ECG of the Week – 24th August 2015 – Interpretation

This ECG is from a 70 year old patient who presented to the Emergency Department complaining of progressive cough and intermittent fever. She has an extensive medical history but is unable to provide you with specific details other than she sees a cardiologist.
Check out the comments on our original post here.




Click to enlarge

Rate:
  • 66 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (~180ms)
  • QRS - Normal (80-100ms)
  • QT - 480ms
Segments:

  • ST depression leads I, V2-6
  • Subtle ST elevation lead V1

Additional:

  • High precordial R wave voltages
  • Deep T wave inversion leads V2-3
  • Global T wave inversion - all leads except aVR

Interpretation:
  • Apical Hypertrophic Cardiomyopathy
    • Deep T wave inversion, high R wave voltages, QT prolongation
What happened ?

This patient had known hypertrophic apical cardiomyopathy with diastolic dysfunction but preserved systolic function.

There is a nice review of the ECG features that can be seen in apical hypertrophic cardiomyopathy here:


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 August 2015

This ECG is from a 70 year old patient who presented to the Emergency Department complaining of progressive cough and intermittent fever. She has an extensive medical history but is unable to provide you with specific details other than she sees a cardiologist.


Click to enlarge

Things to think about

  • What are the key ECG features ?
  • What is the patient's likely underlying medical complaint ?

ECG of the Week – 17th August 2015 – Interpretation

This ECG is from an 85 year old male who presented to the Emergency Department confused and drowsy. He had a recent diarrhoeal illness and had been non-compliant with his long-term medications. 
On arrival his vital signs were: SBP 85 RR 34 Sats 90% RA GCS 12.
Check out the comments from our original post here.



Click to enlarge

Rate:
  • ~185 bpm
Rhythm:
  • Regular
  • Nil atrial activity visible
Axis:
  • Extreme / NW Axis
Intervals:
  • QRS - Normal (80ms)
  • QT - 260ms
Segments:

  • ST Elevation leads I, aVL, V1
  • ST Depression leads II, III, aVF, V2-6

Additional:

  • Late R wave transition
  • High voltages in infero-lateral leads with deep S waves

Interpretation:

  • Narrow complex tachycardia in patient with cardiovascular compromise

What happened ?

Prior to DC cardioversion the patient was treated with oxygenation, iv volume replacement and adenosine bolus with resultant reversion to sinus rhythm.
The ST changes resolved rapidly following cardioversion and were likely due to demand ischaemia. The patients resting ECG showed extreme axis deviation with persisting high inferior QRS voltage and deep S waves.
The patient was admitted to hospital for management of his multiple medical issues and social situation.

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 – 17th August 2015

This ECG is from an 85 year old male who presented to the Emergency Department confused and drowsy. He had a recent diarrhoeal illness and had been non-compliant with his long-term medications. 
On arrival his vital signs were: SBP 85 RR 34 Sats 90% RA GCS 12.


Click to enlarge
Things to think about
  • What are the key ECG features ?
  • How would you manage this patient ?

ECG of the Week – 10th August 2015 – Interpretation

This ECG is from a 70 year old male who presented to the Emergency Department complaining of feeling light-headed and dizzy. Past medical history or hypertension, diabetes, chronic atrial fibrillation and chronic renal failure on dialysis. His medications included metoprolol but no digoxin.
Check out the comments from our original post here.




Click to enlarge
Rate:
  • 36 bpm
Rhythm:
  • Irregular
  • Nil consistent atrial activity
  • Possible atrial activity in ST segment of 2nd complex and after T wave of 3rd complex
Axis:
  • LAD
Intervals:
  • QRS - Normal (100ms)
  • QT - 480ms (QTc Bazette 375 ms)
Additional:

  • T waves leads V3-5 appear prominent and peaked


Interpretation:


  • Slow atrial fibrillation
  • Broad differentials including:
    • Drug toxicity
    • Sinus node dysfunction
    • Hypothermia
    • Electrolyte abnormalities
    • Ischaemia

In this case the major concerns were hyperkalaemia and drug toxicity from beta-blocker.

What happened ?

The patient had taken an extra metoprolol dose earlier in the day ! Venous blood gas revealed a potassium of 7.0 mmol/L.
Further beta-blocker medication was withheld and hyperkalaemia was treated with calcium gluconate and insulin / dextrose therapy prior to planned dialysis later in the day. 
Following ED treatment of hyper-k the patients heart rate improved to ~50 bpm and he made an uneventful recovery.

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 August 2015

This ECG is from a 70 year old male who presented to the Emergency Department complaining of feeling light-headed and dizzy. Past medical history or hypertension, diabetes, chronic atrial fibrillation and chronic renal failure on dialysis. His medications included metoprolol but no digoxin. On arrival to the ED he was GCS 15 with a BP 135/78.


Click to enlarge


Things to think about

  • What are the key ECG features ?
  • What investigation would you request on this patient ?
  • How would you mange him ?