Himalayan Osborn Waves

Abstract

A 57-year-old man with history of polysubstance abuse was found in the snow in an intoxicated state by emergency medical services personnel. On arrival, his rectal temperature was 81 F and the rest of the physical examination was consistent with hypotension, bradycardia, and somnolence. His electrocardiogram (ECG) showed atrial fibrillation, tremor artifact, wide QRS, prolongation of PR and QT interval, and giant Osborn waves (Fig. 1, arrows). Initial laboratory data was consistent with anion-gap (lactic) metabolic acidosis and rhabdomyolysis. Serum and urine toxicology screens were positive for ethanol and opiates, respectively. After rewarming with an external rewarmer and warm intravenous fluids, repeat ECG showed normal sinus rhythm and decreased Osborn wave amplitude at a temperature of 89 F (Fig. 2A), followed by complete normalization after restoration of normothermia (Fig. 2B). Electrocardiographic J (or Osborn) waves are typically known to be associated with hypothermia, however, rarely can be seen in other conditions like head injury, subarachnoid hemorrhage, hypercalcemia, cardiac ischemia, cocaine use, and haloperidol overdose. Apart from these conditions in which discrete J-waves can be readily distinguished, J-waves can often be partially buried in the R wave in benign early repolarization, manifesting as J-point or ST segment elevation and terminal slurring of QRS. Recent evidence has suggested that arrhythmias associated with an early repolarization pattern in the inferior or mid to lateral precordial leads,