ECG of the Week – 22nd May 2017 – Interpretation

The following ECG is from a 67yr old male who presented with a 36 hour history of central chest pain and diaphoresis. He has a history of CABG. 





Click to enlarge


Rate:

  • Ventricular rate 36 bpm
  • Atrial rate ~ 60 bpm
Rhythm:
  • Regular ventricular and atrial rhythms
  • Complete heart block
Axis:
  • Normal
Intervals:
  • PR - AV dissociation with no relation between P and QRS
  • QRS - Normal
Segments:
  • ST Elevation leads II (1mm), III and aVF (3mm) V5-6 (1mm)<1mm avf="" font="" iii="" mm="" v5-6="">
  • ST Depression leads V2 - flat morphology
  • ST Depression leads I, aVF
Interpretation:

  • Infero-lateral STEMI
    • Likely posterior extension
    • Complete heart block
    • Ventricular bradycardia with narrow complex escape rhythm
What happened ?

The patient was taken for urgent angiography which showed:
  • LMCA: 80% Stenosis
  • LAD: Patent LIMA (left internal mammary artery) and SVG (saphenous vein graft)
  • Cx: Patent SVG
  • RCA: Subacute thrombotic occlusion with severe ostial and proximal vessel stenosis.
The RCA lesion was stented but the patient's recovery was complicated by repeated PEA, VT and VF cardiac arrests necessitating placement of an Intra-Aortic Balloon Pump (IABP).

A bit on IABPs

Check out the following LitFL pages for a nice overview of IABPs:


A bit on CABG anatomy and techniques

This is outside of the scope of this blog but I found the following links useful refreshers on CABG techniques and post CABG angiography / intervention:



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 – 15th May 2017 – Interpretation

The following ECG is from an 81yr old female who presented with a 48hr history of palpitations. She underwent a cardioversion for an atrial arrhythmia 1 year ago. Her medications include metoprolol, digoxin and eliquis.





Click to enlarge

Rate:
  • 132 bpm
Rhythm:
  • Regular
  • Possible atrial activity seen in leads I, II, III and aVF
  • Lead II suggests inverted small atrial waves seen with ST segment and T-QRS interval
Axis:
  • Normal
Intervals:
  • QRS - Normal 
Additional:
  • ST Elevation lead aVR
  • ST Depression leads II, III, aVF, V4-6
    • Likely to reflect rate related demand changes and superimposed atrial activity

Interpretation:

  • Regular narrow complex tachycardia
  • Differentials:
    • Atrial flutter with 2:1 block - favoured due to the patient's history of AF
    • Atrial tachycardia with 2:1 block


What happened ?

Following screening for acute electrolyte disturbance, non-cardiac precipitant, drug toxicity and ensuring compliance with coagulation regime the patient underwent an uneventful DC cardioversion under procedural sedation.

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 – 15th May 2017

The following ECG is from an 81yr old female who presented with a 48hr history of palpitations. She underwent a cardioversion for an atrial arrhythmia 1 year ago. Her medications include metoprolol, digoxin and eliquis.




Click to enlarge


Things to think about

  • What are the key ECG features ?
  • What consideration would influence your management of this patient ?

ECG of the Week – 8th May 2017 – Interpretation

The following ECG is from a 12 yr old who presented to the Emergency Department following an episode of dysponea and palpitations.


 
Click to enlarge

Rate:
 
  • 72 bpm
Rhythm:
 

  • Sinus rhythm
    • Note baseline irregularity due to printing issue
Axis:
  • Normal
Intervals:
 
Complexes #1-9, #12
  • PR - Normal
  • QRS - Normal
Complexes #10-11
  • PR - Short
  • QRS - Prolonged

Additional:
  • Distinct QRS morphology complexes #10-11
    • Delta wave
    • Abnormal ST / T wave likely secondary to pre-excitation

Interpretation:
  • Intermittent pre-excitation / WPW
    • Only seen in complexes #10-11

What happened ?
 
The patient was referred to paediatric cardiologists for further follow-up and investigation.
 
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.