ST Elevation after Stab Wound to the Heart

A young man presented after a stab wound to the chest.  Rapid ED diagnosis of cardiac penetrating trauma was made by ED ultrasound, and the patient went to the OR and had a wound to the right atrium repaired.  There was no laceration of any coronary vessel.  He did well.  Because of tachycardia, this ECG was recorded at day 3:

There is sinus tach with diffuse ST depression, and a bit of ST depression in lead III.  There is PR depression, especially in leads II and V5.  QTc is 383 ms.

This diffuse ST elevation is clearly due to pericarditis, especially given the clinical scenario.  It is slightly unusual, though: The ST vector is directly lateral (highest STE in lead I, with some reciprocal ST depression in lead III).  

[It is unusual to have any ST depression in percarditis, and, if the scenario is one of possible ACS, it would not be wise to assume that diffuse ST elevation is pericarditis without first considering high lateral MI.]

Other ECG factors also support pericarditis: short QTc, significant PR depression, and especially the high ST elevation to T-wave amplitude ratio (in other words, the T-waves are relatively flat, thus non-ischemic).  There is no Spodick’s sign (downsloping TP segment).

2 weeks later, his ECG had evolved:

There is resolution of ST elevation, except in V1-V3, and there is now T-wave inversion in V1-V3.

This looks a lot like a common normal variant, and it may actually be, even if it is not seen on the 4 month ECG below.

4 months after the stab wound, it was all resolved:

2 months later (6 months after the stab wound), he again presented with pain typical of pericarditis:

This is more typical: inferolateral ST elevation (ST vector towards lead II), with no reciprocal ST depression.  PR depression is again present.

He was treated with colchicine and NSAIDs, and discharged.

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