ST Depression and T-wave Inversions after ROSC from Resp and Cardiac Arrest after Head Trauma

This patient had a head injury and was unconscious.  He was found without respirations or pulse.  Prehospital CPR resulted in ROSC.  He remained comatose.

Here is his initial ED ECG:

What do you think?

There is sinus rhythm at a rate of about 75.  There is ST depression in right precordial leads, with deep T-wave inversions.  This is what catches the eye.

What SHOULD catch your eye?

Whenever there is abnormal repolarization (abnormal ST segments and T-waves), the FIRST thing you should do it look for abnormal depolarization.

In fact, don’t even get distracted by ST-T waves!  Even before you look at them, look at the QRS.

Is it normal?  Abnormal?  Is there an abnormal axis?  Abnormal voltage?  Abnormal R-wave progression in precordial leads?   Abnormal Q-waves?  RBBB?  LBBB?  Etc.

You should read the ECG systematically!

Look for:

Rhythm, rate
P waves
PR interval  
QRS Duration (IVCD? RBBB? LBBB? Paced?)
QRS Axis 
Abnormal Q waves
R-wave progression

Only then do you look at:

ST segments
T wave axis (inversion?)
Size of T-waves, whether upright or inverted
QT interval

Only THEN should you look at the ST-T.

But let’s be realistic!!

Realistically, our eyes are drawn to the ST-T.  We can’t help ourselves.

Therefore, we have to be aware that the ST-T is dependent on the QRS.

In this case, there is a deep S-wave in lead I.  There is right axis deviation.

Whenever there is a right axis, you should think about right ventricular hypertrophy.  (There is also large voltage consistent with LVH.)

How would you verify that??

Look at the R-wave in V1.  If is it abnormally large, you have RVH until proven otherwise.

So I looked for it and, lo and behold, there it is!  A large R-wave in V1.

Now it is useful to know that these ST-T morphologies are CLASSIC for RVH.

I knew immediately that all of this was due to chronic RVH with secondary ST-T abnormalities.  I was not concerned for ischemia at all.

In other words, all these findings were old and had nothing to do with the patient’s present condition.

Later, it was confirmed from outside records that this patient has pulmonary hypertension from Eisenmenger’s syndrome.


One might think that these are central nervous system T-waves, but they are not.  Here are some examples of CNS T-waves:

Bizarre T-wave Inversions in a Patient without Chest Pain

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