96
Correspondence / American Journal of Emergency Medicine 32 (2014) 86–106
BPPV sufferers commonly present to EDs for help and in most cases do not get the appropriate treatment. In a study comprising 3522 dizzy patients attending the ED only 0.2% were offered a physical maneuver, and even with a confirmed diagnosis of BPPV by Dix-Hallpike maneuver only 3.9% were offered a physical maneuver [15]. These results are comparable to our study with only 4% of our study ED physicians offering a physical maneuver only to manage BPPV. Until now the exact pathophysiology of BPPV was not well understood. BPPV symptoms can resolve spontaneously and in some patients it can last for weeks, months, and even years. There may be other reasons both central and peripheral that contribute to the success of the treatments. Physical maneuvers appear to provide the quickest relief of symptoms. There is a need for prospective, randomized controlled studies that include long term follow-up of BPPV patients as recurrence of symptoms and prolonged disability appear to be common. BPPV sufferers commonly present to EDs, most physicians do not apply this evidence based approach. It is thus recommended that dizziness, in particular BPPV management should be included in the induction for physicians coming to work in ED.
Khalid Bashir FCEM, FRCS Ed, FRCS Glas, DIMC Ed, Dip in Sports med Galal S. Alessai MBChB, CABMS-EM Waleed Awad Salem MBBS, CABMS-EM Furqan B. Irfan MBBS Emergency Department, Hamad General Hospital Doha, Qatar E-mail addresses: [email protected], [email protected], [email protected], [email protected] Peter A. Cameron MBBS, MD, FACEM Hamad Medical Corporation Doha, Qatar E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.10.012
References [1] von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5. [2] Hilton M, Pinder D. The Epley manoeuvre for benign paroxysmal positional vertigo — a systematic review. Clin Otolaryngol Allied Sci 2002;27(6):440–5. [3] Baloh RW, Honrubia V. Childhood onset of benign positional vertigo. Neurology 1998;50(5):1494–6. [4] Dix M, Hallpike C. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341. [5] Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol 1986;15:101. [6] Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope 1997;107:607. [7] Hall SF, Ruby RR, Mclure JA. The mechanism of benign paroxysmal vertigo. J Otolaryngol 1979;8:151. [8] von Brevern M, Lezius F, Tiel-Wilck K, et al. Benign paroxysmal positional vertigo: current status of medical management. Otolaryngol Head Neck Surg 2004;130:381–2. [9] Li JC, Li CJ, Epley J, et al. Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg 2000;122:334. [10] Comparison of three types of self-treatments for posterior canal benign paroxysmal positional vertigo: modified Epley maneuver, modified Semont maneuver and Brandt-Daroff maneuver. Zhang YX, Wu CL, Xiao GR, et al. Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2012 Oct; 47(10):799–803. [11] Frohman EM, Kramer PD, Dewey RB, et al. Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques. Mult Scler 2003;9:250–5. [12] Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;17: 85–100. [13] Hain TC, Yacovino D. Pharmacologic treatment of persons with dizziness. Neurol Clin 2005;23:831–53, vii.
[14] Fujino A, Tokumasu K, Yosio S, et al. Vestibular training for benign paroxysmal positional vertigo. Its efficacy in comparison with antivertigo drugs. Arch Otolaryngol Head Neck Surg 1994;120:497–504. [15] Kerber KA, Burke JF, Skolarus LE, Meurer WJ, et al. Use of BPPV processes in emergency department dizziness presentations: a population-based study. Otolaryngol Head Neck Surg 2013;148(3):425–30.
Does chest radiograph confirm tracheal intubation? To the Editor, The article by Hossain Nejad et al is encouraging in view of their conclusion that in more than 85% cases, emergency physicians are putting the endotracheal tube (ETT) in the appropriate position [1]. The study was based on clinical examination and chest radiography to ascertain the proper position of the endotracheal tube. According to studies clinical examination and chest radiography are not reliable methods to confirm tracheal intubation. Their sensitivity to detect esophageal intubation is also low [2]. According to the American College of Emergency Physicians (ACEP) 2009 and American Heart Association (AHA) 2010 guidelines the most accurate and widely accepted method to know the correct position of the ETT is estimation of end tidal CO2 (ETCO2) detection. The end tidal CO2 estimation is quite accurate in adequately tissue perfused condition [3]. Esophageal detector device can also be used to know ETT position, but they are not as reliable as ETCO2 [4]. Ultrasonography imaging and transthoracic impedance methods are proven useful adjuncts to monitor the proper location of the endotracheal tube. Proper position of ETT under ultrasonography imaging is defined as single A-M interface with Comet-tail artefact [5]. Electric impedance tomography is also emerging as a technique to know the position of the endotracheal tube [6]. This technique is based on the assumption that a ventilated lung will have increased impedance. Therefore, by measuring the impedance over the chest cavity, a discrimination between esophageal and tracheal intubation can be made. Correct position of the endotracheal tube tip is 5 ± 2 cm from carina, when the head and neck are in neutral position. When the carina is not visible, then it can be assumed that the endotracheal tube tip positioned at the level of the T2-T4 level is safe and effective [7]. Optimal depth of ET placement can be estimated by the formula: (height in cm/7) − 2.5. Despite the fact that there are several methods to verify the ETT placement, visualization of vocal cords during laryngoscopy and capnography to estimate ETCO2 is the gold standard for it. Chest radiography is not useful for detecting esophageal intubation as the esophagus lies posterior to the trachea. Furthermore, it is not full proof, for instance, an ETT misplacement rate of 14% with the use of chest radiography has also been reported [8]. So to conclude it could have been a much better study if the author had ruled out esophageal intubation. Nayer Jamshed MD Department of Emergency Medicine All India Institute of Medical Sciences, Ansari Nagar New Delhi, India E-mail address: [email protected] Fouzia F. Ozair MBBS, DO Department of Forensic Medicine Hamdard Institute of Medical Sciences and Research, Hamdard Nagar New Delhi, India E-mail address: [email protected]
Correspondence / American Journal of Emergency Medicine 32 (2014) 86–106
Meera Ekka MD Praveen Aggarwal MD Department of Emergency Medicine All India Institute of Medical Sciences, Ansari Nagar New Delhi, India E-mail addresses: [email protected] [email protected] http://dx.doi.org/10.1016/j.ajem.2013.10.013
by experts [7]. In these cases ECG patterns resembling the Brugada type 2 pattern can be obtained (Fig. 3), despite the absence of the syndrome. It would be interesting to see the ECG obtained 5 minutes after the initial recording, which the authors describe as normal, to evaluate whether the V1-V2 electrodes were placed differently. • It is very important to differentiate Brugada-like patterns from real Brugada patterns [8] because of the serious therapeutic and prognostic implications.
References [1] Hossein-Nejad Hooman, Payandemehr Pooya, Bashiri Sayed Ali. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31:1181–2. [2] Robert Maniscalco WM, Cohen AR, Litman RS, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995;19:262–8. [3] Sutherland PD, Quinn M. Nellcor; Stat Cap differentiates oesophageal from tracheal intubation. Arch Dis Child Fetal Neonatal Ed 1995;73:F184–6. [4] Phelan MP, Ornato JP, Peberdy MA, et al, American Heart Association's Get with the Guidelines-Resuscitation Investigators. Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from inhospital cardiac arrest. Resuscitation 2013 Jan;84(1):31–6. [5] Sağlam C, Unlüer EE, Karagöz A. Confirmation of endotracheal tube position during resuscitation by bedside ultrasonography. Am J Emerg Med 2013 Jan;31(1): 248–50. http://dx.doi.org/10.1016/j.ajem.2012.08.02. [6] Steinmann D, Stahl CA, Minner J, Schuman S, et al. Electrical impedance tomography to confirm correct placement of double-lumen tube: a feasibility study. Br J Anaesth 2008;101(3):411–8. [7] Goodman Lawrence R, Conrardy Peter A, Laing Faye, et al. Radiographic evaluation of endotracheal tube position. Am J Roentgenol 1976;127:433–4. [8] Brunel W, Coleman DL, Schwartz DE. Assessment of routine chest reoentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;96:1043–5.
Type 2 Brugada pattern is suggestive but not diagnostic of the syndrome To the Editor, We have read with great interest the article by Celik [1] et al in the American Journal of Emergency Medicine. The authors present a clinical case report involving a 23-year-old man attended in the emergency department 30 minutes after an episode of syncope. The initial electrocardiogram (ECG) showed rSr′ morphology in the precordial lead V1 and a saddleback pattern in V2, which the authors describe as Brugada type 2 ECG pattern. From this, they conclude that the patient had Brugada syndrome and make much of having obtained this early ECG since no further ECGs showed the patterns which characterize this syndrome [2]. However, this case report raises a number of issues which we would like to clarify:
97
Javier García-Niebla RN Jorge Díaz-Muñoz MD Servicios Sanitarios del Área de Salud de El Hierro Valle del Golfo Health Center Islas Canarias, Spain E-mail address: [email protected] Miquel Fiol MD, PhD Hospital Universitario Son Espases Unidad Coronaria Palma de Mallorca, Spain http://dx.doi.org/10.1016/j.ajem.2013.10.014 References [1] Celik OF, et al. Earliest electrocardiogram is golden for the diagnosis of Brugada Syndrome. Am J Emerg Med 2013 [In press] http://dx.doi.org/10.1016/j.ajem.2013. 07.036. [2] Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70. [3] Brugada R, Brugada J, Antzelevitch C, Kirsch GE, Potenza D, Towbin JA, et al. Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts. Circulation 2000;101:510–5. [4] Bayes de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria of diagnosis for types 1 and 2 Brugada pattern: a consensus report. J Electrocardiol 2012;45:433. [5] Chevallier S, Forclaz A, Tenkorang J, et al. New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block. J Am Coll Cardiol 2011;58:2290. [6] Serra G, Goldwasser D, Capulzini L, et al. New ECG criteria taken from r′ characteristics for differentiate type 2 Brugada pattern from incomplete RBBB in athletes. Abstract accepted to European Congress of Cardiology; 2012. [7] Wenger W, Kligfield P. Variability of precordial electrode placement during routine electrocardiography. J Electrocardiol 1996;29:179–84. [8] Baranchuk A, Nguyen T, Ryu MH, et al. Brugada phenocopy: new terminology and proposed classification. Ann Noninvasive Electrocardiol 2012;17:299–314.
• The initial ECG presenting saddleback morphology is indeed suggestive of Brugada syndrome, but not sufficient. To establish the diagnosis, Brugada type 1 ECG pattern (Fig. 1) must be present, either manifesting spontaneously or after the administration of a sodium channel blocker [3]. • A recent consensus report on electrocardiographic criteria for types 1 and 2 Brugada pattern [4] describes new diagnostic tools to help differentiate them from other similar patterns. Applying these tools to the initial ECG presented by the authors, we measured the α and β angles first described by Chevallier et al [5] as well as the base of the triangle [4,6] as shown in Fig. 2. None of these measurements indicate that the patient had Brugada syndrome (Fig. 2). • V1-V2 electrodes are frequently placed on higher intercostal spaces than recommended, even in ECG recordings performed
Fig. 1. Type 1 (A) and type 2 (B) Brugada electrocardiographic patterns. Only type 1 is diagnostic of Brugada syndrome. Type 2 requires sodium channel blocker administration to reveal the pattern that confirms the diagnosis.
Correspondence / American Journal of Emergency Medicine 32 (2014) 86–106
BPPV sufferers commonly present to EDs for help and in most cases do not get the appropriate treatment. In a study comprising 3522 dizzy patients attending the ED only 0.2% were offered a physical maneuver, and even with a confirmed diagnosis of BPPV by Dix-Hallpike maneuver only 3.9% were offered a physical maneuver [15]. These results are comparable to our study with only 4% of our study ED physicians offering a physical maneuver only to manage BPPV. Until now the exact pathophysiology of BPPV was not well understood. BPPV symptoms can resolve spontaneously and in some patients it can last for weeks, months, and even years. There may be other reasons both central and peripheral that contribute to the success of the treatments. Physical maneuvers appear to provide the quickest relief of symptoms. There is a need for prospective, randomized controlled studies that include long term follow-up of BPPV patients as recurrence of symptoms and prolonged disability appear to be common. BPPV sufferers commonly present to EDs, most physicians do not apply this evidence based approach. It is thus recommended that dizziness, in particular BPPV management should be included in the induction for physicians coming to work in ED.
Khalid Bashir FCEM, FRCS Ed, FRCS Glas, DIMC Ed, Dip in Sports med Galal S. Alessai MBChB, CABMS-EM Waleed Awad Salem MBBS, CABMS-EM Furqan B. Irfan MBBS Emergency Department, Hamad General Hospital Doha, Qatar E-mail addresses: [email protected], [email protected], [email protected], [email protected] Peter A. Cameron MBBS, MD, FACEM Hamad Medical Corporation Doha, Qatar E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.10.012
References [1] von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5. [2] Hilton M, Pinder D. The Epley manoeuvre for benign paroxysmal positional vertigo — a systematic review. Clin Otolaryngol Allied Sci 2002;27(6):440–5. [3] Baloh RW, Honrubia V. Childhood onset of benign positional vertigo. Neurology 1998;50(5):1494–6. [4] Dix M, Hallpike C. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341. [5] Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol 1986;15:101. [6] Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope 1997;107:607. [7] Hall SF, Ruby RR, Mclure JA. The mechanism of benign paroxysmal vertigo. J Otolaryngol 1979;8:151. [8] von Brevern M, Lezius F, Tiel-Wilck K, et al. Benign paroxysmal positional vertigo: current status of medical management. Otolaryngol Head Neck Surg 2004;130:381–2. [9] Li JC, Li CJ, Epley J, et al. Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg 2000;122:334. [10] Comparison of three types of self-treatments for posterior canal benign paroxysmal positional vertigo: modified Epley maneuver, modified Semont maneuver and Brandt-Daroff maneuver. Zhang YX, Wu CL, Xiao GR, et al. Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2012 Oct; 47(10):799–803. [11] Frohman EM, Kramer PD, Dewey RB, et al. Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques. Mult Scler 2003;9:250–5. [12] Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;17: 85–100. [13] Hain TC, Yacovino D. Pharmacologic treatment of persons with dizziness. Neurol Clin 2005;23:831–53, vii.
[14] Fujino A, Tokumasu K, Yosio S, et al. Vestibular training for benign paroxysmal positional vertigo. Its efficacy in comparison with antivertigo drugs. Arch Otolaryngol Head Neck Surg 1994;120:497–504. [15] Kerber KA, Burke JF, Skolarus LE, Meurer WJ, et al. Use of BPPV processes in emergency department dizziness presentations: a population-based study. Otolaryngol Head Neck Surg 2013;148(3):425–30.
Does chest radiograph confirm tracheal intubation? To the Editor, The article by Hossain Nejad et al is encouraging in view of their conclusion that in more than 85% cases, emergency physicians are putting the endotracheal tube (ETT) in the appropriate position [1]. The study was based on clinical examination and chest radiography to ascertain the proper position of the endotracheal tube. According to studies clinical examination and chest radiography are not reliable methods to confirm tracheal intubation. Their sensitivity to detect esophageal intubation is also low [2]. According to the American College of Emergency Physicians (ACEP) 2009 and American Heart Association (AHA) 2010 guidelines the most accurate and widely accepted method to know the correct position of the ETT is estimation of end tidal CO2 (ETCO2) detection. The end tidal CO2 estimation is quite accurate in adequately tissue perfused condition [3]. Esophageal detector device can also be used to know ETT position, but they are not as reliable as ETCO2 [4]. Ultrasonography imaging and transthoracic impedance methods are proven useful adjuncts to monitor the proper location of the endotracheal tube. Proper position of ETT under ultrasonography imaging is defined as single A-M interface with Comet-tail artefact [5]. Electric impedance tomography is also emerging as a technique to know the position of the endotracheal tube [6]. This technique is based on the assumption that a ventilated lung will have increased impedance. Therefore, by measuring the impedance over the chest cavity, a discrimination between esophageal and tracheal intubation can be made. Correct position of the endotracheal tube tip is 5 ± 2 cm from carina, when the head and neck are in neutral position. When the carina is not visible, then it can be assumed that the endotracheal tube tip positioned at the level of the T2-T4 level is safe and effective [7]. Optimal depth of ET placement can be estimated by the formula: (height in cm/7) − 2.5. Despite the fact that there are several methods to verify the ETT placement, visualization of vocal cords during laryngoscopy and capnography to estimate ETCO2 is the gold standard for it. Chest radiography is not useful for detecting esophageal intubation as the esophagus lies posterior to the trachea. Furthermore, it is not full proof, for instance, an ETT misplacement rate of 14% with the use of chest radiography has also been reported [8]. So to conclude it could have been a much better study if the author had ruled out esophageal intubation. Nayer Jamshed MD Department of Emergency Medicine All India Institute of Medical Sciences, Ansari Nagar New Delhi, India E-mail address: [email protected] Fouzia F. Ozair MBBS, DO Department of Forensic Medicine Hamdard Institute of Medical Sciences and Research, Hamdard Nagar New Delhi, India E-mail address: [email protected]
Correspondence / American Journal of Emergency Medicine 32 (2014) 86–106
Meera Ekka MD Praveen Aggarwal MD Department of Emergency Medicine All India Institute of Medical Sciences, Ansari Nagar New Delhi, India E-mail addresses: [email protected] [email protected] http://dx.doi.org/10.1016/j.ajem.2013.10.013
by experts [7]. In these cases ECG patterns resembling the Brugada type 2 pattern can be obtained (Fig. 3), despite the absence of the syndrome. It would be interesting to see the ECG obtained 5 minutes after the initial recording, which the authors describe as normal, to evaluate whether the V1-V2 electrodes were placed differently. • It is very important to differentiate Brugada-like patterns from real Brugada patterns [8] because of the serious therapeutic and prognostic implications.
References [1] Hossein-Nejad Hooman, Payandemehr Pooya, Bashiri Sayed Ali. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31:1181–2. [2] Robert Maniscalco WM, Cohen AR, Litman RS, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995;19:262–8. [3] Sutherland PD, Quinn M. Nellcor; Stat Cap differentiates oesophageal from tracheal intubation. Arch Dis Child Fetal Neonatal Ed 1995;73:F184–6. [4] Phelan MP, Ornato JP, Peberdy MA, et al, American Heart Association's Get with the Guidelines-Resuscitation Investigators. Appropriate documentation of confirmation of endotracheal tube position and relationship to patient outcome from inhospital cardiac arrest. Resuscitation 2013 Jan;84(1):31–6. [5] Sağlam C, Unlüer EE, Karagöz A. Confirmation of endotracheal tube position during resuscitation by bedside ultrasonography. Am J Emerg Med 2013 Jan;31(1): 248–50. http://dx.doi.org/10.1016/j.ajem.2012.08.02. [6] Steinmann D, Stahl CA, Minner J, Schuman S, et al. Electrical impedance tomography to confirm correct placement of double-lumen tube: a feasibility study. Br J Anaesth 2008;101(3):411–8. [7] Goodman Lawrence R, Conrardy Peter A, Laing Faye, et al. Radiographic evaluation of endotracheal tube position. Am J Roentgenol 1976;127:433–4. [8] Brunel W, Coleman DL, Schwartz DE. Assessment of routine chest reoentgenograms and the physical examination to confirm endotracheal tube position. Chest 1989;96:1043–5.
Type 2 Brugada pattern is suggestive but not diagnostic of the syndrome To the Editor, We have read with great interest the article by Celik [1] et al in the American Journal of Emergency Medicine. The authors present a clinical case report involving a 23-year-old man attended in the emergency department 30 minutes after an episode of syncope. The initial electrocardiogram (ECG) showed rSr′ morphology in the precordial lead V1 and a saddleback pattern in V2, which the authors describe as Brugada type 2 ECG pattern. From this, they conclude that the patient had Brugada syndrome and make much of having obtained this early ECG since no further ECGs showed the patterns which characterize this syndrome [2]. However, this case report raises a number of issues which we would like to clarify:
97
Javier García-Niebla RN Jorge Díaz-Muñoz MD Servicios Sanitarios del Área de Salud de El Hierro Valle del Golfo Health Center Islas Canarias, Spain E-mail address: [email protected] Miquel Fiol MD, PhD Hospital Universitario Son Espases Unidad Coronaria Palma de Mallorca, Spain http://dx.doi.org/10.1016/j.ajem.2013.10.014 References [1] Celik OF, et al. Earliest electrocardiogram is golden for the diagnosis of Brugada Syndrome. Am J Emerg Med 2013 [In press] http://dx.doi.org/10.1016/j.ajem.2013. 07.036. [2] Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70. [3] Brugada R, Brugada J, Antzelevitch C, Kirsch GE, Potenza D, Towbin JA, et al. Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts. Circulation 2000;101:510–5. [4] Bayes de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria of diagnosis for types 1 and 2 Brugada pattern: a consensus report. J Electrocardiol 2012;45:433. [5] Chevallier S, Forclaz A, Tenkorang J, et al. New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block. J Am Coll Cardiol 2011;58:2290. [6] Serra G, Goldwasser D, Capulzini L, et al. New ECG criteria taken from r′ characteristics for differentiate type 2 Brugada pattern from incomplete RBBB in athletes. Abstract accepted to European Congress of Cardiology; 2012. [7] Wenger W, Kligfield P. Variability of precordial electrode placement during routine electrocardiography. J Electrocardiol 1996;29:179–84. [8] Baranchuk A, Nguyen T, Ryu MH, et al. Brugada phenocopy: new terminology and proposed classification. Ann Noninvasive Electrocardiol 2012;17:299–314.
• The initial ECG presenting saddleback morphology is indeed suggestive of Brugada syndrome, but not sufficient. To establish the diagnosis, Brugada type 1 ECG pattern (Fig. 1) must be present, either manifesting spontaneously or after the administration of a sodium channel blocker [3]. • A recent consensus report on electrocardiographic criteria for types 1 and 2 Brugada pattern [4] describes new diagnostic tools to help differentiate them from other similar patterns. Applying these tools to the initial ECG presented by the authors, we measured the α and β angles first described by Chevallier et al [5] as well as the base of the triangle [4,6] as shown in Fig. 2. None of these measurements indicate that the patient had Brugada syndrome (Fig. 2). • V1-V2 electrodes are frequently placed on higher intercostal spaces than recommended, even in ECG recordings performed
Fig. 1. Type 1 (A) and type 2 (B) Brugada electrocardiographic patterns. Only type 1 is diagnostic of Brugada syndrome. Type 2 requires sodium channel blocker administration to reveal the pattern that confirms the diagnosis.
