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Barking Up the Wrong Tree

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Barking Up the Wrong Tree: Regional Pericarditis Mimicking STEMI

Treatment of a trauma patient became even more complicated when a postsurgical electrocardiogram (ECG) suggested he was having an ST-segment elevation myocardial infarction (STEMI). A 60-year-old man presented to the emergency department after falling from a tree. He had sustained multiple fractures, spleen and liver injuries, and a left hemopneumothorax. Prior to intubation for emergent exploratory laparotomy and splenectomy, the patient complained of chest pain, which was attributed initially to musculoskeletal trauma. He had no history of cardiovascular disease.

On physical examination the patient was afebrile, his heart rate was 92 beats/min, and his blood pressure was 162/106 mm Hg. He had tenderness to palpation over the left chest. Cardiac auscultation revealed normal heart sounds without murmurs or rub. There was no jugular venous distention, pulmonary rales, or dependent edema. An ECG was not obtained in the emergency department.

Surgery was performed without complications or mention of any intraoperative ST-T changes. However, a postoperative ECG revealed ST-segment elevation in leads II, III, aVF, V5, and V6 (Figure 1). The patient remained intubated and sedated, precluding assessment of symptoms. A prior ECG was not available, and his serum troponin I level was normal (0.04 ng/mL; reference, < 0.05 ng/mL). Because of the evidence of STEMI, he was taken emergently to the cardiac catheterization laboratory for coronary angiography to determine if he was a candidate for myocardial revascularization.

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– Stephen Rechenmacher, MD, Daniel Jurewitz, MD, Jeffrey Southard, MD, Ezra Amsterdam, MD

This article originally appeared in the August 2013 issue of The American Journal of Medicine.

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