ECG of the Week – 20th October 2014

This ECG is from a 70 yr old male who presented with general lethargy and postural dizziness. He has a collapse the evening prior and recently had a diarrhoeal illness.
His medications include warfarin, metoprolol, frusemide, allopurinol, colchicine and digoxin.



Vital signs on arrival in the Emergency Department were:

  • GCS 14 
  • BP 78/36 
  • RR 16
  • Temp 36.2 C

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Exam Thoughts

Some things to consider give the patient's history and ECG findings:

  • What would your immediate management be ?
  • What investigations would you order ?
  • What will be the patient's disposition and likely long-term management ?

ECG of the Week – 13th October 2014 – Interpretation

This ECG is from a 45 yr old female. She presented with abdominal pain and vomiting. Investigations revealed an acute small bowel obstruction. Prior to admission to the ward a 'routine' ECG was performed and is below.
Check out the comments from our original post here.

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Rate:
  • Mean ventricular rate ~78 bpm
Rhythm:
  • Regularly irregular
  • Repeating pattern of sinus complex followed by two ventricular complexes

Axis:
  • Sinus complexes: Normal
  • Ventricular complexes: Left axis deviation
Intervals - Sinus Complexes:
  • PR - Normal (140ms)
  • QRS - Normal (80ms)
  • QT - 380ms
Intervals - Ventricular Complexes:
  • QRS - Prolonged (120-140ms)
  • QT - 360 ms
Segments:

  • Minor ST elevation sinus complex in lead V6
  • Ventricular complexes show appropriate ST segment and T wave discordant change

Additional:

  • Notching in terminal portion of ventricular QRS best seen in leads aVL and aVF ? native atrial activity - thanks to Ken for spotting this.

Interpretation:

Benign arrhythmia which will likely resolve once the underlying bowel obstruction has resolved. 
Causes could include:

  • Electrolyte abnormality
  • Acid/base disturbance
  • High vagal tone secondary to pain and nausea
  • Drug toxicity pending a review of the patient's usual medication



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 – 6th October 2014 – Interpretation

These ECG's are from a 55 yr old female who presented with an hour of chest pain. She was a smoker and on treatment for hypercholesterolaemia.
Check out the comments on our original post here.






ECG 1
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ECG 2
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ECG 3
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ECG 4
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I'm going to tackle the interpretation of all the ECG's in one go to save duplicating the non-essential points.

Rate:
  • 72
Rhythm:
  • Sinus rhythm
    • ECG 1 shows a sinus arrhythmia
    • ECG's 2 show regular sinus rhythm

Axis:
  • Normal
Intervals:
  • PR - Normal (~160ms)
  • QRS - Normal (80-100ms)
  • QT - 320-360ms
Segments:

  • The is progressive ST segment changes during the 4 serial ECG recordings.
    • In ECG 1 ST elevation occurs in leads aVR(1mm), V1-2(1mm), V3(3-4mm) and V4 (1mm). 
    • During the serial ECG's we see the ST elevation in leads V1-4 progress, maximal on ECG 4 with ST elevation in V1(2mm), V2(1-2mm), V3(4-5mm) and V4 (3mm).
    • ECG 3 also shows early ST elevation in the inferior leads although this is less pronounced on ECG 4.
  • ST Depression leads I, V5-6
    • As the ECG's progress the ST depression resolves in leads V5-6 (potentially prior to becoming ST elevation)

Additional:

  • Hyperacute T-waves in leads II, III, aVF, V3-6
  • T-wave in V2 progressively becomes more hyper-acute as the ECG's progress
  • Biphasic T wave V1

Interpretation:

  • Progressing antero-septal ST elevation with hyperacute T-waves
  • Likely LAD lesion, I agree with Ken that I suspected a 'wrap-around' component due to the inferior changes best seen in the 3rd ECG


What happened ?

The patient was sent for urgent coronary angiogram which showed:

  • 100% LAD occlusion --> Stented
  • 30% mid-RCA stenosis

I don't have the full angio report so can't comment on the exact location of the lesion or the anatomy of the LAD.
The patient's echo post procedure showed dital anteroseptal and anteroapical akinesis with preserved systolic function.


References / Further Reading

KG-EKG Press


Life in the Fast Lane
Dr Venkatsen's Blog



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 – 6th October 2014

These ECG's are from a 55 yr old female who presented with an hour of chest pain. She was a smoker and on treatment for hypercholesterolaemia.






ECG 1
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ECG 2
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ECG 3
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ECG 4
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The ECG's in this series were performed at 10 minute intervals.

I also want to point out that the current Australian Heart Foundation STEMI Criteria differ from those in the latest ESC and AHA guidelines. The current Australian Guidelines define a reperfusion therapy STEMI as:

  • Persistent ST elevation >1mm in 2 contiguous limb leads or
  • ST elevation >2mm in 2 contiguous chest leads or
  • New LBBB pattern

ECG of the Week – 29th September 2014 – Interpretation

This week's ECG is from a 60 yr old male who presented with 3 days of vomiting & diarrhoea.
Past medical history of hypertension and mild chronic renal impairment.
Thanks to Dr Anand Senthi for sharing this ECG case.
Check out the comments from our original post here.



Click to enlarge
Rate:

  • ~90 bpm
Rhythm:

  • Regular
  • Sinus rhythm
    • P waves best seen in the inferior leads
    • P waves difficult to see in the precordial and high-lateral leads
Axis:

  • Normal
Intervals:

  • PR - Prolonged (~240ms)
  • QRS - Prolonged (120ms)
  • QT - ms (QTc Bazette 380-400 ms)
Segments:
  • Nil significant abnormality
Additional:
  • Not typical LBBB or RBBB morphology given QRS widening
  • Peaked T waves leads V2-6
Interpretation:



  • ECG Features suggestive of hyperkalaemia


What happened ?

The patient had an urgent VBG which showed a K+ of 8.0 mmol/L ! 
Therapy with calcium gluconate, nebulised salbutamol and insulin/dextrose was commenced. 

Following treatment the ECG was repeated as is shown below:

ECG Post Treatment of Hyperkalaemia
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This ECG shows resolution of PR prolongation, QRS widening and T wave peaking seen on the first ECG.

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.