Case ECG
Before watching this week’s video, ask yourself this question:
- What do you consider to be the acceptable miss rate for deadly ECG findings?
Case Interpretation
Case interpretation
Case 1: LBBB and AMI
Which patients with LBBB need emergent reperfusion therapy?
- Sgarbossa A & concordant STE = AMI
- Sgarbossa B & concordant STD in V1, V2, or V3 = AMI
- Revised Sgarbossa C & discordant ST segment > 25% size of R or S wave = AMI (pending validation study)
For more on this, review the case from June 1st, 2015
Case 2: Atrial Fibrillation with WPW
- Very rapid, irregularly irregular tachycardia
- Rates may approach 250-300 bpm or higher
- Variable QRS-complex shape and width
- Often misdiagnosed as SVT, VT, or A.fib with aberrancy
- AV nodal blockers (BB/CCB’s, Digoxin, Amiodarone, etc.) can cause V.fib & death
Avoid all AV nodal blockers in Atrial fibrillation with WPW!
Case 3: Septal STEMI vs Hyperkalemia?
ECG findings in Hyperkalemia
- Peaked T-waves
- Widening of the QRS (often marked)
- Prolonged PR-interval
- Flattening and eventual loss of P-waves
- Tachydysrrhythmias
- Advanced AV Blocks and sinus pauses
- Fascicular & Bundle Branch Blocks
- Pseudo ACS with ST-segment changes (can mimic STEMI with focal STE!)
- Pseudo Brugada syndrome pattern
- Sine wave morphology
Beware…Hyperkalemia does whatever it wants to the ECG!
For more on hyperkalemia, review the case from Jan 12th, 2015
Case 4: Ventricular Tachycardia vs. AIVR
- Accelerated idioventricular rhythm (AIVR) is a relatively benign reperfusion arrhythmia
- It often occurs during reperfusion with thrombolytics after MI
- True ventricular tachycardia typically has a rate > 120 bpm
Case 5: Syncope & Anteroseptal ST-segment Depression
Differential for ST-depression in anteroseptal leads
- Anteroseptal ischemia
- Posterior STEMI
- Mirror image of septal STEMI in leads V1-V3
- Look for tall R waves, ST-depression, and upright T waves in V1-V3 on conventional 12 lead ECGs
- Even 0.5 mm of STE on posterior lead ECGs is diagnostic
- Miscellaneous
- RBBB
- Hypokalemia
ST-depression in the anteroseptal leads might represent posterior STEMI. Get posterior leads!
Case 6: Really Wide Complex Tachycardia
- When the QRS complex is really wide (> 1 big box or 200 ms) think of tox. and metabolic etiologies (ex. hyperkalemia and severe acidosis)
- Consider empiric treatment with Calcium & Sodium Bicarbonate!
For more about Na2+ channel blocker toxicity, review the case from Feb 23rd, 2015
Case 7: Bizarre Bradycardia
- Remember that hyperkalemia can also cause bizzare bradycardias and AV blocks
- When dealing with a bizarre rhythm that is not responding to ACLS therapy, consider empiric treatment for hyperkalemia!
Case 8: Low Voltage
Low Voltage Definition
- Specific Definition
- QRS amplitudes in limb leads all < 5 mm OR in all chest leads < 10mm
- Sensitive Definition
- QRS amplitudes in I+II+III < 15 mm OR V1+V2+V3 < 30 mm
Low Voltage QRS Differential
- “Low Power”
- Myxedema (severe hypothyroidism)
- Infiltrative diseases (Amyloid, Sarcoid, etc.)
- End stage cardiomyopathy
- Conduction blockage
- Fluid/Effusion (pericardial or pleural)
- Fat (obesity)
- Air (COPD)
New low voltage ECG + Tachycardia = Pericardial effusion until proven otherwise!
Avoid anticoagulants until pericardial effusion is ruled out.
For more, review the case from April 6th, 2015
Kudos: Congratulations to all the 2015 Emergency Medicine Residency Graduates!
Notes: Questions for Amal? Email him at amalmattu@comcast.net or find him on Twitter @amalmattu.
Dr. Mattu, I have heard you mention that you had an another website with EKGs before beginning eggweekly. If it is still up, can you provide the web address as the address I thought was correct does not have EKGs at this time? If not, are you planning to make that material available on this website? Sorry for posting this in the comments. I just wasn’t sure the best way to contact you. As always your insight is appreciated. Thank you.
David,
Thanks for the query. others have asked about this also. I had briefly discussed this on the initial videos in Jan2015 but to reiterate here:
The old website no longer exists. Unfortunately, the site
was run by our university IT experts (I know NOTHING about running or
maintaining a website, and don’t have much extra time for this anyway.
Recently our university is focusing on development of a new electronic
information system, and so the IT specialists have been re-deployed to
focus their efforts on that. As a result, late in 2014 it became very
evident that they would be unable to find time to work with me to improve the site or
maintain the site. I switched to the new site in Jan 2015, but it was no
longer free to me because it was not a university run site (thus the
subscription fee to pay the person to run the site), and the old website
eventually had to be closed because it was no longer being overseen. I
had no way of maintaining it.
The old videos are still on You Tube, but the written descriptions are gone. We didn’t maintain a database of them.
Dr. Farzad and I are recreating all the prior
themes/topics on the new site though I think the new site and writeups
are better than before. We’ll eventually cover all of the old topics and
improve on the prior cases.
In the
meantime, if there are specific topics that you’d like me to prioritize,
or if you have good cases with good quality ECGs you’d like to
contribute, please let me know. Thanks.
Amal
Thank you