2. Question1
• A 35 year old man presents with
palpitations. He has been drinking
heavily with friends over the weekend.
This is his ECG. Present your findings
and give a diagnosis.
3.
4. Answer
• Rate100 – 150
• Rhythm Irregularly irregular
• AxisNormal
• PR/P-wave No p-wave seen. Fibrillating base line
• QRSNarrow
• ST/T-wave Normal
• QTc/other Normal
• Diagnosis:
• This ECG shows atrial fibrillation (AF) with a fast ventricular response. With this history the
underlying diagnosis would fit with a ‘holiday heart’ syndrome.
5. Question2
• A 45 year old business man presents with
a feeling that his heart is racing. He also
has some shortness of breath. This is his
ECG. Present your findings and give a
diagnosis.
6.
7. Answer
• Rate150
• Rhythm Regular
• AxisNormal
• PR/P-wave No p-waves. Seesaw baseline
• QRSNarrow
• QTc/other Normal
• Diagnosis:
• This is atrial flutter. The atria contract at 300 beats per minute causing a ‘seesaw’ baseline.
Beats are transmitted with a 2:1, 3:1 or 4:1 block, leading to ventricular rates of 150, 100 and 75
BPM respectively.
8. Question 3
• A 75 year old man with a history of
COPD presents with fever and increased
sputum production. An ECG is taken in
the emergency department. What does it
show?
9.
10. Answer
• Rate100 – 150
• Rhythm Irregularly irregular
• AxisNormal
• PR/P wave Polymorphic p-waves (see arrows)
• QRSNarrow
• ST/T wave Normal
• QTc/other Normal
• Diagnosis:
• This is polymorphic atrial tachycardia. It occurs in respiratory disease and reflects an aberrant foci
of atrial excitation. The morphology of the p-waves is therefore variable but all p-waves are
transmitted via the bundle of His and therefore the QRS complexes are all the same.
11. Question4
• A 65 year old man is found
unresponsive. He has no central pulse
and is making no respiratory effort.
Surprisingly someone has done an ECG.
What would you do?
12.
13. Answer
I. We will not go through the ECG as the most important information is in the clinical
history.
II. This is pulseless electrical activity (PEA). It is the most extreme example of why you
should look at the patient in conjunction with the ECG! There are no specific ECG
changes in PEA – the most important thing is to recognize that this patient is in cardiac
arrest and to start chest compressions and Advanced Life Support (ALS) immediately.
III. However, the ECG may help you ascertain the underlying pathology. In this case there
are low voltage QRS complexes which may simply due to large body habitus or could
indicate pathology ‘interrupting’ the signal between the heart and the electrode. This
can include pericardial fluid or pneumothorax. This is worth thinking about as
tamponade and tension pneumothorax are both reversible causes of PEA.
14. Question5
•A fit and well 31 year old man
presents for a routine insurance
medical. This is his ECG. Present
your findings and give the diagnosis.
15.
16. Answer
• Rate85 ............ Rhythm Regular
• AxisNormal
• PR/P-wave Normal
• QRSNarrow
• ST/T-wave Normal
• QTc/other Normal
• Diagnosis:
• This is a normal ECG. There are many variants of normal and it is worth looking at as many ECGs
as possible to get exposed to the common variants. It is crucial to remember that a very sick patient
can have a normal ECG so always use all the information available to you and don’t rely on the ECG
alone.
17. Question6
• A 65 year old man with a history of
ischaemic heart disease is found
unresponsive. He has no central pulse and is
making no respiratory effort. This is his
ECG. What is the diagnosis and what will
you do?
18.
19. Answer
• Rate 150
• Rhythm Regular
• Axis Left axis deviation
• PR/P wave Not visible
• QRS Wide
• ST/T wave Unable to assess
• QTc/other Unable to assess
• Diagnosis:
• This is ventricular tachycardia (VT) and in this case the patient is in cardiac arrest as they have no central pulse. He should
be treated as per ALS guidelines with chest compressions beginning immediately. This is a shockable rhythm and should be
treated using the ALS algorithm with DC cardioversion and adrenaline.
• If the patient was conscious the ALS algorithm would not be necessary and management depends on symptoms. If acutely
symptomatic urgent DC cardioversion is indicated. If there were no symptoms of decompensation (e.g. shortness of breath,
chest pain, shock, confusion, syncope) he could be managed pharmaceutically in the first instance.
20. Question7
• A 40 year old lady comes to the emergency
department from her husband’s funeral with
a sensation of ‘fluttering’ in her chest. She is
feeling very anxious. An ECG is performed.
What is the diagnosis?
21.
22. Answer
• Rate 160 .............. Rhythm Regular
• Axis Normal
• PR/P wave Not visible
• QRS Narrow
• ST/T wave Slight lateral ST depression
• QTc/other Normal
• Diagnosis:
• The history makes a sinus tachycardia secondary to anxiety seem likely. However, sinus rhythm rarely goes above 120
BPM and in this case there are no p-waves visible. This is therefore a junctional supraventricular tachycardia (SVT): a
narrow-complex tachycardia originating from the AV node. Treatment includes vagal manoeuvres followed by
adenosine.
• Atrial flutter would be a reasonable differential as the rate is regular and close to 150. However, there is no variation in
the baseline and not a hint of sawtooth appearance so this is less likely than SVT.
23. Question8
• A 58 year old man who attends the
emergency department with chest pain loses
consciousness whilst he is having his initial
ECG. He has no central pulse and is taking
occasional deep breaths. What is going on?
24.
25. Answer
• Rate Initially 100, then 300
• Rhythm Initially regular, then irregular
• PR/P wave Initially present, then unable to visualise
• QRSInitially narrow, then wide
• ST/T wave Initially massive ST elevation in II III and aVF with reciprocal depression in I and
aVL. Then unable to visualise
• QTc/other Unable to assess
• Diagnosis:
• This is ECG initially shows an inferior STEMI, which then deteriorates into ventricular
fibrillation (VF). The breaths described are agonal breaths – this does not represent normal
respiratory effort and resuscitation for cardiac arrest with CPR should be started immediately.
26. Question9
•A 72 year old lady presents
with collapse. This is her ECG.
Present your findings. How
would you proceed?
27.
28. Answer
• Rate50 bpm .......Rhythm Regular
• AxisNormal
• PR/P wave Normal
• QRSNarrow
• ST/T wave Normal
• QTc/other Normal
• Diagnosis:
• This is sinus bradycardia. In a young fit person this rate may be normal. However, in the
context of a more elderly person and presenting with collapse it should be further
investigated. A medication review, blood tests including thyroid function, repeat ECGs, chest
x-ray, echocardiogram and 24-hour tape would be reasonable first-line investigations.
29. Question 10
•A 60 year old man presents with
tight central chest pain radiating to
his left shoulder. This is his initial
ECG. Present your findings and give
a diagnosis.
30.
31. Answer
• Rate 90 ...... Rhythm Regular
• AxisNormal .......... PR/P wave Normal
• QRSNarrow
• ST/T wave Grossly elevated in V2, V3, V4, V5 and V6. Reciprocal depression in II, III and
aVF.
• QTc/other Normal
• Diagnosis:
• This patient has ST elevation in the anterior and lateral leads. This is therefore an
anterolateral ST elevation MI (STEMI). This dramatic ST elevation is also referred to as
‘tombstone’ ST elevation, both for its resemblance to a tombstone and as a reflection on the
poor prognosis without rapid intervention.
32. Question11
• A 55 year old renal dialysis patient presents
to the emergency department having missed
his last session of dialysis due to feeling dizzy
and unwell. This is his ECG. Present your
findings and give a diagnosis.
33.
34. Answer
• Rate 100 – 150 .............. Rhythm Irregular
• Axis Unable to establish ...................... PR/P wave Not visible
• QRS Widened ..................... ST/T wave Merged with QRS
• QTc/other Unable to assess
• Diagnosis:
• This is the classic sine wave ECG pattern of severe hyperkalaemia. It can quickly deteriorate into
ventricular fibrillation (VF). There are three main ECG changes in hyperkalaemia:
I. 1. In the early stages of you may only see tenting or peaking of the t-waves.
II. 2. Later changes involve a decrease in height of the p-wave and increase in length of the PR interval as
conduction is slowed through the atrial myocardium.
III. 3. This is later accompanied by widening of the QRS and merging of the QRS complex and the t-wave.
This pattern eventually deteriorates to the sine wave pattern seen above.
35. Question12
• A 65 year old woman presents with chest
pain radiating to her jaw and down her left
arm. It feels like her ‘normal’ angina but on
this occasion it has not eased with GTN
spray. This is her ECG. Present your findings
and give the diagnosis.
36.
37. Answer
• Rate60 ................ Rhythm Normal
• AxisNormal .................... PR/P wave Normal
• QRSNormal
• ST/T wave T wave inverted in II III and aVF , V4 – V5. ST elevation in aVR>1mm
• QTc/other Normal
• Diagnosis:
• On initial inspection this looks like an inferolateral NSTEMI. There is (we assume new) t-wave
inversion in consecutive leads which fit with an anatomical territory (inferolateral) and most
importantly there is ongoing ischaemic sounding chest pain not eased by GTN. However,
note the ST elevation in aVR. As such, this is more suggestive of critical left main stem
38. Question13
• A 25 year old man presents with a
collapse which occurred as he was
playing in a football match. He has
suffered episodes of fainting in the past.
This is his ECG. What is the diagnosis?
39.
40. Answer
• Rate60 ....................... Rhythm Regular
• AxisNormal ................... PR/P wave Shortened PR interval
• QRS‘Slurred’ upstroke on QRS ........... ST/T wave Normal
• QTc/other Normal
• Diagnosis:
• This picture of shortened PR interval and slurred QRS upstroke – also know as a ‘delta wave’
– are typical of Wolff-Parkinson White (WPW) syndrome. These changes represent
transmission through an accessory pathway. The history of collapse in this case is concerning
as these episodes could be due to re-entrant tachycardias which can be fatal. Other features
not seen here which may be present in WPW include a dominant R wave in V1 and T wave
inversion in the anterior chest leads.
41. Question14
•An 18 year old man signs up to
join the army. He is fit and well.
This is his ECG taken at his
medical examination. Is it
42.
43. Answer
• Rate60 ................ Rhythm Regular
• AxisNormal ............. PR/P wave Prolonged PR interval
• QRSWide in the inferior lateral leads
• ST/T wave Abnormal in V1, V2 and V3 with unusually-shaped ‘coved’ ST elevation
• QTc/other Normal
• Diagnosis:
• No it is certainly not normal. This ECG is characteristic of Brugada Syndrome (Type 1). In
leads V1 – V3 there is >2mm ST elevation, the T waves are inverted and the ST segment has a
characteristic ‘coved’ shape. This condition has a high risk of sudden death from ventricular
fibrillation (VF). Treatment is with an implantable cardioverter-defibillator (ICD).
44. Question15
•A 58 year old smoker presents with
tight epigastric pain. He looks sweaty
and unwell. One of the nurses shows
you his routine ECG. What is the
diagnosis?
45.
46. Answer
• Rate45 ............ Rhythm Regular
• AxisNormal ............... QRS Narrow
• ST/T wave Dramatic ST depression in V1 – V3
• Diagnosis:
• This is acute posterior MI. What we see in the anterior leads is the equivalent of ‘upside
down’ ST elevation. Imagine flipping the ECG paper over and looking at it from behind or
looking at the ECG in a mirror held along the inferior border. You would see ST elevation (the
deep ST depression reversed), t-wave inversion (upright t-waves seen upside down) and this
represents what is going on in the posterior region of the heart. Another clue is the
bradycardia seen in this case: the vessels supplying the posterior of the heart also supply the
‘pacemaker’ region of the SA node.
47. Question16
•A 29 year old presents with central
chest pain. She has a history of
recent flu-like illness but no
significant past medical history. This
is her ECG. What is the diagnosis?
48.
49. Answer
• Rate60
• Rhythm Regular
• AxisNormal
• PR/P wave PR segment depression
• QRSNarrow
• ST/T wave Widespread ST elevation (saddle shaped)
• QTc/other Normal
• Diagnosis:
• The diagnosis is pericarditis. Pericarditis often presents in young people after a history of
viral illness. He you can see the characteristic widespread saddle-shaped ST elevation and PR
depression.
50. Question17
• A 70 year old woman presents with
sudden onset of chest pain. The pain is
crushing in nature and radiates up to
her jaw. This is her ECG. Present your
findings and give the diagnosis.
51.
52. Answer
• Rate100 ....... Rhythm Regular
• AxisNormal
• PR/P wave Every p-wave followed by a QRS
• QRSNarrow
• ST/T wave ST elevation in II III and aVF
• QTc/other Normal
• Diagnosis:
• This ECG shows ST elevation in the inferior region of the heart. This patient should be
assessed and treated urgently for a STEMI, ideally with primary angioplasty. Immediate
management also includes aspirin, clopidogrel, heparin, nitrites, morphine and controlled
oxygen.
53. Question18
• A 45 woman has just stepped off a flight
from Japan when she develops severe
pleuritic chest pain and shortness of breath.
On examination her chest is clear. Present
your findings. What is the most likely
diagnosis?
54.
55. Answer
• Rate100 ............. Rhythm Regular
• AxisRight axis deviation ................ PR/P wave Normal
• QRSWide – right bundle branch block (RBBB)
• ST/T wave T wave inversion in lead III ............. QTc/other Normal
• Diagnosis:
• Given the history, examination and ECG findings, pulmonary embolism (PE) is the most
likely diagnosis. In PE the constellation of ECG findings of ‘S1Q3T3’ is classically described. It
refers to a deep S wave in lead I, pathological Q wave in lead III and inverted T in V3 (and
other anterior leads). However, though it may be classical it is extremely rare in clinical
practice! The most commonly observed ECG abnormality in PE is a sinus tachycardia. There
may also be RBBB or a RV strain pattern with T wave inversion in V1 to V4.
56. Question19
• It is early January and a middle-aged
man is found lying in a park. He is
surrounded by bottles of Buckfast and
has a GCS of 9. An ECG is performed in
the ambulance. What is going on?
57.
58. Answer
• Rate50 ........... Rhythm Regular
• AxisNormal ................. PR/P wave Normal
• QRSNarrow ................ ST/T wave Normal
• QTc/other J wave visible after the QRS
• Diagnosis:
• This patient is hypothermic. The positive deflection after the QRS but before the t-wave is an
Osbourne J-wave; these can also be seen in subarachnoid haemorrhage (SAH) and
hypercalcaemia. Classically a hypothermic patient is bradycardic and their ECG will show J-
waves. Treatment in this case would be with gentle rewarming provided there was no
immediate risk to life from an arrhythmia.
59. Question20
• A 61 year old woman presents to the
emergency department with diarrhoea and
vomiting. She has recently been started on
furosemide by her GP for hypertension.
What has happened?
60.
61. Answer
• AnswerRate 85 ............. Rhythm Regular
AxisLeft axis (may be normal) ........... PR/P wave Normal
QRSNarrow .............. ST/T wave Normal
• QTc/other Prolonged QTc
Diagnosis:
This ECG shows changes consistent with hypokalaemia. This has likely be precipitated by the
new loop diuretic. Note also that furosemide is not a first-line treatment for hypertension.
Classically hypokalaemia causes t-wave flattening with ST depression. In severe cases you
may see a U-wave. This is a positive deflection following the t-wave but preceding the p-wave.
These are found in hypokalaemia but also in hypercalcaemia and thyrotoxicosis.
62. Question21
• An 18 year old lady is found collapsed at
home. When you see her she has a GCS
of 10 and you notice that her pupils are
dilated. This is her ECG. Present your
findings and give the diagnosis.
63.
64. Answer
• Rate 85 .... Rhythm Regular ........ PR/P wave Unable to assess ............... QRS Wide
• ST/T wave Wide ............... QTc/other Prolonged
• Diagnosis:
1. The diagnosis is tricyclic antidepressant overdose. This causes widening of the QRS complex and
lengthening of the QT interval due to blockade of sodium channels. 2. [/toggle_item]
3. [toggle_item title=”What would you do?” active=”false”].......4. A,B,C,D,E (ventilation may be required)
5. Bloods including paracetamol level; ABG (likely metabolic acidosis) .6. Activated charcoal if within 8hrs of
ingestion
7. Sodium bicarbonate (50ml of 8.4%).. 8. Give if any arrhythmia or QRS>110
Further options:
If ventricular tachycardia: lignocaine (avoid beta blockers, amiodarone and calcium blockers)
If seizures: benzodiazepines
65. Question22
•A 45 year old man is found
collapsed at home. There is no
history available. This is his ECG.
What is the diagnosis?
66.
67. Answer
• RateHighly variable – up to 300 bpm .... Rhythm Irregular
• AxisUnable to assess ............ PR/P wave Absent during episodes of extreme
tachycardia
. QRSWide ............. ST/T wave Unable to assess ............. QTc/otherUnable to assess
• Diagnosis:
• This is a difficult case and shows runs of polymorphic VT or Torsades de pointes (literally
translated as twisting of the points). It has a number of causes including medications
(especially psychotropics) and electrolyte imbalance. Essentially any cause of long QT can
precipitate polymorphic VT.
• Management in the first instance is magnesium 2g IV, independent of serum magnesium
concentration before treating any other cause of long QT.
68. Question23
• A 50 year old man presents with collapse. He has
been unwell recently with a chest infection for
which he has been prescribed clarithromycin
from his GP. He also takes medication for his
hayfever at this time of year. What is most
concerning here?
69.
70. Answer
• Rate60 ............. RhythmRegular ............ Axis Normal
• PR/P wave Normal ... QRS Narrow ........ ST/T wave Normal
• QTc/other Prolonged QT interval
• Diagnosis:
• This patient has a prolonged QT interval and a cause for this should be sought. Medications
are the likely culprits in this case: both clarithromycin and the antihistamine
diphenhydramine can cause prolonged QT interval.
• The normal length of the QT varies with heart rate and there is a formula that is applied to
correct for this. ECG machines automatically provide you with this ‘corrected QT’ (QTc).
Normal QTc is generally under 480ms. As a rule of thumb, if the end of the QT interval is
over over half way to the next QRS then consider long QT.
