Amal Mattu’s ECG Case of the Week – June 8, 2020

Question 7. A 62-year-old woman with a prior history of CAD presents with lightheadedness and palpitations. BP is 130/75. The following ECG is obtained:

A.  What is the ECG interpretation? (2 points)

B.  Electrolytes are all normal. What is the optimal ED drug therapy? (2 points)

Question 7 Answer 

A.  Sinus rhythm, non-sustained monomorphic ventricular tachycardia

B.  Beta-blockers

Question 8. What is the difference between monomorphic ventricular tachycardia, generic polymorphic ventricular tachycardia, and torsades de pointes in terms of:
A. The most likely underlying cause (3 points)
B. The best plan for treatment after you cardiovert the patient back to sinus rhythm (3 points)

Question 9. A 36-year-old male presents with chest pain and this ECG:

A.  Name 4 causes of diffuse ST segment elevation? (2 points)

B.  What is the diagnosis here? (1 point)

C.  List 2 reasons for your diagnosis. (2 points)

Question 9 Answer

A.  Large STEMI, pericarditis, early repolarization, ventricular aneurysm, vasospasm

B.  STEMI

C.  Horizontal ST segments, ST depression (reciprocal change) in aVL

Question 10.

A 30-year-old male presents after a syncopal episode. The following ECG is obtained.

A.  What is diagnosis? (1 point)

B.  Name 2 other conditions that are known to mimic this pattern (2 points)

C.  What is the best management strategy? (1 point)

Question 10 Answer

A.  Brugada syndrome

B.  Sodium channel blocker toxicity, Hyperkalemia, etc.

C.  Send for EP study and AICD

Question 11.

A 62-year-old man presents with chest pain and shortness of breath. The following ECG is obtained:   

A.  What is the FULL ECG diagnosis? (3 points)

B.  What immediate treatment is needed for this rhythm? (1 point)

C.  When the QRS complexes are so irregular, what “rookie trick” can you do to estimate the ventricular rate? (1 point)

Question 11 Answer

A.  Sinus tachycardia, Mobitz II, LBBB

B.  No immediate treatment (HR in the 70s); pacemaker on standby

C.  # of QRS complexes x 6 (ECG is run over 10 seconds)

Question 12.  A 54-year-old male presents with signs and symptoms that are highly concerning for a massive PE, but the computer is reading the ECG as a STEMI.

A.  In which leads would you expect STE in the setting of a massive PE? (2 points)

B.  Besides STEMI, name another condition which can typically produce STE in the same leads. (1 point)

C.  List up to 6 ECG findings in patients with large PEs (2 points)

D.  Which of the answers you listed in c. is the most common abnormality in cases of large PE? (1 point)

Question 12 Answer

A.  V1-V2, aVR, ± III

B.  Hyperkalemia

C.  Sinus tachycardia, ST elevation, ST depression, Right axis deviation, tall R wave in V1, S1Q3T3, T-wave inversions, normal

D.  T-wave abnormalities

Question 13 (Bonus). Ignoring the non-specific T-wave flattening, what is the main abnormality in this ECG, and list 8 causes

Question 13 Answer

Poor R-wave Progression (PRWP)

• Defined as a R-wave < 3 mm by lead V3
• 8 L’s of PRWP
  • Left bundle branch block
  • Left ventricular hypertrophy
  • Left anterior fascicular block
  • Low voltage
  • LAD (Prior anteroseptal MI)
  • Long life (elderly)
  • Lungs (COPD)
  • Lead misplacement