A middle aged male presented for evaluation of AMS; he had agitation, confusion, and tremors. He has a history of Bipolar disease and schizophrenia as well as HTN.  Vital signs were all stable on presentation and within normal limits.  On exam he was oriented only to name, but not place or time. Neurological exam was normal, with the exception of tremors.  Med list includes Haldol Injection, Lithium, Benztropine, Olanzapine, and Propranolol.  At this point, I was not quite sure what is going on with him, so I had a bit of a shotgun approach.  Initial EKG revealed the EKG below.

It appears to be similar to Wellens’ syndrome but not consistent with my gentlemen’s symptoms.

A quick literature search revealed a case report showing lithium induced EKG changes, similar to his EKG above.  Further supporting his lithium induced changes in this scenario is no clinical findings to suggest ACS, and a negative troponin 3x.  He was ultimately admitted and treated for lithium toxicity, without any cardiac complications.

EKG changes seen in lithium toxicity:
– ST elevations (1 other single case report)
– QT prolongation
– non-specific ST segment changes/T-wave abnormalities