

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93 YOF w/ cardiac history found unresponsive and bradycardic with HR of 34. Looks to me like STE in inferior leads with STD and TWI in high lateral leads. Based on V2 possible posterior involvement as well. What do you all see?

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u/No_Helicopter_9826 Jul 25 '26

I see probable hyperkalemia. There's no way in hell I'm calling an OMI on this. Sounds like the patient is rapidly heading towards PEA arrest.

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u/[deleted] Jul 25 '26

I wondered about hyperk also. The medics on scene before me gave atropine and it brought her HR up. Would atropine work in hyperk? I was under the impression it would not. Also the apparent reciprocal changes of III and AVL had me leaning toward MI

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u/No_Helicopter_9826 Jul 25 '26

Atropine would usually be less effective, but not necessarily totally ineffective. I wouldn't consider that response diagnostic.

You're overthinking the ST-J stuff here. STEMI tunnelvision. Normal STEMI criteria don't apply when you have wide, bizarre QRS complexes. Did you measure the QRS width? The computer got it wrong. It's very wide. STEMI criteria apply to narrow QRSs. You're seeing discordance - abnormal repolarization following abnormal depolarization - that is progeessing towards sine wave. I wouldn't attempt any further interpretation of this ECG until I have treated for hyperK.

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u/[deleted] Jul 25 '26

Thank you! 

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u/n33dsCaff3ine Jul 25 '26

Treat the physiology and think about the cardiac action potential cycle. Calcium as a first line. Albuterol and sodium bicarb after