Usefulness of the Electrocardiogram in a Patient Presenting with Right-Sided Pneumothorax and Presyncope

Figures

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  Figure 1. The electrocardiogram on admission. Voltage expressed in millivolts is displayed under each QRS complex. Phasic variations of the QRS amplitude seen in lead V2 with the minimum voltage (blue arrow) during inspiration and maximum voltage (red arrow) during expiration. Isolated low QRS voltage is seen in lead III (green arrow).

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  Figure 2. Transverse unenhanced chest CT scan revealing a large right-sided pneumothorax (green arrow) with compressive atelectasis of the right lung and emphysematous changes in both lungs (A); multiple bullae due to the underlying emphysema were noted in the left (red arrows) as well as the right lung in addition to the right-sided pneumothorax (B).

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  Figure 3. A 12-lead electrocardiogram recorded after chest tube placement. Isolated very low voltage is still seen in lead III (green arrow).

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  Figure 4. Posteroanterior chest X-ray showing limited expansion of the right lung day 4 after placement of the chest tube.

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  Figure 5. Intraoperatively a perforated bulla (green arrow) was found at the right middle lobe and was treated with bullectomy and talc pleurodesis.

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  Figure 6. Possible mechanism for the phasic changes in QRS complex voltage noted on lead V1 and V2 on the initial 12-lead electrocardiogram. QRS voltages expressed in millivolts are shown under each beat. Both direction and magnitude of change of the QRS voltage are displayed. Red arrows point to an increase in voltage, while blue arrows depict a decrease in voltage. The complex with maximum and minimum voltage is depicted with “Max” and “Min” labels, respectively. The magnitude of change measured as percent change between the complex with minimum voltage and maximum voltage is shown on the right side of the tracing on a yellow label (A); A mechanistic hypothesis that could explain the phasic QRS complex changes. As a consequence of the atelectatic right lung, during inspiration (light blue arrows), the expansion of the left lung displaces the heart towards the right, bringing the septum and apex of the heart more towards lead V1 with an increase in QRS amplitude. During expiration the heart moves in the opposite direction (dark blue arrows). V1–V6 electrocardiographic leads across the precordium (B).