ECG in ED. What usually missed and underestimate ECG. STEMI equivalent ST depression. Tachy and brady. A doctor in ED must know this.

1. DECIPHERING COMMON ECG
FINDINGS IN
EMERGENCY DEPARTMENT
Dr Sazwan Reezal Bin Shamsuddin
Consultant Emergency Physician & Head,
Emergency & Trauma Department,
Hospital Sultan Haji Ahmad Shah,
Temerloh, Pahang DM.

2. • Ischemia/Infarction
• Arrythmia (Tachyarrhythmia, Bradyarrhythmia)
• Electrolyte imbalance
• Special medical condition

3. • The Eyes See What the Mind
Knows
• ECG is a tool. It still need a good
history taking and physical
examination.
• Indication?
• Expectation?

4. • Tonight is experience sharing of real cases.
• Cases missed or detected despite atypical presentation.

5. Basics ……

6. Confirm the rate ….

7. 30 squares = 6 second = 15 cm
In this example R wave = 6 ………. 6x 10 = 60/min
Always do this before interprete ECG :
 patient details/name in the ECG
 verify the correct time and date
 verify correct paper speed (25 mm/sec) and amplitude (10 mm/mv)

8. Case 1
• 52/Male
• No known illness (seldom fall sick), heavy smoker+
• c/o epigastric discomfort after meal, pressing in nature+, nausea+,
initially sweating+
• Had asam pedas earlier.
• FHx – brother was told to have ‘sakit jantung’
• Rushed to EU in a district hospital.
• Hemodynamically stable, pain score 5
• ECG stat

9. ECG

10. • Imp: GERD
• Rx :
• Syp MMT 30 mls stat
• IV Omeprazole 40 mg stat
• Pain score 2 after 1 H
observation
• Discharge with medication
• 6 hours later, patient came back.

11. What was missed?
• The risk factor was not take into
consideration.
• Serial ECG
• Cardiac enzyme after 4 H chest
pain
• SC Fundaparinux
• ?unstable angina

12. Case 2
• 28/F, G3P2 @ 28/52 POA. SN just finished her evening shift
• c/o easily feels lethargy & breathless x 4/7. Claimed that the gravid
uterus pushed her diaphragm. Bilateral leg pain is as her previous
pregnancy. No other symptoms.
• V/S BP 106/68 mmHg, PR 110, RR 26/min, T 37 C, Pain score 0

13. Sinus tachycardia
RBBB
T-wave inversions in the right precordial leads (V1-3) as well as
lead III

14. PE ECG findings:
• Sinus tachycardia
• Complete or incomplete RBBB
• Right ventricular strain pattern – T
wave inversions in the right precordial
leads (V1-4) ± the inferior leads (II, III,
aVF). This pattern is associated with
high pulmonary artery pressures
(34%)
• Right axis deviation
• Dominant R wave in V1
• Right atrial enlargement (P
pulmonale)
• SI QIII TIII pattern – deep S wave in
lead I, Q wave in III, inverted T wave
in III (20%). This “classic” finding is
neither sensitive nor specific for PE

15. Progress:
• The calf feels ‘tense’ & tender R>L
• POCUS –The 2-point technique tests the compressibility of the
common femoral vein (CFV)  R side not compressible.
• CT pulmonary angiogram  present of thrombus.
• Treatment as per protocol
• Highlight : risk factor, some patient in GZ need further evaluation

16. Case 3
• 48/M, HPT+, hypercholesterolemia, smoker+
• When to district hospital EU
• c/o central chest pain x 2 hours, heaviness+, nausea+, vomiting+
• p/e- DRNM, lungs clear, no pedal edema
• Hemodynamically stable.
• Troponin NEGATIVE
• SL GTN, Aspirin, Clopidogrel was given.

17. Widespread ST segment depression in leads II, III, aVF, V4, V5, and V6

18. • Pt was admitted to the ward.
• SC Fundaparinux given
• 2 hours later patient become
restless, sweating++
• asystole
• This pattern of ECG findings is
consistent with left main
coronary artery occlusion.

19. STEMI equivalent patterns
• It is now recognized that ECG patterns which do not meet the
traditional diagnostic criteria for STEMI may represent significant
AMI.
• these patterns are generally referred to as the STEMI equivalent
patterns

20. ST segment elevation in
leads aVL and V2
ST segment depression
in leads III and aVF
This ECG pattern is consistent with a first diagonal, or D1, lesion.
The first diagonal branch (D1) of the LAD supplies blood to the
anterolateral wall of the left ventricle

21. ST segment depression with
J point depression in
leads V2 to V5
prominent T waves are noted
in leads V2 to V4
ST segment elevation is seen in lead aVR
This ECG pattern is termed the de Winter finding and is
consistent with a proximal LAD occlusion.

22. biphasic T wave abnormalities
in leads V1 to V4.
Biphasic refers to both upright and inverted T wave abnormalities in a single T wave
Wellen’s syndrome and is consistent with proximal LAD
occlusion.

23. The clinical relevance of Wellens’ Syndrome
• Patients may be pain free by the
time the ECG is taken, and have
normal or minimally elevated
cardiac enzymes. However, they
are at extremely high risk for
extensive anterior wall MI within
the subsequent days to weeks
• Due to the critical LAD stenosis,
these patients usually require
invasive therapy, do poorly with
medical management, and may
suffer MI or cardiac arrest.
• The T wave changes, being the
most important diagnostic feature
of Wellens’ Syndrome, consist of
two distinct patterns in leads V2
and V3.
The more common abnormality
(75% of cases) consists of deeply
inverted and symmetric T waves.
the second subtype consists of
biphasic T waves (25% of cases)

24. Wellens pattern A:
Biphasic T waves
Wellens pattern B:
Deeply inverted T waves

25. Case 4
• 54/F
• Central chest pain (classical) x 6 hours progressively worsening.
• No other sx
• P/e BP 136/82 mmHg, PR 76/min, RR 20/min. Pain score 6
• ECG : …………
• Trop: -ve
• Rx : SL GTN, Aspirin, Clopidogrel, SC Fundaparinux
• Admit

26. Next step?

27. •Isolated posterior MI is less common (3-11% of infarcts).
•Isolated posterior infarction is an indication for emergent coronary
reperfusion. However, the lack of obvious ST elevation in this
condition means that the diagnosis is often missed.

28. STEMI equivalent patterns ECG

29. Case 5
• 65 years old presented with central chest pain describe as ‘somebody
shoots from front to back’.
• Associated with nausea+ sweating ++
• o/e BP 210/110 mmHg PR RR 28/min SpO2 98% OA T 37C
• ECG stat
• SL GTN 1/1
• Aspirin served after ECG

30. • Decision : fibrinolytic therapy
• Aim BP < 160 mmHg before
therapy.
• Trace RP, CXR

32. Case 6
• 16/M
• c/o syncope at school during assembly. Not eat breakfast today.
• Previously well.
• FHx – father passed away at 38 y.o, brother passed away at 22 years
old.
• BP standing & lying 110/70 mmHg PR 86/min, RR 16, Pain sore 0
• Dsix 5.2
• ECG ……

33. Brugada Syndrome

34. Brugada Syndrome
• is an ECG abnormality with a high
incidence of sudden death in
patients with structurally normal
hearts.
• Incidence high in Southeast Asia
where it had been previously
described as Sudden Unexplained
Nocturnal Death Syndrome
(SUNDS).
• The only proven therapy is an
implantable cardioverter –
defibrillator (ICD).
• Coved ST segment elevation >2mm in >1 of V1-V3 followed
by a negative T wave. (Type I)
• >2mm of saddleback shaped ST elevation. (Type II)
• <2mm of ST segment elevation (Type III)

35. Case 7
• A 58/M presented with dizziness, mild breathlessness.
• BP 200/120 mmHg, HR 180/min
• Patient diagnosed as unstable SVT, sync cardioversion was given.
• 1st dose 50 J – not revert
• 2nd dose 100 J – not revert
• 3rd dose 150 J - succesful

37. Tachyarrythmia HR > 150/min

38. Regularity

39. Why important to differentiate?
• AF  risk for thrombus
• Might need assessment prior to
sync cardioversion.
• Higher energy for sync
• Pharmacological treatment
different

40. Case 8: Bradyarrhythmia

41. Why need to differentiate?
• 3rd degree (complete) heart block most probably will need TCP
• 2nd degree heart block (Mobitz Type II) increased risk to be 3rd degree
…….. Transfer of patient must be with TCP standby

42. PR interval > 200ms (five small squares)
• Athletic training
• Inferior MI
• Mitral valve surgery
• Myocarditis
• Electrolyte disturbances (e.g. Hyperkalaemia)
• AV nodal blocking drugs (beta-blockers, calcium channel blockers, digoxin,
amiodarone)
• May be a normal variant

43. PR interval is longest immediately before dropped
beat
PR interval is shortest immediately after dropped
beat
• Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
• Increased vagal tone (e.g. athletes)
• Inferior MI
• Myocarditis
• Following cardiac surgery (mitral valve repair, Tetralogy of Fallot
repair)

44. A form of 2nd degree AV block in which there is
intermittent non-conducted P waves without
progressive prolongation of the PR interval
• Anterior MI (due to septal infarction with necrosis of the bundle branches)
• Cardiac surgery, especially surgery occurring close to the septum e.g.
mitral valve repair
• Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease)
• Autoimmune (SLE, systemic sclerosis)
• Infiltrative myocardial disease (amyloidosis, haemochromatosis,
sarcoidosis)
• Hyperkalaemia
• Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone

45. complete AV dissociation, with independent
atrial and ventricular rates
• Inferior myocardial infarction
• AV-nodal blocking drugs (e.g.
calcium-channel blockers, beta-
blockers, digoxin)
• Idiopathic degeneration of the
conducting system (Lenegre’s or
Lev’s disease), causing true
trifascicular block
 Patients with third degree heart block are at high risk of
ventricular standstill and sudden cardiac death
 They require urgent admission for cardiac monitoring,
backup temporary pacing and usually insertion of a
permanent pacemaker

46. Take home messages
• Normal ECG doesn't mean everything is fine.
• Don’t simply blame sinus tachycardia because patient walk in from
parking lot.
• ST elevation not always Myocardial Infarction
• Before administer fibrinolytic therapy in STE ECG, examine for
anaemia & feel the pulses.
• ST depression is NOT a benign condition.
• Must confirm regularity manually.
• 3rd degree heart block by exclusion.

47. Thank you
• You may download the lecture :
SlideShare >> drwaque >>
Deciphering Common Ecg
Findings In ED