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Okonkwo ER, Schuetz C, Hyman B, Samuels B, Sayad D, Bower J. Electrocardiograms Revealing Epsilon Waves Following Use of Hormone Supplements in Young Cardiac Arrest Patient. Cureus 2021; 13:e14305. [PMID: 33968517 PMCID: PMC8098703 DOI: 10.7759/cureus.14305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION An underlying cardiomyopathy should be suspected in young patients presenting with ventricular arrhythmias and sudden cardiac arrest. Electrocardiograms revealing epsilon waves are associated with many serious conditions such as arrhythmogenic right ventricular cardiomyopathy, posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report features epsilon waves in a young cardiac arrest patient suspected of having an unrecognized cardiomyopathy that resulted in a fatal arrhythmia in the setting of exogenous bovine thyroid hormone and steroid use. Case presentation: A previously healthy 33-year-old male with a history of anabolic steroid use and bovine thyroid hormone use presented to the emergency department following witnessed cardiac arrest with bystander cardiopulmonary resuscitation (CPR). Upon emergency medical service (EMS) arrival, the patient was in ventricular fibrillation and received defibrillation with the return of spontaneous circulation. In the emergency department, he was unresponsive and required norepinephrine to maintain blood pressure. An epsilon wave and a prolonged QTc interval were noted on his electrocardiogram (ECG). CT angiogram of the chest and CT head were negative for acute abnormalities. Pertinent laboratory work-up included a lactate level of 12.0 mmol/L, thyroid-stimulating hormone of 0.02 ulU/L, and a free thyroxine level of 0.04 ng/dL. Cardiac ultrasound showed globally decreasedleft ventricular function with an ejection fraction of 25-30% and mild dilation of the right ventricle. A cardiac MRI was ordered but the patient had recurrent ventricular fibrillation and was too unstable to complete. He suffered anoxic brain injury with no improvements in neurologic function and was transitioned to comfort care. The patient died two months later in hospice care. The cause of cardiac arrest was attributed to the patient's steroid and bovine thyroid supplementation, but autopsy results revealed histologic evidence of possible arrhythmogenic right ventricular cardiomyopathy. Discussion: Epsilon waves are widely known to be associated with structural abnormalities of the heart, most notably, arrhythmogenic right ventricular cardiomyopathies. Epsilon waves may be present in a variety of other medical conditions including posterior myocardial infarction, right ventricular infarction, infiltration disease, sarcoidosis, Brugada Syndrome, Tetralogy of Fallot, and hypothermia. This case report describes an epsilon wave found in a patient with suspected arrhythmogenic right ventricular cardiomyopathy that suffered a fatal arrhythmia triggered by bovine thyroid hormone and steroid use.
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Affiliation(s)
- Enola R Okonkwo
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christian Schuetz
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Bryan Hyman
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Brian Samuels
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Dany Sayad
- Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - James Bower
- Cardiology, Sanger Heart & Vascular Institute, Charlotte, USA
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Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Intern Emerg Med 2017; 12:513-518. [PMID: 27300036 DOI: 10.1007/s11739-016-1481-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
There are a number of potential physical advantages to performing orotracheal intubation in an upright position. The objective of this study was to measure the success of intubation of a simulated patient in an upright versus supine position by novice intubators after brief training. This was a cross-over design study in which learners (medical students, physician assistant students, and paramedic students) intubated mannequins in both a supine (head of the bed at 0°) and upright (head of bed elevated at 45°) position. The primary outcome of interest was successful intubation of the trachea. Secondary outcomes included log time to intubation, Cormack-Lehane view obtained, Percent of Glottic Opening score, provider assessment of difficulty, and overall provider satisfaction with the position. There were a total of 126 participants: 34 medical students, 84 physician assistant students, and 8 paramedic students. Successful tracheal intubation was achieved in 114 supine attempts (90.5 %) and 123 upright attempts (97.6 %; P = 0.283). Upright positioning was associated with significantly faster log time to intubation, higher likelihood of achieving Grade I Cormack-Lehane view, higher Percent of Glottic Opening score, lower perceived difficulty, and higher provider satisfaction. A subset of 74 participants had no previous intubation training or experience. For these providers, there was a non-significant trend toward improved intubation success with upright positioning vs supine positioning (98.6 % vs. 87.8 %, P = 0.283). For all secondary outcomes in this group, upright positioning significantly outperformed supine positioning.
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Affiliation(s)
- Joseph S Turner
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA.
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Enola R Okonkwo
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
- Carolinas Medical Center Emergency Medicine Residency, Medical Education Bldg., Third Floor 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Tyler M Stepsis
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Andrew C Stevens
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Christopher S Eddy
- Department of Anesthesia, Indiana University School of Medicine, Fesler Hall Room 204, 1130 West Michigan Street, Indianapolis, IN, 46202-5115, USA
| | - Erik G Sembroski
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
- Southern Illinois University Emergency Medicine Residency, 801 North Rutledge, PO Box 19638, Springfield, IL, 62794-9638, USA
| | - Anthony J Perkins
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor Emergency Medicine Office, Indianapolis, IN, 46202, USA
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