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Challenges in Clinical Electrocardiography
April 13, 2020

Distinguishing Entities on the J Wave Spectrum: Solving a Cold Case

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Division of Cardiology, Department of Medicine, University of California, San Francisco
  • 3Division of Cardiology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
JAMA Intern Med. 2020;180(6):898-899. doi:10.1001/jamainternmed.2020.0790

A man in his 70s with a history of hypertension and alcohol use disorder was brought to the hospital unconscious. He had been last seen in his normal state of health 4 days prior. Before arrival, he was noted to be cold with intact pulses. On arrival to the emergency department, the patient was able to localize pain and open his eyes spontaneously but was only able to make incomprehensible sounds; his Glasgow Coma Scale score was 11. Vital signs were notable for severe hypothermia (25.6 °C by urinary catheter, undetectable by rectal thermometer), bradycardia (heart rate, 40/min), and hypotension (blood pressure, 90/40 mm Hg). Physical examination revealed an older adult man, shivering, diffusely cold with diminished but palpable pulses, and evidence of trauma including ecchymoses on his chest and temple. Aside from bradycardia, findings from the cardiac examination were normal. Initial laboratory workup results were notable for metabolic acidosis (pH, 7.24; reference range, 7.35-7.45), mildly elevated troponin level (0.07 ng/mL; reference range, <0.04 ng/mL), markedly elevated creatine kinase level (6350 U/L; reference range, 38-174 U/L), and elevated creatinine level (2.78 mg/dL; reference range, 0.70-1.30 mg/dL). An electrocardiogram (ECG) was obtained (Figure).

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