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Is a Shaking Hand or a Trembling Heart Producing Changes in Electrocardiogram Findings?

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1 Credit CME

An individual in their early 70s presented to the emergency department with dizziness and weakness in bilateral lower limbs for 7 days. The patient had a 7-year history of hypertension; a 10-year history of diabetes; and denied tobacco, alcohol, or illicit drug use. The patient had bradykinesia, left-hand tremor, and postural instability. At admission, blood pressure and pulse rate were 149/76 mm Hg and 92 beats per minute, respectively. Laboratory results (hemogram, serum electrolytes, kidney and hepatic function tests, and D-dimer levels) were all within normal limits. An electrocardiogram (ECG) was obtained on admission (Figure, A). On initial evaluation, the emergency department resident suspected that the patient had ventricular tachycardia (VT). However, the patient did not have palpitations or hemodynamic instability; heart sounds and pulse rate were normal; and pulse oxygen saturation waveform showed that the ventricular activity had a normal rate. The senior clinician suggested holding the patient’s tremulous left upper extremity while obtaining a repeat ECG (Figure, B).

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Electrocardiographic artifacts are defined as ECG abnormalities caused by sources other than the electrical activity of the heart. Artifacts are observed commonly in the ECGs of patients requiring evaluation and monitoring in the prehospital, emergency department, or intensive care unit settings. In general, sources of ECG artifacts can be divided into 2 categories: physiological and nonphysiological. Physiological sources may involve muscular activity (eg, tremors, shivering, convulsions) and patient motion. All muscle contractions are initiated by the flow of electrically charged ions. This electrical flow produces a signal that appears on the ECG as rapid spikes arising simultaneously with the muscle contraction.

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Article Information

Corresponding Author: Guilan Zhai, MD, Emergency Department, The First Affiliated Hospital of Jinzhou Medical University, Renmin St, Jinzhou, Liaoning 121000, China (zhaiguilan@yeah.net).

Published Online: May 23, 2022. doi:10.1001/jamainternmed.2022.1796

Conflict of Interest Disclosures: None reported.

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