EKG#1
EKG #2
EKG #3
EKG #4
EKG #5
EKG #6
EKG#1
Third Degree Heart Block
EKG#2
Hypertrophic Cardiomyopathy
EKG#3
Wolff Parkinson White
EKG#4
Arrhythmogenic Right Ventricular Dysplasia (ARVD)
EKG#5
Brugada
EKG#6
Prolonged QT
EKG #1
What’s the rhythm?
EKG #2
Dude, what’s the rhythm?
EKG #3
Home skillet, what’s the rhythm?
EKG #1 - Atrial Fibrillation
· Super irregular! This is probably the most common irregularly irregular rhythm we see
· You may have confused this with atrial flutter because of the coarse fib waves in V1
o First, you’re not alone: 1999 study showed high frequency of incorrect diagnosis, even by cardiologists: https://www.ncbi.nlm.nih.gov/pubmed/10549907
o It may not matter, since aflutter and afib are treated same way in the ED
But since you’re all nerds like me, here’s how to differentiate…
1. The waves in atrial flutter are much more uniform than the ones above.
2. Flutter waves are classically sawtooth morphology
3. Remember atrial flutter can be regular. It is only irregular when you have variable conduction.
I.e. when you have two flutter waves and a QRS, then three flutter waves and a QRS, then four, then two again…
EKG #2 - Multifocal Atrial Tachycardia (MAT)
· Multiple foci in the atria triggering the AV node. Look at all the different P wave shapes!
· Three separate P wave morphologies = diagnostic of MAT
· The slow version of MAT is a wandering pacemaker (MAT without the T)
· Classically presents in a patient with COPD or CHF
· Note that this EKG has R axis deviation, perhaps from cor pulmonale
EKG #3 - Premature Atrial Contractions, Normal Sinus Rhythm
· So this is yet another irregularly irregular EKG, and at first glance you may call this atrial fibrillation.
· However, note all the well defined p waves – this is sinus tach
· So why is it irregular?
· Before those irregularly occurring QRS complexes, there is a p wave, and it looks exactly the same as all the other p waves (in height, width, and axis)
· The SA node is firing early, depolarizing the ventricles, and creating an irregular rhythm
Ohmygod, great question, so glad you asked!
From Wikipedia: “A Lewis Lead is a modified ECG lead used to detect atrial [activity] when [it] is suspected… but is not definitively demonstrated on the standard 12 lead ECG.”
So you think someone has atrial flutter (sustained HR of 145 perhaps?) but you can’t see any p waves or sawtooth activity.
Maybe you’re trying to discern SVT from fast sinus tach?
How can you solve this conundrum?
Lewis Lead!
1. You can do this on the monitor, you don’t need a 12lead
2. Arrange the leads as seen here. (The green one can go anywhere, it’s just an electrical ground)
3. Check for atrial activity
Before the Lewis Lead… (where the p waves at?)
After the Lewis Lead! (Retrograde p waves, mostly upright at the end of the QRS. No p waves prior to the QRS. This is SVT.)
Lewis Lead
https://en.wikipedia.org/wiki/Lewis_lead
http://hqmeded-ecg.blogspot.com/2018/03/hypotensive-and-tachycardic-in-clinic.html
Long article about atrial fibrillation:
http://www.emdocs.net/more-atrial-fibrillation-management-pearls-in-the-ed/
You need to memorize this flow chart! (Courtesy of ALiEM)
Tachydysrhythmia Algorithm
EKG #1
36 year old, swole, healthy male, sharp diffuse anterior chest pain after pumping mad weights at the gym yesterday. He has a snake tattoo on his shoulder.
Like, what? Why?
How would you describe this EKG over the phone to a consultant?
What's the most likely EKG diagnosis? Anything else on your ddx?
Name two EKG findings that support your diagnosis.
Are you getting a troponin on this patient? If so, how many?
EKG #2
28 year old female, recent fever/cough, now with pleuritic/central/sharp chest pain. Kind of whiney. She’s on her phone.
1. What’s the most likely diagnosis?
2. Name two findings that support your diagnosis.
3. Is this EKG different from the previous? If so, how?
EKG #3
46 year old male with chest pain
1. What is the diagnosis? What about the EKG supports your diagnosis?
2. Is this EKG different from the previous two? If so, how?
EKG #1
Benign Early Repolarization
· BER is a super common EKG pattern, so be familiar!
· Two main findings:
o Diffuse concave ST elevation, more-so in the precordial leads (usually < 2mm)
o Elevation & notching at the J-point.
§ Notching best seen in V4 – may look slurred in other leads
· Importantly, there are NO RECIPROCAL CHANGES
· Be suspicious of this diagnosis in patients over 50yo, consider ischemia
· With regards to the troponin, this is probably a style point, and I’m not sure there’s a right answer. Some attendings probably won’t get one. Most will just order one at the onset and call it a day. Some will argue that you can’t rule out ACS without serial troponins.
EKG #2
Pericarditis
· Like BER, pericarditis also has diffuse concave ST elevation!
So how do we distinguish between BER and pericarditis??
EKG #3
Anterior STEMI
THIS IS AN IMPORTANT EKG. Our job isn’t to diagnose BER – it’s to see if our patient is having a heart attack.
Why is this an AMI and not benign early repolarization?
1. ST segments are nearly linear and lack the obvious concavity of the other EKGs
2. There is reciprocal change in lead III (look to inferior leads in anterior STEMI)
3. Leads V2-V4 have scary (pathologic) Q waves
4. There is poor R wave progression (there should be at least 3mm in V3 – here it’s 0mm)
Finally, for those of you who want to take it to the next level…
· This is actually an anterior MI, which is super frightening.
· It’s concave, there aren’t Q waves, there’s not reciprocal depressions (?III is inverted), though there is poor R wave progression and the T waves look big.
· There is a crazy formula you can use to distinguish BER from an AMI.
(1.062 x STE at 60 ms after the J-point in V3 in mm) + (0.052 x computerized QTc) - (0.151 x QRSV2) - (0.268 x R-wave Amplitude in V4 in mm)
· >18.2 is likely an LAD occlusion.
· More important than knowing this formula is knowing…
o Just because you don’t see a STEMI doesn’t mean they’re not infarcting
o If you’re suspicion is high enough, get a repeat EKG
RESOURCES FOR FURTHER READING:
Benign Early Repol - https://litfl.com/benign-early-repolarisation-ecg-library/
Pericarditis - https://litfl.com/pericarditis-ecg-library/
Anterior STEMI vs BER - http://www.emdocs.net/ber-vs-anterior-stemi/
Anterior STEMIs - https://litfl.com/anterior-myocardial-infarction-ecg-library/
For a super crazy next level anterior STEMI lesson…
https://hqmeded-ecg.blogspot.com/search/label/Examples%20of%20Formula%20Use--12%20of%20them