A sign of raised ICP

Left arm artefact !!

👆At first glance, the ECG looks scary, it looks like some form of regular wide complex tachycardia (regular WCT), but if you look at lead II, you can see that it is spared (green arrows) and does not show regular WCT. Why?

Let me tell you a little secret about lead II, in fact lead II is the only lead in the ECG that does not need electrical inputs from the left arm electrode, every other ECG lead is dependent directly or indirectly (via Wilson’s central terminal) on left arm electrode except lead II, as lead II is dependent only on the inputs coming from right arm and left leg electrodes.

Therefore, any continuous artefact coming from the left arm will be recorded by all 11 leads except lead II, things like tremor in the left arm can produce an artefact in the ECG that look like regular WCT. Spared lead II is a strong and simple observation that will save a lot of thinking and possibly unnecessary actions.

Another observation that strongly suggests an artefact, is that the amplitude of the waves in the limb leads is much larger than that in the chest leads (normally, cardiac electrical events should be more pronounced in the chest leads as the chest leads are more closer to the heart), it means that the source of these large waves is closer to the limbs compared to the heart (left arm tremor).
The waves in the chest leads are about 1/3 that in bipolar limb leads (lead I, II and III), while the waves in the unipolar limb leads (aVR, aVL, and aVF) are about 2/3 that in lead I, II and III. It means that these waves are not coming from the heart.

Let’s analyse lead II (fortunately lead II is the rhythm strip), you can see that the ventricular rate is around 30bpm, while the atrial rate is around 80bpm, and the P waves are upright (suggesting sinus origin) and regular (red arrows), there is clearly AV dissociation, as there is no relation between atrial and ventricular events, therefore, there is complete AV block, and the QRS complexes are either ventricular escape rhythm or junctional escape rhythm with some form of intrventricular conduction delay (I see slightly wide QRS complexes). I support junctional escape rhythm, as the T waves are concordant with the QRS in lead II. Beat #4 is a PVC.

This patient has Parkinson’s disease, knowing that would make the decision much clear and easier, but I avoided mentioning this important note in the presentation to raise the level of the challenge😁

Thank you for reading, I hope the above helps, I learned this from Dr. Ken Grauer, he kindly explained a similar case for me long time ago.

Ahmed Marai

Additional notes:
▫️Lead III, is the only lead in the ECG that does not depend on electrical inputs coming from right arm electrode
▫️Lead I, is the only lead in the ECG that does not depend on electrical inputs coming from left leg electrode

Why Acute Pyelonephritis is More Common in the Right Kidney?
The uterus is slightly rotated to the right in pregnancy
→ causes more compression on the right ureter
→ which increases urinary stasis on the right side.

the right ovarian vein crosses the right ureter
→ increasing chances of compression.

The anatomical position of the colon
→ The left sigmoid colon protects the left ureter more
→ so the right ureter is more exposed and more easily compressed.

Miscarriage is the spontaneous loss of pregnancy before fetal viability (between 20–24 weeks of gestation

Occurs in 10–15% of clinically recognized pregnancies.
More than 50% of conceptions are lost within the first 14 days after fertilization

Etiology

Mcc in First Trimester Chromosomal abnormalities
• Trisomy 16, 21, 22
• Triploidy
• Monosomy

Uterine causes
• Submucosal fibroid

In Second Trimester
mcc
• Cervical incompetence

Coagulation disorders:
• Antiphospholipid syndrome -> recurrent miscarriage

Threatened Miscarriage
Vaginal bleeding
• Cervical os is closed
• Fetus is viable
Gestational sac

Inevitable Miscarriage
• Vaginal bleeding and uterine pain
• Cervical os is open
• Pregnancy cannot be preserved

Incomplete Miscarriage
• Partial expulsion of products of conception
• Cervical os is open
• Retained products present in the uterus

Complete Miscarriage
• All products of conception are expelled
• Cervical os is closed
• Uterus is empty

Missed Miscarriage
• Fetal death with retention of products inside the uterus
• No bleeding or minimal bleeding
• Cervical os is closed

Diagnosis
Ultrasound (TVS)
Gestational sac appears at 5 weeks
• Yolk sac at 5–6 weeks
• Fetal pole + cardiac activity at 6 weeks
• Used to:
• Confirm viability
• Detect retained products
• Differentiate types of miscarriage

β-hCG
Quantitative β-hCG:
• Should double every 48 hours in normal pregnancy
• Used to:
• Detect non-viable pregnancy
• Help in pregnancy of unknown location

Threatened → Reassure
• Incomplete → Stabilize + Evacuate
• Complete → Reassure only
• Missed → Expectant / Medical / Surgical
• Septic → IV antibiotics + Evacuation immediately
• Recurrent → Treat the cause

Hydatidiform mole is an abnormal form of pregnancy caused by a chromosomal abnormality, resulting in abnormal proliferation of trophoblastic tissue with grape-like vesicles instead of a normal fetus.

Complete Mole :46
The ovum is empty (no maternal DNA).
One or two sperm fertilize it → paternal DNA duplicates.
Result: no fetal tissue, only abnormal placenta.

Ultrasound shows the classic:

Snow-storm appearance,
with no visible fetus

• Vaginal bleeding
• Severe vomiting
• Uterus larger than gestational age
• Very high β-hCG
• Signs of hyperthyroidism
• Early preeclampsia (rare)