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UMEM Cases, Part 4: When the Computer Misses the Rhythm and Flutter Fakes a STEMI
A 44-year-old man with severe cardiomyopathy, an LVAD, chronic amiodarone therapy, and an AICD presents with palpitations. His ECG shows a regular wide-complex tachycardia, but the rate is only 135….
Right Bundle Branch Block (RBBB)
Key Points: RBBB delays right ventricular activation. The left ventricle depolarizes normally through the left bundle, while the right ventricle is activated late by slow myocardial spread. ECG hallmark: QRS…
New RBBB + LAFB (Bifascicular Block) in ACS: OMI Pattern
Key Points: In a patient with ischemic symptoms, new RBBB + LAFB should raise concern for proximal LAD or septal ischemia until proven otherwise, especially if the patient has ongoing…
Wide QRS Complex: DDx
Key Points: A QRS duration greater than 120 ms reflects delayed or abnormal ventricular depolarization. A wide QRS may be chronic and benign in context, or it may be the…
Junctional Tachycardia
Key Points: Junctional tachycardia is an uncommon supraventricular tachycardia arising from the AV junction, usually due to enhanced automaticity rather than reentry. It is usually a regular narrow-complex tachycardia, although…
Dysrhythmias in LVAD Patients
Key Points: Continuous-flow LVADs can mask cardiovascular collapse. Patients may remain awake during sustained VT or even VF because the pump can provide temporary flow. Treat the rhythm and the…
Pediatric ECG Red Flags
Key Points: Any wide QRS (>90 ms) in an infant or small child is abnormal and should trigger evaluation for VT, sodium-channel blockade, or conduction disease. QTc >450 ms in…
Unstable Bradyarrhythmias
Key Points: Unstable bradyarrhythmias cause poor perfusion which can rapidly progress to shock, irreversible organ injury, or cardiac arrest. Priority: Do not treat the heart rate alone. Treat clinical instability….
Pediatric ECG: Basics
Key Points: Pediatric ECGs are not scaled-down adult ECGs. Right axis deviation, large R waves in V1, and T wave inversions in V1 to V3 are expected in healthy children….
Severe Hypothermia
Key Points: Severe hypothermia causes predictable ECG slowing and conduction delay. Sinus bradycardia, PR/QRS/QT prolongation, and atrial fibrillation with a slow ventricular response are common as core temperature falls. Osborn…
Heart Rhythm: Basics
Key Points: Don’t trust the ECG machines automated interpretation. Confirm the rhythm yourself. Start with the ventricles (R–R pattern), then the atria (P waves), then the AV relationship (PR behavior/P:QRS)….
Normal STAT ECGs
Key Points: Clinical Context: A single normal 12-lead ECG in the emergent setting does not exclude all life-threatening conditions such as early occlusion MI/ACS, PE, tamponade, or aortic catastrophe. Do…
Computer Interpreted “Normal” ECGs
Key Points: Do not trust a computer read of “normal” without your own review. Computer interpretation is especially unreliable for subtle or early ischemia, including hyperacute T waves, minimal ST…
Torsade de Pointes (TdP)
Key Points: Definition: Torsade de pointes is a specific subtype of polymorphic ventricular tachycardia that occurs in the setting of QT prolongation. ECG pattern: TdP shows beat-to-beat variation in QRS…
Abnormal STAT ECGs
Key Points: Clinical Context: Abnormal ECGs must be interpreted within the patient’s presentation. Not all abnormalities are life-threatening, and high-risk conditions can still appear subtle or even “normal.” Serial Monitoring:…
ST Elevation in aVR with Diffuse ST Segment Depression: OMI Pattern
Key Points: Pattern, not a STEMI equivalent. ST elevation in aVR (≥1 mm), often with ST elevation in V1 and diffuse ST depression (≥1 mm in ≥6 leads), represents high-risk…
Hyperkalemia Emergencies
Key Points: Severe Hyperkalemia Mimics Several Life-Threatening Conditions: Severe hyperkalemia is one of the most dangerous ECG mimics in emergency medicine. It can resemble unstable bradyarrhythmias, VT, STEMI, and pacemaker…
Polymorphic Ventricular Tachycardia (PMVT)
Key Points: Definition: Polymorphic ventricular tachycardia is VT with beat-to-beat variation in QRS morphology, axis, and amplitude. Clinical significance: PMVT is electrically unstable and can rapidly deteriorate into ventricular fibrillation…
Nonsustained Ventricular Tachycardia (NSVT)
Key Points: Definition: Nonsustained ventricular tachycardia is 3 or more consecutive ventricular beats lasting less than 30 seconds and terminating spontaneously. Rate: VT is usually faster than 120 bpm, but…
STEMI vs Wide QRS (BBBs & Paced Rhythms): DDx
Key Points: Wide QRS rhythms distort repolarization. Bundle branch block and ventricular pacing create secondary ST-T changes even without occlusion MI. Appropriate discordance is expected. ST segments and T waves…
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