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ECG Quiz

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Essential ECGs for an EM physician.

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ECG Quiz

  1. 1. ECG QUIZ Tricky ED ECGs - ‘The Magnificent 7’ in ‘To cath or not to cath’.. Dr Jono Holme
  2. 2. ECG 1 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 35 yo male, diaphoretic, now pain - free
  3. 3. ANSWER: There are T-wave inversions in V3 and V4, lead III and aVF with BIPHASIC T-waves in V2 and V3. These BIPHASIC T- waves in V2 / V3 are highly specific for a CRITICAL STENOSIS of the LEFT ANTERIOR DESCENDING coronary artery. These findings are known as a WELLEN’S SYNDROME These patients are often PAIN FREE at the time of their ECG as the BIPHASIC T- waves indicate coronary reperfusion. If the artery remains open, they will progress from a TYPE A to a TYPE B. If the artery re-occludes, HYPER-DYNAMIC T- waves will develop and PAIN will reoccur This patient needs referral for an angiogram within 24 hours. If treated medically they will do poorly, and if sent for a treadmill test, they could have a fatal arrhythmia Type A Type B Hyper-dynamic Re-perfusion Re-occlusion
  4. 4. ECG 2 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 51 yo male, 8/10 chest pain
  5. 5. ANSWER: There is ST depression in leads I and II, with ST depression and HYPER-ACUTE T- waves in the precordial leads. This ST DEPRESSION with HYPER-ACUTE T-waves in the PRECORDIAL leads is known as DE - WINTER’s PATTERN This pattern is an ANTERIOR STEMI EQUIVALENT WITHOUT ST ELEVATION It is seen in 2% of Left Anterior Descending coronary artery occlusions, and requires swift CATH LAB ACTIVATION
  6. 6. ECG 3 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 58 yo male, 10/10 chest pain
  7. 7. ANSWER There is ST depression in leads V2 - V3, ? slight ST elevation lead III This is a POSTERIOR STEMI, occurring in 25% of STEMIs , usually occurring in the context of other inferior or lateral STEMIs. Posterior extension of one of these infarcts implies a larger area of myocardial damage, resulting in higher mortality It is sometimes MISSED because of the ST depression appearance at V2 - V3 Posterior leads The posterior chest leads reveal the ST DEPRESSION to be ST ELEVATION This patient needs to be taken to the CATH LAB The anteroseptal leads are directed from the anterior precordium towards the internal surface of the posterior myocardium. Because posterior electrical activity is recorded from the anterior side of the heart, the typical injury pattern of ST elevation and Q waves becomes inverted
  8. 8. ECG 4 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 22 yo 2/10 chest pain, palps, syncope
  9. 9. ANSWER T - wave inversions II, III, aVF, V4 - V6 Did you notice the delta - waves? This patient has WPW or WOLFF-PARKINSON-WHITE Short PR interval <120 ms, delta waves - slurring slow rise of the initial portion of the QRS segment. The ST segment and T - wave discordant changes reflect a ‘pseudo infarction pattern’ due to accessory pathway conduction. The T-wave inversions in V4-V6 reflects the ‘pseudo - infarction’ pattern of WPW as seen on the left, NOT LVH This is a right sided accessory pathway - a TYPE B WPW A Type A WPW demonstrates T-wave inversions from V2 - V3. This shows a left sided accessory pathway This patient needs referral to a cardiologist for further testing
  10. 10. ECG 5 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 35 yo collapse, no chest pain
  11. 11. ANSWER V1/V2 have ‘SADDLEBACK ST CHANGES’ - BRUGADA syndrome BRUGADA is an ECG abnormality with a high incidence of sudden death in patients with structurally normal hearts. It is due to a mutation in the cardiac SODIUM CHANNEL. ECG changes can be transient, and are often unmasked by fever, trauma, ischaemia or drugs, so we are often the only ones to see these changes. Definitive treatment is with an Implantable Cardiac Defibrillator Diagnosis depends on these ECG changes AND CLINICAL CRITERIA The ECG findings in ISOLATION are of questionable significance They need to be associated with a history of syncope, arrhythmia, or family history of sudden cardiac death However, this is a rare ECG finding, and if you find it, you should discuss it with a cardiologist.
  12. 12. ECG 6 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 27 yo pregnant female, collapse, no chest pain
  13. 13. ANSWER T-wave inversion II, III, aVF, V2-V6 (seen in 85% at V1-V3) ‘Epsilon waves’ (seen in 30%) These Epsilon waves are characteristic of an ‘ARVC’ EPSILON WAVES - small peak following s-wave ARVC stands for Arrhythmogenic Right Ventricular Cardiomyopathy It is a genetic disorder that involves weakness developing in the right ventricle of the heart, with resultant changes in the way electricity is conducted around it. It has an association with SUDDEN CARDIAC DEATH. ALL patients need cardiology referral The most specific and subtle finding is a ‘prolonged S-wave upstroke’ V1-3
  14. 14. ECG 7 Where / What is the abnormality? What is the importance of the abnormality? What do we do about it?! 19 yo athlete, collapse during marathon
  15. 15. ANSWER Difficult right?! Increased precordial voltages ‘Dagger like Q - waves’ V5-V6, I, aVL, II, III, aVF This patient has HOCM - Hypertrophic Obstructive Cardiomyopathy It is an inherited disease where the left ventricle hypertrophies until it obstructs its own outflow. This LEFT VENTRICULAR HYPERTROPHY is visible on some ECGs, namely as the deep T - wave inversions with tall r- waves in V4 - V6 HOCM is the number one cause of sudden cardiac death in young athletes annual mortality is 1-2% for these individuals EXERTIONAL SYNCOPE, CHEST PAIN OR PALPITATIONS are the symptoms. REFER ANY PATIENT with this history and these ECG findings
  16. 16. ADDITIONAL RESOURCES n lifeinthefastlane.com - ECG series n ECGAcademy.com n EMS12lead.com n Amal Mattu’s ECG videos (Youtube) n Dr Smith’s ECG blog (Google)

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