A previously healthy young patient presents to the ED with sudden onset headache followed by progressive and profound altered mental status. You rush them to radiology for a head CT, which shows a large subarachnoid hemorrhage. Upon return from the CT scan, your nurse runs up to you with the patient’s EKG taken just before leaving to the scan, which shows wide, deep T-wave inversions in II, III, avF, and V1-V6. None of these changes were seen on a previous EKG from one year ago.
In addition to standard care of this severely ill patient, should you be calling CPORT? What’s going on?
Increased ICP secondary to massive intracranial hemorrhage may cause significant changes to a patient’s EKG, including ST changes, T-wave inversions, QT prolongation, and Q waves.
While non-specific ST/T waves changes and QTc prolongation were independently associated with increased in-hospital mortality in the setting of SAH, the above-mentioned changes have been shown to resolve with normalization of ICP.
In a critically ill patient, never write off EKG changes. However, be aware that your scary EKG might not be due to a primarily cardiac etiology.
See this great post at LITFL for some example EKGs: http://lifeinthefastlane.com/ecg-library/raised-intracranial-pressure/
- Bhattacharya I, Sandeman D, Dweck M, McKie S, Francis M. Electrocardiographic abnormalities in a patient with subarachnoid haemorrhage. BMJ Case Rep. 2011 Feb 17;2011. pii: bcr0820103253. doi: 10.1136/bcr.08.2010.3253.
- Huang CC, Huang CH, Kuo HY, Chan CM, Chen JH, Chen WL. The 12-lead electrocardiogram in patients with subarachnoid hemorrhage: early risk prognostication. Am J Emerg Med. 2012 Jun;30(5):732-6. Epub 2011 Jun 8.
- van Bree MD, Roos YB, van der Bilt IA, Wilde AA, Sprengers ME, de Gans K, Vergouwen MD. Prevalence and characterization of ECG abnormalities after intracerebral hemorrhage. Neurocrit Care. 2010 Feb;12(1):50-5.