Osborn waves in a hypothermic patient

Sami W. Serafi, Crystal Vliek, Mehnaz Taremi
Osborn waves in a hypothermic patient

ORIGINAL ARTICLE

Osborn waves in a hypothermic patient

Sami W. Serafi, BA1*, Crystal Vliek, MD2 and Mahnaz Taremi, MD3

1Union Memorial Hospital, American University of Antigua, Baltimore, MD, USA; 2Union Memorial Hospital, Department of Cardiology, Baltimore, MD, USA; 3Union Memorial Hospital, Department of Medicine, Baltimore, MD, USA

Received: 11 October 2011; Revised: 15 November 2011; Accepted: 28 November 2011; Published: 26 January 2012

Citation: Journal of Community Hospital Internal Medicine Perspectives 2011, 1: 10742 - DOI: 10.3402/jchimp.v1i4.10742

Journal of Community Hospital Internal Medicine Perspectives 2011. © 2011 Sami W. Serafi et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

A 56-year-old man presented with hypothermia (rectal temperature of 30.1°C) and hypotension after being found by emergency medical services (EMS) on his basement floor. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with a rate of 62 bpm, right bundle branch block, prolonged QT interval (QTc of 564 ms), wide QRS (110 ms), and a prominent J wave in the precordial leads (Fig. 1). After the patient was warmed to a normal core body temperature, hydrated, and made normotensive, repeat ECG showed a normal sinus rhythm of 79 bpm, right bundle branch block, prolonged QT (QTc of 488), and resolution of the J waves (Fig. 2).


Fig 1

Fig. 1.  Osborn waves on admission ECG can be seen clearly in the precordial leads. Arrows point to Osborn waves.


Fig 2

Fig. 2.  Osborn waves resolved 48 hours after admission.

The J wave is also known as an Osborn wave, camel-hump sign, late delta wave, hathook junction, and hypothermic wave (1). The prominent J deflection attributed to hypothermia was first reported in 1938 by Tomaszewski. Over time, the wave has increasingly been referred to as an Osborn wave, in most part due to Osborn's 1953 article in the American Journal of Physiology on experimental hypothermia (2).

An Osborn wave is characterized as an extra deflection of the terminal junction of the QRS complex and the start of the ST segment (3). Typically, the deflection at the J point is in the same direction as that of the QRS complex (4). It is more commonly observed in leads II, III, AVF, V5, and V6. The J wave disappears with normothermia (5). This deflection has been attributed to delayed depolarization, to a current of injury, or to early repolarization. In leads that face the left ventricle, the deflection is positive and its size is inversely related to body temperature (6). The earliest morphologic abnormality in patients with mild hypothermia is a tremor artifact due to the shiver response. This is non-specific and becomes uncommon at core body temperatures less than 32°C as the body's ability to generate a shiver response diminishes. As core body temperature approaches moderate hypothermia, we find the appearance of the J waves. J waves can be considered highly suggestive of hypothermia but are not considered to be pathognomonic (3). Conditions other than hypothermia have been reported to cause an abnormal J wave deflection such as hypercalcemia, brain injury, subarachnoid hemorrhage, damage to sympathetic nerves in the neck, and cardiopulmonary arrest from oversedation (2). A deflection similar to the J wave is also present in patients with Brugada syndrome (7). J waves have no relationship to pH, sodium, potassium, or chloride concentrations (3).

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

References

  1. Aydin M, Gursurer M, Bayraktaroglu T, Eyup Kulah, Onuk T. Prominent J Wave (Osborn Wave) with coincidental hypothermia in a 64-year-old woman. Texas Heart Insti J 2005; 32(1): 105.
  2. Hurst JW. Naming of the waves in the ECG, with a brief account of their genesis. Circul J Ameri Heart Assoc 1998; 98: 1937–42.
  3. Brady WJ, Jonathon DT. Critical decisions in emergency and acute care electrocardiography, 1st ed. Hoboken, USA: Wiley-Blackwell; 2009, p. 381–2.
  4. Wagner GS. Marriott's practical electrocardiography,10th ed. Philadelphia: Lippincott Williams & Wilkins; 2001, p. 221.
  5. Topol EJ, Robert MC, Eric NP, Jeffrey MI, Judith LS. Textbook of cardiovascular medicine, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002, p. 1350–1.
  6. Fuster V, O'Rourke RA, Walsh RA, Poole-Wilson P. Hurst's the heart, 12th ed. New York: McGraw Hill; 2008, p. 316–7.
  7. Surawics B, Knilans TK. Chou's electrocardiography. In: Lyn Carmire, Marc Mugman, eds, Clinical Practice, 5th ed. Philadelphia: W.B. Saunders Company; 2001, p. 532–3.

*Sami W. Serafi, BA
American University of Antigua
Union Memorial Hospital
Baltimore, MD, USA.
Email: samiserafi@gmail.com

About The Authors

Sami W. Serafi
American University of Antigua, Union Memorial Hospital
United States

4th year medical student attending American University of Antigua. ECG was found in a patient during a Sub-internship in the inensive care unit at Union Memorial Hospital, in Baltimore, MD.

Crystal Vliek
Cardiologist, University of Maryland Medical Center, Union Memorial Hospital
United States

Cardiologist, University of Maryland Medical Center, Union Memorial Hospital

Mehnaz Taremi
Internal Medicine Resident at Union Memorial Hospital, Baltimore, MD
United States

Internal Medicine Resident at Union Memorial Hospital, Baltimore, MD