Cardiovascular Disease |

“T”racheal Deviation and T-Wave Changes FREE TO VIEW

Hamid Habibi, MD; Kavitha Bagavathy, MD; Ranjit Joseph, MD; Narayanan Kowgli, MD
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University of Connecticut, Farmington, CT

Chest. 2013;144(4_MeetingAbstracts):147A. doi:10.1378/chest.1705169
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SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Electrocardiographic (ECG) changes have been reported before but remain poorly appreciated by clinicians. We report a case of a right-sided pneumothorax (PTX) in a patient with ECG findings concerning for acute ischemia. Although right sided-pneumothoraces have less specific findings than left-sided ones, clinicians must be of aware of non-cardiac causes ECG changes.

CASE PRESENTATION: A 57 year old male with a history of hypertension, COPD, CAD—s/p CABG presented to an outside hospital with chest pain, hypotension and new ECG findings of ST depressions in leads V2-V5 concerning for a posterior wall MI. He was transferred to our facility for an emergent cardiac catheterization, which revealed patent coronary vessels. Post procedure he was intubated for airway protection. On exam, his BP was 95/65, with oxygen saturation of 98% on 100% FIO2. He appeared tachypnic with decreased breath sounds on the right side and had a right tracheal deviation. His CBC, electrolytes and cardiac biomarkers were unremarkable. A repeat ECG in our facility revealed new T-wave inversions in V1-V3 (Figure 1) and a post intubation chest radiograph showed a large right-sided PTX (Figure 2). He had a chest tube placed with complete right lung re-expansion on repeat imaging. His repeat ECG had resolution of the T-wave inversions.

DISCUSSION: A variety of ECG changes are associated with PTX and in 1928 Walston and Brewer described the first case it. Non-specific ECG changes such as ST segment elevation, ST depression, diminution of R wave amplitude in the precordial leads, and inversion of T waves can be seen with PTX. These changes are reversible and resolve with reexpansion of the lung. Most of the cases reported have been of left sided PTX affecting the ECG. Our case involved a complete right-sided lung collapse with ST depressions and T wave inversions. Some studies have postulated that these findings might be due to transient hypoxia from impaired coronary blood flow. Mediastinal displacement can impair coronary blood flow even more. Others have attributed ECG changes in PTX due to air in the retrosternal space and alternations in the pendular motions of the heart.

CONCLUSIONS: Clinicians must be aware of ECG changes caused by PTX. A complete history and physical exam along with proper diagnostic modalities are crucial in making an accurate diagnosis and preventing therapeutic pitfalls.

Reference #1: Alikhan M, Biddisn JH. Electrocardiographic Changes With Right Sided Pneumothorax. Southern Medical Journal 1998; 91(7):677-680.

Reference #2: Paige GB, Spalding K. Electrocardiographic Changes as the First Indicator of a Right Pneumothorax in an Anesthetized Child. Anesthesiology 1996; 85(5):1200-1202.

Reference #3: Price JP, Novel Electrocardiographic Changes Associated With Iatrogenic Pneumothorax. American Journal of Critical Care 2006; 15(4):415-419.

DISCLOSURE: The following authors have nothing to disclose: Hamid Habibi, Kavitha Bagavathy, Ranjit Joseph, Narayanan Kowgli

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