Turkish Journal of Emergency Medicine 17 (2017) 148e150

Contents lists available at ScienceDirect

Turkish Journal of Emergency Medicine

journal homepage: http://www.elsevier.com/locate/TJEM

Typical pericarditis ECG findings after falling from height. The PR

a r t i c l e i n f o a b s t r a c t

Article history: Acute pericarditis (AP) following blunt thoracic trauma is rare and difficult to diagnosis. A 43-year-old
Received 7 March 2017 man with offered to the emergency department (ED) after falling from height before a week ago. The ECG
Received in revised form performed in the ED was abnormal, ECG revealed PR segment depression in leads DII, DIII, aVF, and V3-6
29 April 2017
and a preliminary diagnosis of acute inferolateral STEMI was presumed. Patients have evidence of sys-
Accepted 16 May 2017
temic inflammation, including leukocytosis, elevated erythrocyte sedimentation rate. We are reporting a
Available online 26 May 2017
case of post-traumatic acute pericarditis presenting with PR-segment depression and normal cardiac
enzymes mimicking acute STEMI.
Keywords:
ECG
Copyright © 2017 The Emergency Medicine Association of Turkey. Production and hosting by Elsevier B.V.
Pericarditis on behalf of the Owner. This is an open access article under the CC BY-NC-ND license (http://
Trauma creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2. Case report

Blunt chest trauma can result in severe injuries to the all of the A 43-year-old man with offered to the emergency department
intrathoracic organs. Acutepericarditis (AP) following blunt (ED) afterfalling from height before a week ago. The pneumothorax,
thoracic trauma is rare and difficult to diagnosis. AP is the most a mediastinal shift, lung collapse and pleural effusion was not
common disorder of the pericardium. AP may manifest following observed in the on the posterior-anterior chest radiograph. The ECG
trauma to the pericardium or after iatrogenic causes.1 AP has a rare performed in the ED revealed PR segment depression in leads DII,
clinical presentation, physical findings, and ECG changes. AP has DIII, aVF, and V3-6 derivations (Fig. 1) and a preliminary diagnosis
been noted to occur in as many as 22% of patients after penetrating of acute inferolateral ST-Elevation Myocardial Infarction (STEMI)
cardiac injurybut has also been reported after blunt thorax injury.2 was presumed. Results of laboratory tests were as follows;
The ECG patterns in AP follow a typical evolution as the disease WBC:14.700, sedimentation first hour 80, the first cardiac enzymes
progresses from the acute inflammatory phase through resolution. were normal; Creatin Kinase 50 U/L (normal value 20e200 U/L),
The duration of ECG abnormalities varies with the different etiol- CKMB 30 U/L(normal value 0e25 U/L) and Troponin T High Sensi-
ogies and may proceed from 1 week to months.3 The 12-lead tivity <0.004 ng/ml (normal value < 0.04 ng/ml). Apart from signs
electrocardiogram (ECG), acquired by the clinician for the suspi- of inflammation, laboratory investigations were otherwise normal.
cion for acute coronary syndrome, must be viewed according to the Upon transfer, to the intensive care unit, the patient complained of
clinical situation. The ECG is not the diagnostic test of choice for chest pain, which was presumed to be due to musculoskeletal
evaluating a patient with traumatic heart injury. system trauma. He had no history of cardiovascular disorders, hy-
pertension, dyslipidemia, and positive family history of coronary
artery disease. There was a history of diabetes mellitus and smok-
ing. Blood pressure was 110/70 mmHg, pulse 120 beats/min, and
temperature 37.8  C. Cardiac examination was normal. There was
no pericardial rub. The transthoracic echocardiographic examina-
* Corresponding author. tion showed a normal biventricular systolic function without any
E-mail address: sucu@gantep.edu.tr (M. Sucu). myocardial segmental wall motion abnormalities and pericardial
Peer review under responsibility of The Emergency Medicine Association of effusion. The patient was then taken to the cardiac angiography
Turkey.

http://dx.doi.org/10.1016/j.tjem.2017.05.004
2452-2473/Copyright © 2017 The Emergency Medicine Association of Turkey. Production and hosting by Elsevier B.V. on behalf of the Owner. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 M. Sucu et al. / Turkish Journal of Emergency Medicine 17 (2017) 148e150 149

Fig. 1. Acute pericarditis with diffuse PR-segment depression and concave upwards ST-segment elevation (except V1 and aVR derivations where PR-elevation is noted). PR-
depression and ST-segment elevation with downward sloping TP-segment (Spodick's sign).

laboratory, which showed normal coronary arteries with the the additional ST-segment elevation in DIII, aVL, aVF, and V3eV4
normal coronary flow. He was transferred to the cardiology clinic. derivations were not uncommon. However, in addition to ST-
segment elevation, ST-segment depression may be present. The
PR-segment depression is observed later after the ST-segment
3. Discussion returns to baseline and could be of help in the differential diag-
nosis of ST-segment changes due to bundle branch block, acute
The ECG results were AP, myocardial contusion, stress cardio- STEMI or left ventricular hypertrophy. In patients with AP, PR
myopathy, pneumothorax, intracranial hemorrhage, pulmonary depression can be accepted as a sign of inflammation of the peri-
embolism, aortic dissection, a left ventricular aneurysm, hyper- cardium.7 The major differences of ECG changes in patients with AP
kalemia, or benign early repolarization(4). The ST-segment eleva- and acute STEMI are as follows8;
tion with pneumothorax might be the acute increase in right-sided
cardiac pressures caused by elevated pulmonary vascular resistance 1. ST-segment elevation in APis classically diffuse except aVR and
related to the collapsed lung, leading to right ventricular pressure V1 derivations and is characteristically concave upwards
overload, ischemia, and injury.4 Our patient's lung was not without reciprocal changes differentiating it from ischemic
collapsed and pneumothorax. Blood potassium level was normal,- changes.
Furthermore, electrocardiography excluded of early repolarization. 2. ST-segment elevation in AP is generally 5 mm, but in STEMI ST-
The left ventricular aneurysm was eliminated by echocardiographic elevation is  2 mm in two contiguous derivations.
examination and there were not Q waves on the ECG. Incorrect 3. In the acute phase of the AP, the changes develop gradually
interpretation of the ECG may also affect the rate of missed acute which shows spread of the inflammation of various parts of the
ST-segment elevation myocardial infarction (STEMI) in the ED. The pericardium. AP causes ST-segment elevation in both the limb
ECG is being used blunt trauma patients with chest pain. In the and precordial derivations, differentiating it from characteristic
emergency setting, it is not always easy to differentiate AP from regional changes in STEMI.
acute STEMI based on ECG findings.5 Surawicz et al. described ST- 4. The ratio of the height of the ST-segment junction to the height
segment elevation in 90% of patients in their patients who had of the apex of the T wave of more than 0.25 in DI, V4, V5 and V6
proven AP and they described ST-segment depression in aVR and derivations.
V1 derivations.6 The most common pattern involved ST-segment 5. Pathologic Q waves or atrioventricular block is seen in acute
elevation in derivations DI, DII, and V5eV6, which was present in STEMI.
70% of patients. More involvement that is extensive indicated by
150 M. Sucu et al. / Turkish Journal of Emergency Medicine 17 (2017) 148e150

6. The atrial tissue injury is present with AP which is seen on ECG Conflict of interest
as PR-segment elevation in aVR derivation and PR-segment
depression in other derivations.9 None declared.
7. A down-sloping TP-segment (Spodick's sign) in patients with AP
and this sign is best seen in DII and lateral precordial deriva-
tions. The Spodick's sign may an important distinguishing
electrocardiographictool between the AP and acute STEMI.10 References
8. The ECG of acute STEMI shows prolonged QRS duration and
1. Spodick DH. Pericardial diseases. In: Braunwald E, Zipes DP, Libby P, eds. Heart
shortened QT-interval in leads with ST-segment elevation.11
Disease: A Textbook of Cardiovascular Medicine. sixth ed. Philadelphia: WB
Saunders; 2001:1823e1876.
The patient's ECG demonstrated PR-segment depression in 2. Wiegand L, Zwillich CW. The post-cardiac injury syndrome following blunt
addition to ST-segment elevation, further supporting the diagnosis chest trauma: case report. J Trauma. 1993;34:445e447.
3. Surawicz B, Knilans T. Pericarditis and cardiac surgery. In: Surawicz B,
of AP. This case shows that PR-segment depressions are frequent in Knilans T, eds. Chou's Electrocardiography in Clinical Practice. Philadelphia: WB
the AP and that careful evaluation of the PR segment is a helpful Saunders; 2001:239e255.
means for patients presenting with ST-segment elevations in the 4. Rechenmacher Stephen, Jurewitz Daniel, Southard Jeffrey, Amsterdam Ezra.
Barking up the wrong tree: regional pericarditis mimicking STEMI. Am J Med.
ED. 2013;126(8):679e681.
5. Imazio Massimo, Demichelis Brunella, Cecchi Enrico, et al. Cardiac troponin i in
4. Conclusion acute pericarditis. J Am Coll Cardiol. 2003;42(12):2144e2148.
6. Surawicz B, Lassiter KC. Electrocardiogram in pericarditis. Am J Cardiol.
1970;26:471e474.
The PR-segment depression is a frequent ECG change associated 7. Kudo Yoshihiro, Yamasaki Fumiyasu, Doi Yoshinori, Sugiura Tetsuro. Clinical
with acute pericarditis. We are reporting a case of post-traumatic correlates of pr-segment depression in asymptomatic patients with pericardial
effusion. J Am Coll Cardiol. 2002;39(12):2000e2004.
acute pericarditis presenting with PR-segment depression and 8. Alraies MC, Klein ALQ. Should we still use electrocardiography to diag-
normal cardiac enzymes mimicking acute STEMI. A rapid and ac- nosepericardialdisease? Cleve Clin J Med. 2013;80:97e100.
curate diagnosis and the decision is critical on account of providing 9. Porela Pekka, Kyto € Ville, Nikus Kjell, Eskola Markku, Airaksinen KEJ. PR
depression is useful in the differential diagnosis of myopericarditis and ST
appropriate management and avoid unneeded and harmful
elevation myocardial infarction. Ann Noninvasive Electrocardiol. 2012;17(2):
therapies. 141e145.
10. Makaryus JN, Makaryus AN, Boal B. Spodick's sign. Am J Med. 2008;121:
Funding 693e694.
11. Rossello Xavier, Wiegerinck Rob F, Alguersuari Joan, et al. New electrocardio-
graphic criteria to differentiate acute pericarditis and myocardial infarction. Am
None declared. J Med. 2014;127(3):233e239.