1. ECG Jeopardy
Charlie Bloe
Clinical Manager, CCU, Raigmore Hospital

2. Site of Infarct
Anterior MI
Inferior MI

4. Site of Infarct
Anterior MI
Inferior MI

8. Sufficient ECG criteria
to administer
thrombolysis in this
patient with chest pain
for last 90 minutes?

10. Sufficient ECG criteria to administer
thrombolysis?
Yes
No

11. ECG criteria for thrombolysis
• Characteristic Pain
• Gradual onset of pain (>30 mins < 12 hours)
• Pain not relieved by nitrates
• ECG changes
• 1mm or > ST elevation in 2 limb leads
• 2 mm or > ST elevation in 2 or more adjacent chest
leads
• New left bundle branch block

13. Case study
• 64 year old man with 1 hour of chest pain.
Wife dialled 999. Friday 6pm.
• Recent bout of Flu.
• Severe, heavy, central pain with radiation to
jaws and arms.
• Pale and sweaty.
• Lives 5 minutes from Raigmore Hospital.

15. Anterior STEMI
Viral Pericarditis

17. What would you do?
Thrombolysis if no
contraindications
‘Scoop and Run’

18. In the early stages of STEMI each 1 minute delay
to thrombolysis reduces life expectancy by:
1 day
11 days

19. The 12-lead ECG in a patient with
Unstable Angina may appear
normal?
True
False

20. STEMI or not STEMI?
• 45 year old man with 3 days of chest pain.
• First aware of it while playing 5-a-side
football.
• Varying intensity over last 3 days but there
pretty much all of the time.
• Feels like a pulled muscle.
• No radiation.
• A bit pale but otherwise looks well.

22. STEMI?
Yes
No

23. Pericarditis
ECG changes:
• ST elevation
• Upward concavity
• Widespread
• Notching at end of QRS
• Not evolving
• No Q wave
• Pain often pleuritic in nature,
worse on inspiration.

25. What rhythm?

26. What rhythm?
VF – cardiac arrest
Atrial Flutter

27. What rhythm?

28. Case study
• 32 year old man.
• No significant PMH. Smoker.
• Chest pain for about 8 hours.
• Dull central ache. No radiation.
• ECG #1 recorded - not transmitted to CCU.

29. ECG 1 at
1.15am by GP

30. ECG within normal
limits
Anterior STEMI

31. ECG 1 at
1.15am by GP

32. Case study
• Arrives in AMAU at Raigmore Hospital 1 hour
later.
• ECG #2 recorded.

33. ECG 2 at
2.30am

34. ECG within normal
limits
Anterior lateral
STEMI

35. ECG 2 at
2.30am

36. Case study
• 59 year old lady.
• Hypertension and smoker.
• Ischaemic chest pain for 2 hours.
• Lives in isolated croft 2 hours from
Raigmore.
• Call made in January 2010.
• When Paramedics arrived 2 feet of snow
outside her house!

38. Diagnosis?
Inferior MI with
complete heart block.
Inferior MI
with 2:1 block.

40. What’s the rhythm?

41. Nodal Rhythm
Atrial Fibrillation

43. What proportion of
all strokes are
attributable to Atrial
Fibrillation (AF) ?

44. 30-40%
15-20%

45. Record a 12-Lead
ECG in all patients
that have an
irregular pulse!

46. Case study
• 50 year old man from Aviemore
complaining of central chest pain.
• Feels like trapped wind.
• Diagnostic ECG machine querying
anterior MI.

48. Anterior STEMI – advise
Thrombolysis.
Normal ECG – advise he
has a fart.

50. Heart Block
Which Degree?

52. Second degree
heart block Type II
Complete heart
block

54. Fast and wide rhythm.
Is it Ventricular
Tachycardia (VT)?

56. VT?
Yes
No

58. What type of block
RBBB or LBBB?

60. Right bundle
branch block (RBBB)
Left bundle
Branch block (LBBB)

62. Cardiac Axis

64. Right axis deviation
Left axis deviation

66. 70 year old man with dyspnoea

67. Atrial Flutter?
Yes
No

68. 70 year old man with dyspnoea

69. Final Question!
Which drug
effect?

71. Which drug?
Digoxin
Amiodarone

72. CASE 4