This document discusses ECG abnormalities seen in various conditions commonly presenting in the emergency room, including pulmonary embolism, cardiac tamponade, hypokalemia, and dilated cardiomyopathy. For pulmonary embolism, the ECG may show sinus tachycardia, signs of right ventricular strain, S1Q3T3 pattern, and T wave inversion in anterior leads. Cardiac tamponade can cause electrical alternans. Hypokalemia results in ST depression, flattened T waves, QT prolongation, negative T waves, and possible U waves. Dilated cardiomyopathy is associated with left atrial enlargement, left or biatrial enlargement, left ventricular hypertrophy, left or right

2. The eye does not see what the
mind does not know...

3. The EKG must be interpreted in
the clinical context.
Don’t order a test unless you
know what to do with the
results…

4.  In this session we will discuss ECG abnormalities
found in various miscellaneous conditions commonly
presenting in ER (ACS & ARRHYTHMIAS– already
covered; ACUTE PULMONARY EMBOLISM, COPD,
CVA, TAMPONADE, PERICARDITIS, ELECTROLYTE
ABNORMALITIES & DRUG TOXICITIES etc)

5. PULMONARY
EMBOLISM
1) Sinus tachycardia
2) Stress on the right ventricle
○ Right atrial dilatation
○ Heart axis is to the right(RAD)
○ Right bundle branch block
3) S1Q3T3 PATTERN
Deep S in lead I
Q and negative T in lead III
4) T wave inversion anterior leads
Pulmonary embolism cannot be
diagnosed using only an ECG, but
it can be helpful.

6. ECG Signs of Acute Pulmonary
Embolism
Sinus tachycardia:8-73%
P Pulmonale : 6-33%
Rightward axis shift : 3-66%
Inverted T-waves in right chest leads: 50%
S1Q3T3 pattern: 11-50% (S1-60%, Q3-53% ,T3-20%)
Clockwise rotation:10-56%
RBBB (complete/incomplete): 6-67%
AF or A flutter: 0-35%
No ECG changes: 20-24%
Am J Med 122:257,2009

7. ACUTE PULMONARY
EMBOLISM

8. CARDIAC TAMPONADE

18. Hypokalemia results in:
● ST depression and flattened T waves
● QT prolongation
● Negative T waves
● A U wave may be visible
If extra systoles occur in the T wave (example) the risk of Torsade de Pointes is high and
rhythm monitoring is mandatory

19. HYPOKALEMIA

20. HYPOKALEMIA

25. DILATED
CARDIOMYOPATHY(DCM)
Common ECG associations with DCM
Left atrial enlargement - may progress to atrial fibrillation.
Biatrial enlargement
Left ventricular hypertrophy or biventricular enlargement
Left bundle branch block (RBBB can also occur).
Left axis deviation.
Poor R-wave progression with QS complexes in V1-4 (“pseudo-infarction” pattern).
Frequent ventricular ectopics and ventricular bigeminy (seen with severe DCM).
Ventricular dysrhythmias (VT / VF).

26. DCM

27. Take home message
 Electrocardiograms can be useful in the emergency
department setting when dealing with patients presenting
with chest pain, syncope, palpitations, cyanosis & heart
failure symptoms.
 Though the electrocardiogram may be helpful BUT it
should be used as an adjunct diagnostic tool, not to be
relied upon solely.
 Diagnoses cannot be excluded even in the presence of a
normal electrocardiogram .
 Therefore, it is important to synthesize all data prior to
coming to any conclusions.