ECG of the Week – 1st December 2014 – Interpretation

This ECG is from a 23 yr old female. She presented to the Emergency Department feeling generally unwell. She is a known Type 1 Diabetic.
Check out the comments from our original post here.



Click to enlarge


Rate:
  • ~108 bpm
Rhythm:
  • Regular
  • Rhythm unclear
  • Nil clear P waves
  • Likely sinoventricular
Axis:
  • LAD
Intervals:
  • QRS - Prolonged (200ms)
  • QT - 440ms
Segments:

  • ST elevation leads II, aVF, aVR, V3
  • ST depression leads I, aVL, V1, V6

Additional:

  • Prominent T waves in leads II, III, aVF, aVL, V4-5
  • No fusion / capture beats
  • Absence of concordance
Interpretation:


  • Wide complex tachycardia


The general differentials for WCT include:

  • VT
  • SVT with BBB / aberrancy / pre-excitation
  • Paced rhythms
  • Toxins e.g. sodium channel toxicity
  • Do not forget Hyperkalaemia


The extent of the widening plus the clinical stem of young patient with a metabolic disorder strongly suggests hyperkalaemia as the cause, time for a quick venous gas.


What happened ?

I went back to my ECG folder to find this ECG had been donated by one of my colleagues and is over 14 yrs old. The only comment on the top of the ECG is unsurprisingly hyperkalaemia. The ECG below is also attributed to the same case and one can only assume there was interval treatment of the electrolyte and acid-base disturbance.

Click to enlarge
Dr Ken Grauer shares a very similar case to this one on his blog that I'd recommend our readers check out:



References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

ECG of the Week – 24th November 2014 – Interpretation

This is one of the oldest ECG's I have in my collection and as such I don't have any clinical information on the case other then it's from a 90 yr old female. 
So why do we think she ended up in the Emergency Department based on the ECG ? 
Check out the comments on our original post here.





Click to enlarge
Rate:
  • ~48 bpm
Rhythm:
  • Irregular
  • No p waves visible
Axis:
  • Normal
Intervals:
  • QRS - Prolonged (~180ms)
  • QT - 720ms
Segments:

  • Inferior ST sagging
Additional:
  • RBBB Morphology
  • Osborn J waves
  • Prominent U waves best seen infero-laterally
  • T wave inversion leads aVR, aVL, V1-3



ECG with T, U and J waves labelled
Click to enlarge

Interpretation:


  • Slow Atrial Fibrillation
  • J-waves
  • Prominent U waves

Differentials for this ECG

Without more clinical information it's difficult to give a firm conclusion. I think this ECG is most consistent with hypothermia but some features could be explained by drug toxicity (digoxin, CCB's, beta-blockers), electrolyte abnormalities, ischemia, sinus node dysfunction. We should be mindful in the elderly that the clinical situation is often multi-factorial and could be a combination of the above causes. Also remember hypothermia in the elderly has a multitude of potential causes including environmental, sepsis and endocrine.

New Team Member

I'd like to welcome Dr Richard McClelland to our ECG blogging team - Richard is a EM registrar in Australia planning to continue his training back in the UK.

References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

ECG of the Week – 24th November 2014

This is one of the oldest ECG's I have in my collection and as such I don't have any clinical information on the case other then it's from a 90 yr old female. 
So why do we think she ended up in the Emergency Department based on the ECG ? 



Click to enlarge
Things to think about


  • What are the key abnormalities on the ECG ?
  • What are the differentials for these ECG features ?
  • How would you investigate the patient ?

ECG of the Week – 17th November 2014 – Interpretation

This ECG is from a fit & well 17 yr old male who presented to the Emergency Department with chest pain following a minor chest wall injury. Clinical examination revealed local chest wall tenderness at the site of trauma. Vital signs - BP, RR, Sats, Temp - were within normal limits. Chest x-ray was unremarkable and the pain resolved with simple analgesia. His 'routine' ECG is below.
Check out the comments from our original post here.



Click to enlarge

Rate:
  • ~42 bpm
Rhythm:
  • Complexes #1 & 2 are premature junctional complexes
  • Remainder of ECG sinus rhythm
Axis:
  • Right axis deviation
Intervals:
  • PR - Normal (~160ms)
  • QRS - Normal (100ms)
  • QT - 400ms
Segments:

  • ST elevation leads aVF, V2, V3

Additional:

  • Biphasic T waves leads V2-3
  • Precordial U waves also seen in aVF
  • RS complex in majority of precordial leads but with appropriate R wave progression


Interpretation:

  • Non-specific changes
  • Likely normal for young fit & healthy male


What happened ?

Given the patients benign history and a normal clinical exam he was discharged from the Emergency Department. The patient was advised to follow-up with his GP and have an out-patient echocardiogram to exclude structural abnormality.

Unfortunately the patient did not seek any further follow-up and never had an echo so I can't tell you what it showed. This does highlight the fact that many patients do not seek follow-up as advised once they leave the Emergency Department and should remind us of the need to communicate with our patients what we have found, what should happen next and why.