EKG of the Week 2018-2-4

A 62 year old female presents to the ED complaining of chest pain. Vital signs are within normal limits.

Her EKG is below.

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1.       What does the EKG demonstrate?

2.       What do these findings represent?

 

ANSWER:

Q waves in leads II, III, aVF, V3-V6

An old infero-lateral MI

 

The EKG shows a sinus rhythm with Q waves in leads II, III, aVF, V3-V6. This represents an “old” or “completed” inferolateral MI.

There is no way to tell from the EKG when the MI happened. It may have been 2 days ago or 20 years ago. The only way to get an idea is to compare this EKG to a prior EKG. If the prior EKG from 2 months ago was normal and today’s EKG shows an old inferolateral MI, then we know the patient had an MI at some time during the last 2 months. To try to pin down when it happened, we would need to correlate it with when the patient had symptoms and the results of cardiac enzymes.

Q waves are sometimes a normal part of a QRS complex. To differentiate normal Q waves from pathological Q waves (meaning representing an old MI), we have to look at the width and the depth of the Q wave. Normal Q waves should be narrow and shallow. Pathological Q waves are wide and deep. If the Q wave is 1 small box wide and the depth of the Q wave is >25% of the size of the entire QRS complex, that is abnormal and that Q wave likely represents an old MI. For example, on this EKG, in lead III, the Q wave is 2 boxes wide. The depth of the Q wave is approximately 6 mm while the entire QRS complex is approximately 8 mm. 6/8 is much more than 25% so we know this Q wave is pathological and represents an old MI.

EKG of the Week 2018 1-21

This EKG comes courtesy of Dr. Hahn.

A 68 y/o female with a history of COPD presents c/o SOB. Temp – 98, Pulse – 120, Respirations – 28, BP 160/88, O2 sat 84% on room air and goes up to 92% on nasal cannula. Lungs reveal wheezes b/l but moving good air and minimal accessory muscle use.

Her EKG is below.

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  1. What is the rhythm?

      2. How would you manage this patient?

 

ANSWER:

The rhythm is Multifocal Atrial Tachycardia

The rhythm requires no specific management. The underlying COPD exacerbation should be treated.

 

The EKG demonstrates a tachycardia with a narrow QRS complex, which is irregular. P waves are present but the P wave morphologies and the PR intervals are different from each other. This is consistent with MAT.

To diagnose MAT, there must be at least 3 morphologically different P waves on the EKG rhythm strip. Often you will see the same P wave for several beats followed by a different P wave for several beats and then another different P waves for several beats.

MAT is commonly found in patients with lung disease such as COPD. Typically, the rhythm itself requires no treatment. Treatment is aimed at the underlying respiratory problem.

If the rhythm persists despite treating the respiratory problem and is making the patient symptomatic, it can be treated with magnesium (2g IV).

The following algorithm is helpful in diagnosing tachyarrhythmias.

tachycardia algorithm.jpg

EKG of the Week 2017 12-31

A 24 year old male with no past medical history presents after a syncopal episode. He was sitting at home watching TV and the next thing he knew he was on the floor. He does not recall anything about the episode.

V/S: Pulse – 80, Respirations – 16, Blood Pressure 120/80.

He is on no medications and denies drug use.

His EKG is below.

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1.       What does the EKG demonstrate?

2.       How should this patient be managed?

 

ANSWER:

The EKG demonstartes Brugada syndrome

The patient should be admitted and needs placement of an ICD.

 

The EKG shows downsloping ST elevations in leads V1 and V2 leading into inverted T waves. There is no isoelectric separation between the QRS complex and the T wave. This is consistent with Brugada syndrome.

Brugada syndrome is a genetic (autosomal dominant) sodium channel defect. It predominantly affects males (90%). Patients with Brugada syndrome are at risk for polymorphic V-tach. Patients who had a syncopal episode who have an EKG pattern consistent with Brugada syndrome likely had an episode of V-tach.

There is no specific treatment for Brugada syndrome. So, these patients require placement of an ICD to manage their ventricular arrhythmias.

 

EKG of the Week 2017 12-17

This EKG comes courtesy of Dr. Elias Youssef.

A 44 year old male presented to the ED after a syncopal episode. The syncope occurred while he was walking. There were no premonitory symptoms. He had no chest pain, no shortness of breath. There was no recent travel, immobilization or surgery. His vital signs are normal.

His EKG is below.

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1.       What pattern is demonstrated by this EKG?

2.       How would you manage this patient?

 

ANSWER:

The EKG demonstrates Arrhythmogenic Right Ventricular Dysplasia.

Treatment for ARVD includes implantation of an ICD.

 

The EKG shows an atrially paced rhythm. There is a slightly widened QRS complex with T wave inversions in leads V1-V3. This is consistent with Arrhythmogenic Right Ventricular Dysplasia (ARVD).

ARVD is an inherited cardiomyopathy which causes fibrofatty replacement of the right ventricular myocardium. This leads to structural and functional abnormalities of the right ventricle and arrhythmias originating from the right ventricle.

In ARVD the EKG shows T-wave inversions in the right precordial leads (V2 and V3) with a prolonged QRS complex (>110 ms). There may also be Epsilon waves. These are small undulations in the ST segment just after the QRS complex. They are best seen in the right precordial leads. Epsilon waves are difficult to see on a standard EKG, so they should not be relied on for diagnosis. If you see T wave inversions in V1-V3 with a slightly widened QRS complex in the setting of syncope, suspect ARVD.

ARVD is diagnosed by MRI of the heart which shows the fatty infiltration of the right ventricle.

Treatment for ARVD includes implantation of an ICD.

EKG of the Week 2017 12-3

This EKG comes courtesy of Dr. Kevin Tavangarian.

 

A 17 year old female with no past medical history presents to the ED S/P cardiac arrest. Her father heard her fall in her room and came in to find her “jerking all extremities” then became unresponsive. She was found by EMS in v-fib. She was defibrillated once with ROSC. She presented to the ED with a pulse, intubated and sedated. Her EKG on presentation to the ED is below.

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1.    What does the EKG demonstrate?

2.    How would you manage this patient?

 

Answer:

The EKG shows significant QT prolongation.

Electrolytes should be checked. A medication and drug history should be obtained. If all those are negative, the patient will likely need an ICD.

 

The EKG shows a sinus rhythm with significant QT prolongation (the T wave goes into the next P wave).

QT prolongation can be congenital. It can also be caused by many medications, as well as electrolyte abnormalities including hypocalcemia and hypokalemia.

In our patient, the K was 3.2. All the remaining labs were normal. She was not on any medications. As far as the team was able to elicit, there was no history of drug use.

QT prolongation puts patients at risk for ventricular arrhythmias such as ventricular tachycardia, Torsade de Pointes, and ventricular fibrillation. This is likely what happened in our patient.

 

EKG of the Week 2017 11-19

This EKG comes courtesy of Dr. Elias Youssef.

A 51 year old male with no past medical history complains of chest pain. The pain woke him from sleep. It is right sided, described as sharp. It radiates to the mid back. It is associated with shortness of breath and the pain is worse when he takes a deep breath. There is no nausea or vomiting.

The EKG is below.

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1.    What does the EKG demonstrate?

2.    How would you manage this patient?

 

ANSWER:

The EKG shows hyperacute T waves in leads V2-V4.

Hyperacute T waves can be an early sign of an STEMI. Serial EKG’s should be performed as the ST elevations may develop. Even if the ST elevations do not develop, urgent cardiology consultation should be sought as these patients may have a proximal LAD occlusion and may need urgent PCI.

 

The EKG demonstrates tall symmetric T waves in leads V2-V4. This can be an early sign of a STEMI. Serial EKG’s may evolve and start to show ST elevations in those same leads.

However, in some patients this T wave pattern persists and ST elevations never develop. Nevertheless these patients are found at cath to have proximal LAD occlusions. These are referred to as deWinter’s T waves. The EKG shows 1- to 3-mm upsloping ST-segment depression at the J point in leads V1 to V6 that continue into tall, positive symmetrical T waves. In most patients in the deWinter article there was a 1- to 2-mm ST-elevation in lead aVR.

It is difficult to differentiate these T waves from the peaked T wave seen in hyperkalemia. When you see this T wave pattern, both hyperkalemia and acute coronary syndrome should be considered in the differential.

Our patient went to the cath lab and was found to have a 100% proximal LAD occlusion. He had a stent placed and did well.

REFERENCE: de Winter et al. A New ECG Sign of Proximal LAD Occlusion. N Engl J Med 2008:359;19.