ECG of the Week – 2nd March 2015

These ECG's are from a 20 yr old female who presented to the Emergency Department following an episode of chest pain. At review she was pain free and all vital signs were normal. Her serial ECG's are below, there is ~30 mins between each ECG.




ECG 1
Click to enlarge

ECG 2
Click to enlarge
Things to think about


  • What are the key features on each ECG ?
  • What are the differential diagnoses for these features ?
  • How would you investigate this patient ?

ECG of the Week – 23rd February 2015 – Interpretation

The following ECG is from a 50 yr old male. Nil relevant past medical history. The patient had an out-of-hospital witnesses cardiac arrest with immediate bystander CPR. On paramedic arrival he was found to be in VF and ROSC was achieved following DC cardioversion.

On arrival to the Emergency Department the patient was agitated and combative with episodic abnormal posturing. 

Vital signs: GCS ~5-7 (M=2-4 E=1 V=2), BP 136/78, RR 12, Temp 36.5 (97.7F), BSL 8.4 mmol/L, Sat 100% on 15L/min

The patient received iv sedation to facilitate initial assessment, his ECG is below.

Check out the comments on our original post here.

Click to enlarge
Rate:
  • 66
Rhythm:
  • Sinus arrhythmia
Axis:
  • Normal
Intervals:
  • PR - Normal (160ms)
  • QRS - Normal (80-100ms)
  • QT - 415 ms (QTc Bazette 435 ms)
Segments:
  • Inferior ST Depression
Additional:
  • U waves precordial leads
  • Notched P wave in inferior leads with bifid p wave in V1
    • Consistent with LAE pattern
Interpretation:
  • Non-diagnostic ECG
    • Minor ST segment change
    • Nil clear arrhythmogenic cause
    • Nil evidence of acute myocardial infarction

What happened ?

The patient was promptly intubated following RSI, a VBG showed relatively normal acid-base and electrolytes. Urgent CT head was performed which was normal and an emergent coronary angiogram showed only minor vessel irregularity.

During his ICU stay the patient had 2 further episodes of VF requiring DC cardioversion, rhythm strip of one event below.

Click to enlarge
Long-short coupled PVCs with resultant VT --> VF
The patient was treated with quinidine and a cardiac MRI showed an isolated area of delayed enhancement in the anterolateral basal mid LV wall with features favoring  cardiac sarcoid with a differential of acute myocarditis. The patient had an AICD inserted and was discharge from hospital following an 11 day stay.

Sometimes the emergency ECG doesn't always give us the answer !



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 – 16th February 2015 – Interpretation

This week's ECG case comes with three ECG's. They are from an 85 yr old female who presented with a 12 hour history of feeling generally unwell. Her past medical history includes congestive cardiac failure (EF 35%), chronic renal impairment and paroxysmal atrial fibrillation. Medications included a calcium-channel blocker and a beta-blocker.
On arrival her blood pressure was 125/65 and she had a GCS of 15.
These ECG were each performed at ~30 minutes intervals.
Check out the comments on our original post here.

I'm going to abridge our usual format for this week's interpretation to focus on the key features of the three ECG's.

ECG 1
Click to enlarge
Rate:
  • 30
Rhythm:
  • Regular
  • No p waves visible
Axis:
  • Normal
Intervals:
  • QRS - Normal (80-100ms)
Additional:

  • Flat T waves all leads
  • Baseline artifact

Interpretation:

  • Significant bradycardia with absence of P waves. 
  • DDx: 
    • AF with complete heart block & junctional escape
    • SA Exit Block with junctional escape
    • Sinus Node Dysfunction

What happened next ?

As Vince has mentioned in the comments we were worried about drug toxicity and potassium as potential reversible causes. An urgent VBG showed a potassium of ~6 mmol/L. The patient was on relatively low doses of both beta & calcium channel blockers with no recent change in dose and her renal function was at the patient's normal baseline.
Following discussion with cardiology re: urgent vs semi-elective pacing the patient was commenced on an isoprenaline infusion. The ECG below was performed following 20-30 mins of isoprenaline therapy.

ECG 2
Click to enlarge
I think this is the most interesting of the patient's ECGs.

Rate:
  • 60
Rhythm:
  • Regularly irregular
    • Recurring pattern of long R-R followed by short R-R
    • Complexes following short R-R (#3,6,9) have differing morphology from others, best appreciated in precordial leads
  • No p waves visible
Axis:
  • Normal
Intervals:
  • Complexes #1,2,4,5,7,8,10
    • QRS - Normal (80-100ms)
  • Complexes #3,6,9
    • QRS - Prolonged (120ms) when measured in leads aVF, V1-5
Additional:
  • Baseline artifact in precordial leads
Interpretation:

When I looked at this ECG quickly I thought it was just AF but on examination I think it's still the junctional escape with no organised atrial activity as seen in ECG 1 with the additional of another pacemaker focus / bigeminy likely secondary to the isoprenaline. These additional complexes where mechanical effective and the patient felt symptomatically better. 
Anyone else got any thoughts on this ECG ?

ECG 3
Click to enlarge
The patient now decided to fix herself :-)

Rate:
  • ~96 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • QRS - Normal (80-100ms)
  • QT - 340 ms QTc - 430ms (Bazette's)
Additional:
  • Broad notched P in lead II
  • Baseline artifact - we changed the dots, leads, and the machine !

Interpretation:

  • Patient is back in sinus rhythm
What happened next ?

The following day she had an elective dual chamber pacemaker insertion.

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 – 23rd February 2015

The following ECG is from a 50 yr old male. Nil relevant past medical history. The patient had an out-of-hospital witnesses cardiac arrest with immediate bystander CPR. On paramedic arrival he was found to be in VF and ROSC was achieved following DC cardioversion.

On arrival to the Emergency Department the patient was agitated and combative with episodic abnormal posturing. 

Vital signs: GCS ~5-7 (M=2-4 E=1 V=2), BP 136/78, RR 12, Temp 36.5 (97.7F), BSL 8.4 mmol/L, Sat 100% on 15L/min

The patient received iv sedation to facilitate initial assessment, his ECG is below.



Click to enlarge
Things to think about


  • What does his ECG show ?
  • How would you manage this patient in the Emergency Department ?
  • What happened next ?

ECG of the Week – 9th February 2015 – Interpretation

This ECG is from a 1 yr old who was brought to the Emergency Department following a suspected nicotine ingestion. The child was clinically well and vital signs were within age appropriate ranges.
Check out the comments on our original post here.



Click to enlarge

Rate:
  • ~102 bpm
Rhythm:
  • Sinus Arrythmia
Axis:
  • Normal (40 deg)
Intervals:
  • PR - Normal (120ms)
  • QRS - Normal (60ms)
  • QT - 300ms (QTc Bazette 390 ms)
Segments:

  • Subtle J-point elevation in leads II, & aVF (<1mm)

Additional:
  • Dominant R wave in leads V2-3
  • rSr' Pattern in lead V1
  • T wave inversion leads V1-3
    • Normal paediatric T-wave pattern
  • Prominent Q waves in leads II, III, aVF, V4-6
    • Maximal in lead III at 9-10mm (0.9-1.0 mV)

Interpretation:

  • No concerning toxicological features
  • Normal paediatric features including:
    • Heart Rate
    • T-wave changes
    • Right precordial QRS voltages & T wave changes
  • Unusual feature:
    • Q waves in the infero-lateral leads are normally seen
    • The voltage of the Q wave in lead III is greater than the normal range as proposed by Davignon et al. & Taylor et al.
    • However, Chou's suggests the Q wave amplitude may be up 14 mm !

Interpretation of the paediatric ECG is challenging given the variation of normal features when compared with the adult ECG. The inferior QRS voltages in this ECG would concern me, although they may reflect a normal variant - for this ECG I would be asking a paediatric cardiologist to have a look at it. I will try and get some more information on the case and canvas some opinions from my paediatric colleagues.

For a great overview of paediatric ECG changes check out the Life in the Fast Lane page below:

References / Further Reading

Textbook

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Surawicz B, Knilans TK. Chou's Electocardiography in Clinical Practice, 6th Edition Saunders Elseiver 2008.

ECG of the Week – 16th February 2015

This week's ECG case comes with three ECG's. They are from an 85 yr old female who presented with a 12 hour history of feeling generally unwell. Her past medical history includes congestive cardiac failure (EF 35%), chronic renal impairment and paroxysmal atrial fibrillation. Medications included a calcium-channel blocker and a beta-blocker.
On arrival her blood pressure was 125/65 and she had a GCS of 15.
These ECG were each performed at ~30 minutes intervals.



ECG 1
Click to enlarge

ECG 2
Click to enlarge

ECG 3
Click to enlarge


Things to think about


  • What do each of the ECG's show ?
  • What management would you consider ?