EKG of the Week 2019 4-7

This EKG comes courtesy of Dr. Tony Gao.

A 68 year old male presents complaining of chest pain and SOB x 2 hour. Described as pressure-like. Non-radiating. Began with mild exertion.  Has been persistent since.

Vital signs: Pulse – 65, Respirations – 18, BP 140/90.

His EKG is below.

2019 4-7.jpg

1.      What does the EKG demonstrate?

2.      How would you manage this patient?

ANSWER:

The EKG shows ST elevation in lead I and aVL consistent with a lateral wall MI.

The patient should be managed as a STEMI with antiplatelet therapy and urgent revascularization.

 

 

The EKG shows ST elevations in lead I and aVL as well as 0.5 mm ST elevations in leads V5 and V6. There are reciprocal depressions in lead III.

 

ST elevations represent acute injury to the myocardium. Leads II, III and aVF look at the inferior wall. Leads V1 and V2 look at the interventricular septum. Leads V3 and V4 look at the anterior wall. Leads V5, V6, I and aVL look at the lateral wall.

 

The most common location of a STEMI is in the inferior wall. Next is the anterior wall and the least common location is the lateral wall. Lateral wall ST elevations are often more subtle than in other walls of the heart.

 

Our patient went to the cath lab and was found to have a 100% occlusion of the left circumflex artery. He had a successful PCI and did well.

EKG of the Week 2019 3-17

This EKG comes courtesy of Dr. Podlog, Dr. Zhi, and Dr. S. Hassan.

 

An 83 year old female presented to the emergency department complaining of dizziness and sob on exertion for two days. Her first EKG is below (EKG A):

2019 3-17a.jpg

She later had a second EKG (EKG B):

2019 3-17b.jpg

 

1.    What does EKG A demonstrate?

2.    What does EKGB demonstrate?

3.    How would you manage this patient?

ANSWER:

EKG A shows a 2:1 AV block with a ventricular rate of 40.

EKG B shows a 3rd degree AV block.

The patient should have a pacemaker placed.

 

The patient presented with dizziness and SOB and was found to be bradycardic. The EKG helps elucidate the type of bradycardia.

EKG a shows bradycardia with the presence of P waves but some dropped P waves. This can occur in 2nd degree or 3rd degree AV block. On EKG A, it appears that some P waves are followed by QRS complexes and others are not. This is consistent with 2nd degree AV block. Every 2nd P wave is dropped, so we can not tell if it is 2nd degree type I or 2nd degree type II.

However, on the repeat EKG, there appears to be no relationship between the P waves and the QRS complexes. The R-R intervals are regular and the PR intervals are irregular. This is consistent with 3rd degree AV block.

Patients with 2nd degree AV block can progress to 3rd degree AV block. Close monitoring is essential. Also, running a loner rhythm strip or frequently repeating the EKG can be helpful to allow you to identify higher grade AV block.

Patients with symptomatic 3rd degree AV block require pacing. Prehospital, these patients should be treated with transcutaneous pacing. In the hospital, a transvenous pacemaker should be placed.

Our patient had a transvenous pacemaker placed. EKG C is the repeat EKG after the pacemaker:

2019 3-17c.jpg

The following algorithm is helpful in diagnosing bradycardias on EKG:

Bradycardia algorithm.jpg

EKG of the Week 2019 3-3

This EKG comes courtesy of Dr. Mohammad Hassan and Dr. Husain.

A 30 Year old male with a history of panic attacks presented to the ED complaining of palpitations and SOB. He states it began after drinking iced tea and coffee. He did not syncopize. He denied chest pain, nausea, vomiting.

He appears lethargic with a waxing and waning mental status.

Vital signs: Pulse – 230, Respirations – 20, BP – 90/50.

His EKG is below.

2019 3-3.jpeg

 

1.     What does the EKG demonstrate?

 2.     How would you manage this patient?

ANSWER:

The EKG shows a wide complex tachycardia.

The patient is unstable. The appropriate treatment is electrical synchronized cardioversion.

 

The EKG shows a wide complex tachycardia. That should be treated as v-tach until proven otherwise. In this case, the rhythm is irregular. V-tach should be regular. When you see a very fast irregular wide complex tachycardia, it raises the concern for a-fib with underlying WPW.

The patient was unstable so he was treated with electrical cardioversion. His post-cardioversion EKG is below. It shows a sinus rhythm with a short PR interval and a delta wave consistent with WPW.

2019 3-3b.jpg

It was later discovered that the patient had a history of WPW and had a previous ablation.

WPW puts patients at risk for tachyarrhythmias. SVT is the most common arrhythmia in WPW. A-fib is the most dangerous arrhythmia in WPW. It can lead to unopposed conduction down the accessory pathway which can lead to V fib. 

Patients with a-fib in WPW who are unstable should be treated with electrical cardioversion. Patients who are stable should be treated with procainamide.

Our patient was treated with cardioversion and he converted to sinus rhythm. He became more stable. He was admitted to telemetry and had an ablation performed.

EKG of the Week 2019 2-17

This EKG comes courtesy of Dr. Ross Hardy.

 

A 62 year old male with a history of diabetes presents for generalized weakness for a few days. He also reports nausea and vomiting. He has no fever. No chest pain. Mild shortness of breath.

Vital signs: Pulse – 50, Respirations – 22, BP 160/90, O2 sat 99%, blood glucose 110.

His EKG is below.

2019 2-17.jpeg

1.      What does the EKG demonstrate?

2.      How would you manage this patient?

ANSWER:

The EKG demonstrates bradycardia with peaked T waves, loss of P waves, and a widening of the QRS complex. This is consistent with hyperkalemia. 

The patient should be treated with calcium for myocardial protection. A potassium level should be checked and other medications to lower the potassium should be administered.

 

 

The EKG shows sinus bradycardia with a PAC. There are peaked T waves, loss of P waves, and a widening of the QRS complex.

Labs revealed BUN 90, Creatinine 9, potassium 8.1.

The patient was treated with calcium which improved the EKG. He also was given glucose/insulin and albuterol and was sent for emergent dialysis.

Hyperkalemia causes a series of changes to the EKG. An early sign is peaked T waves. This is followed by flattening of P waves, widening of the QRS complex and ultimately a sine wave. Whenever you see a wide QRS complex with a bizarre rhythm or what looks like “slow V-tach”, think about hyperkalemia.

 

 

EKG of the Week 2019 2-3

An 83 year old male with a history of CHF presents complaining of intermittent dizziness. He has no chest pain. He did not pass out.

Vital signs: Pulse 90, Respirations 18, BP 160/90.

His EKG is below.

2019 2-3.jpg

1.       What does the EKG demonstrate?

2.       How would you manage this patient?

ANSWER:

The EKG shows a sinus rhythm with runs of ventricular tachycardia.

The patient is stable. He has runs of v-tach which are making him symptomatic. He can be managed with anti-arrhythmic medications such as amiodarone.

 

 

The EKG shows an underlying sinus rhythm with runs of v-tach (one at the very beginning of the EKG and another towards the end) at a rate of approximately 200. The V-tach is what is causing the patient’s intermittent dizziness.

The treatment of ventricular tachycardia depends on the stability of the patient.

If the patient is in cardiac arrest (i.e. v-tach without a pulse), the patient should be treated like a v-fib cardiac arrest with defibrillation, CPR, and anti-arrhythmic medication.

If the patient is not in cardiac arrest (i.e. v-tach with a pulse) and the patient is unstable, the patient should be treated with electrical cardioversion.

If the patient is not in cardiac arrest (i.e. v-tach with a pulse) and the patient is stable, the patient should be treated with anti-arrhythmic medications. Options include amiodarone lidocaine and procainamide.

Our patient was not in cardiac arrest and was stable. He was treated with amiodarone with food results. He was admitted to the CCU.

 

EKG of the Week 2019 1-20

This EKG comes courtesy of Dr. Khodorkovsky.

An 88 y/o male with a history of CHF presents after a syncopal episode. He does not remember the event. He is currently awake and alert. BP 130/80.

His EKG is below:

2019 1-20.jpg

1.       What does the EKG demonstrate?

2.       How would you manage this patient?

ANSWER:

A ventricular escape rhythm.

The patient is hemodynamically stable. Atropine can be attempted. Pacing pads should be placed and the patient should be monitored closely. If no reversible cause is identified the patient will need a pacemaker.

 

The EKG shows a bradycardic rhythm with absent P waves, a regular rhythm, with wide QRS complexes and a rate less than 30. This is consistent with a ventricular escape rhythm.

When the SA node fails, the heart has two back-up systems that can temporarily maintain a heart beat. One is the AV node (also known as the junction) which can produce a junctional escape rhythm. Another is the ventricles which can produce a ventricular escape rhythm (also known as an idioventricular or ventricular escape rhythm).

Both rhythms present with absent P waves and a regular rhythm. A junctional escape rhythm produces narrow QRS complexes at a rate of 45-60. A ventricular escape rhythm produces wide QRS complexes at a rate of 30-45.

Treatment of a ventricular escape rhythm depends on the patient’s stability. If the patient is asymptomatic and stable, no emergent treatment is needed. Pacing pads should be placed on the chest in case the patient deteriorates.

If the patient is symptomatic or unstable, they should be treated. Atropine is the first line treatment but it may not be successful. If it is unsuccessful, the patient should be paced (transcutaneous initially followed by transvenous).

This patient was symptomatic in that he had a syncopal episode. He had a normal potassium and was not on any medications that can cause bradycardia. A transvenous pacemaker was placed.

The following algorithm may be helpful in diagnosing bradycardias:

 

Bradycardia algorithm.jpg

EKG of the Week 2019 1-6

This EKG comes courtesy of Dr. Ann Giovanni.

A 63 year old male, with a history of HTN and DM, was teaching computer class when he had a syncopal episode. EMS was called and he had a second syncopal episode while on the EMS monitor. The rhythm strip is below.

2019 1-6 EMS strip.JPG

He woke up on his own prior to being shocked by EMS. He arrived in the ED with no chest pain and no shortness of breath but feeling like he was going to pass out.

His ED EKG is below.

2019 1-6.jpg

1.    What does the EKG demonstrate?

2.    How would you manage this patient?

ANSWER:

The rhythm strip demonstrates ventricular fibrillation. The EKG shows downsloping ST segments in leads V1-V3 consistent with Brugada syndrome.

Patients with Brugada syndrome require placement of an ICD.

 

Evaluating patients after syncope can be challenging. In the absence of a clear history suggesting a particular cause (i.e. subarachnoid hemorrhage, pulmonary embolism), we are often left wondering whether the patient had a cardiac arrhythmia as the cause of their syncope or was it a more benign cause. The only way to know for sure is to have the patient on an EKG machine at the time of the syncope which usually doesn’t happen. Otherwise we are left with looking at an EKG taken after the syncope to see if it gives us clues that the patient may have had an arrhythmia as the cause of their syncope (i.e. prolonged QT, WPW, Brugada, ARVD).

In this case Dr. Giovanni’s team was fortunate that EMS had the patient on a monitor at the time of a syncopal episode and was able to capture the ventricular fibrillation. Now we know that the patient’s syncope was certainly due to a dangerous arrhythmia. The next question becomes why did the patient have spontaneous v-fib? The EKG gives us the answer.

The EKG demonstrates a sinus rhythm with a 1st degree AV block and PVC’s. There are also downsloping ST segments in leads V1-V3 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 ventricular arrhythmias such as polymorphic V-tach and v-fib. Patients who had a syncopal episode who have an EKG pattern consistent with Brugada syndrome likely had a ventricular arrhythmia. There is no specific treatment for Brugada syndrome. So, these patients require placement of an ICD to manage their ventricular arrhythmias.