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.


ECG of the Week – 17th November 2014

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.




Click to enlarge

Things to consider

  • What does his ECG show ?
  • What are you going to do about it ?

ECG of the Week – 10th November 2014 – Interpretation

This ECG is from an 89 yr old female who presented with a week's history of feeling generally unwell and episodic pre-syncope over the prior 24 hours. 
Vital signs: BP 168/67 GCS 15 Sats 96% RA Temp 36.4 C (97.5 F)
Check out the comments on our original post here.


Click to enlarge

Rate:
  • Ventricular rate 42 bpm
  • Atrial rate 105 bpm
Rhythm:
  • Regular ventricular rhythm
  • Regular atrial activity
  • No evidence of atrial to ventricular conduction
    • Number of the P waves are buried in the T waves
    • Atrial activity mapped out in image below
Atrial activity mapped on rhythm strip
Dark green = visible P waves
Light green = mapped location given fixed P-P interval

Click to enlarge
Axis:
  • LAD
Intervals:
  • QRS - Prolonged (120ms)
  • QT - 460ms
Segments:

  • Possible ST elevation leads aVR and V5-6
  • Possible ST depression lead V2
  • Difficult to assess given baseline artefact and relative paucity of ventricular complexes seen in each lead


Additional:


  • RBBB Morphology
  • Prominent T waves leads I, II, aVF, V3-6
  • Voltage criteria for LVH (aVL R wave >11mm)
  • Baseline artefact

Interpretation:

  • Complete heart block
  • Prominent T waves
    • ? Hyperkalaemia
    • ? Ischaemia
What happened ?


There was no history of chest pain and the review of the her medications revealed only low dose calcium channel blocker use. Prior to this attendance she lived independently and alone with minimal prior medical historyAn old ECG on this patient showed long-standing RBBB and LAD in sinus rhythm without evidence of 1st degree AV block with similar T wave prominence as seen in this ECG.  An urgent venous blood gas show no hypo- or hyper-kalaemia and the rest of her electrolytes, renal function and serial troponins were normal.
She was admitted to CCU on an isoprenaline (isoproterenol) infusion and had a pacemaker inserted without complication.

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 – 10th November 2014

This ECG is from an 89 yr old female who presented with a week's history of feeling generally unwell and episodic pre-syncope over the prior 24 hours. 
Vital signs: BP 168/67 GCS 15 Sats 96% RA Temp 36.4 C (97.5 F)


Click to enlarge

Questions for consideration

  • What does the ECG show ?
  • What is your emergent management of this patient ?
  • What are your considerations for the long-term management ?

ECG of the Week – 3rd November 2014 – Interpretation

These ECG's are from a 56 yr old male who present with 2 hours of chest pain. Past history of hypertension and smoking. The ECG's were performed 15 mins apart with ongoing chest pain.
Check out the comments on our original post here.


ECG 1
On arrival to ED
Click to enlarge
Rate:
  • 72 bpm
Rhythm:
  • Sinus rhythm
  • Single PAC (Complex #7)
Axis:
  • Normal 
Intervals:
  • PR - Normal (160ms)
  • QRS - Normal (100ms)
  • QT - 360ms
Segments:

  • ST Depression leads I, V4-6

Interpretation:

  • Lateral ST segment depression
    • Given associated Hx of chest pain ischaemia is the main concern

ECG 2
15 mins following ECG 1
Click to enlarge
Rate:
  • 72 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal 
Intervals:
  • PR - Normal (180-200ms)
  • QRS - Normal (80ms)
  • QT - 360ms
Segments:

  • ST Depression leads I, II, aVL, V2-6
  • ST Elevation lead aVR (~1mm)

Additional:

  • Markedly prominent T waves leads I, V2-6

Interpretation:

  • De Winter's T Wave Pattern
    • Suggests acute LAD lesion requiring emergent reperfusion 
  • Dynamic ECG changes compared with previous ECG

What happened ?

The ECG changes were recognised by the treating team. The patient was taken for emergency PCI which showed:

  • LAD - 100% Occlusion - 2 x stents inserted
  • RAC - 30% proximal stenosis

Post stent echocardiogram showed:

  • Mild systolic dysfunction
  • Akinesis of anterior septum and apical region
  • LVEF ~40-45%

The patient was discharged after a 4 day in-patient stay.

I think there are two key learning points from this case:

  1. The need for serial ECG's
  2. Recognition of De Winter's T Wave Pattern

I'd encourage all our readers to check out the excellent 'De Winter's T Wave' page from the Life in the Fast Lane ECG library (link below) which has a comprehensive overview of this important ECG pattern.

References / Further Reading

Life in the Fast Lane