Missed PE, patient died

[u/Repulsive_Knee1304]

Throwaway account as to be expected.

I had a younger obese smoker male patient come in recently for shortness of breath that was exertional in nature, he said it started after he recently started working out. Patient was a smoker, 1/2 pack a day. SOB Resolved upon rest. patient states that he was carrying some heavy containers at work today, and noticed the shortness of breath again. No chest pain. No diaphoreses . No fever. No lower extremity swelling. No recent uri. Perc negative. Low pretest probability. Physical exam was significant for an expiratory wheeze, diminished sounds at bases. Patient got Breathing treatments, steroids and felt better. Reexamination showed improved aerations. Patient was discharged on steroids, albuterol. EKG NSR rate of 74, t wave inversions in v1-v3. No inversion in lead 3. No st changes. Cxr portable showed poor inspiratory effort, cardiomegaly( rotational?) but read as normal by radiologist and myself. Completely stable vitals. O2 sat of 95%, no tachy. No chest pain. Sob got better. Perc negative. Patient died at home 2 days later. Someone said PE. My guilt is consuming me. How fucked am i

EKG- S1,small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. Upright axis V1-v3 t wave inversions. No previous to compare to

[u/memedoc314]

Can you share more about your thoughts on EKG findings?

[u/Repulsive_Knee1304 → u/memedoc314]

S1, small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. V1-v3 t wave inversions.

[u/tablesplease → u/Repulsive_Knee1304]

I read a recent medmal case of a kid dx with covid who died of a pe a few weeks after ama? The selling point was t wave inversions in the anterior leads. Something I need to read more about.

[u/NeisAEL → u/tablesplease]

Now I'm just a medic, bear with me.

AFAIK Precordial t wave inversions, esp v1-v4, can be signs of right ventricular strain associated with high pulmonary artery pressures, according to LITFL.

Ive never had a prehospital PE patient with abnormal ECG findings so I don't know how sensitive/specific these findings are. If I see patients with SOB and precordial t wave abnormalities I always try to rule out PE as best as I can. Maybe someone with a higher degree can clarify how sensible that sounds

[u/thatlooksinfected_ → u/NeisAEL]

Yes agreed. As a Paramedic every confirmed PE patient I’ve seen had none of the noted EKG changes apart from sinus tachycardia

[u/B52fortheCrazies → u/thatlooksinfected_]

Agreed. In residency they would always remind us the most common EKG in PE is NSR (> 50%). The second most common is sinus tach and/or non-specific S-T changes (40% - 50%). The s1q3t3 and the precordial TWI are only ~30%.

[u/Repulsive_Knee1304 → u/tablesplease]

That Patient had twi in iii and v1-v3, plus precordial chest pain