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.

 

EKG of the Week 2018 12-23

A 34 y/o female presents to the ED complaining of palpitations.

The EKG is below.

2018 12-23.JPG
  1. What finding does this EKG demonstrate?

  2. What is the next step?

ANSWER:

The EKG demonstrates limb lead reversal of the right arm and left arm.

Repeat the EKG with appropriate lead placement.

 

The EKG appears to demonstrate T wave inversions in leads II, III and aVF and can be mistaken for inferior wall ischemia. However, a closer look at the EKG reveals that in lead I the P wave is inverted, the QRS complex is predominantly negative, and the T wave is inverted. In lead aVR, the P wave is upright, the QRS complex is predominantly positive, and the T wave is upright. This is the opposite of what you expect to see in a normal EKG. This clues you in that the right and left arm leads have been reversed. With limb lead reversal, T wave inversions may appear that are not really signs of ischemia.

The findings on EKG in reversal of right and left arm leads are:

  1. inverted P-QRS-T waves in lead I

  2. upright P-QRS-T in lead aVR (as opposed to the expected inversion of these waves in a normal EKG)

  3. QRS vector in lead I does not match that of lead V6

 

Inversion of the P-QRS-T complex in lead I can also occur with dextrocardia. However, with dextrocardia, there will be a lack of normal precordial R-wave progression from leads V1–V6. In reversal of the arm electrodes, the precordial leads will not be affected so R wave progression should be normal.

Reversal of the right leg and left leg leads usually causes no change on the EKG because the right leg lead is only a ground and does not record any electrical activity.

(Harrigan et al. Electrocardiographic Electrode Misplacement, Misconnection, and Artifact. J Emerg Med. 2012;43(6):1038-1044.)

EKG of the Week 2018 12-2

This EKG comes courtesy of Dr. Elias Youssef.

A 66 year old Female with a history of hypertension and hyperlipidemia, presented with abdominal pain radiating to the back and left lower extremity. The pain was sudden onset just prior to arrival.

Her EKG is below.

2018 12-2.jpg

1.       What does the EKG demonstrate?

2.       How would you manage this patient?

ANSWER:

The EKG shows ST elevations in leads II, III and aVF as well as V4-V6 with reciprocal depressions in I and aVL as well as R waves and ST depressions in leads V1-V3, suggesting an infero-postero-lateral STEMI.

 The patient’s symptoms were concerning for an aortic dissection which was confirmed on U/S and CT. The patient was taken to the OR.

 

The EKG shows ST elevations in leads II, III and aVF which suggests an inferior wall MI. There are also ST elevations in leads V4-V6 suggesting lateral wall involvement as well. In addition, the findings of R waves with ST depressions in leads V1-V3 suggest posterior wall involvement.

Remember that ST elevations are not 100% specific for MI and can be mimicked by other disease processes. This patient’s history was concerning for an aortic dissection. If a dissection extends backwards towards the coronary arteries and causes a coronary artery dissection, ST elevations can be manifested on EKG. The most common artery involved in a retrograde dissection is the Right Coronary Artery. This will usually cause ST elevations in the inferior leads.

This patient had a bedside ultrasound which showed an aortic dissection flap with no pericardial tamponade. Below is a slice of the patient’s CT scan.

2018 12-2 CT.jpg

It demonstrated an aortic dissection from the aortic root to the iliac bifurcation with occluded blood flow to the left iliac. The patient was taken to the OR. She was found to have a dissected ascending aorta with a dissected right coronary artery.

Remember to pay attention to the history. It will clue you in to the diagnosis.

EKG of the Week 2018 11-4

This EKG comes courtesy of Dr. Majlesi.

An 81 y/o male presents to the ED complaining of generalized weakness, difficulty speaking and shuffling gait. He has no chest pain or SOB. His vital signs are normal.

His EKG is below.

2018 11-4.jpg

1.       What are the findings on this EKG?

2.       What can explain these findings?

ANSWER:

The EKG shows an extreme right axis deviation with negative complexes in leads I and II and positive complexes in lead aVR. 

Several things can cause these findings including COPD, limb lead reversal and dextrocardia. In this case, the patient was found to have situs inversus.

 

In a normal EKG, the P waves in leads I and II should be upright and the P waves in lead aVR should be inverted. This EKG shows the opposite - negative complexes with inverted P waves in leads I and II and positive complexes and upright P waves in lead aVR.

This pattern can be seen in severe COPD or in limb lead reversal (if the right arm lead is placed on the left arm and the left arm lead is placed on the right arm). However in that scenario, the precordial leads should be normal. In our EKG, the R wave progression in the precordial leads is reversed. The QRS complex is positive in lead V1 and negative in lead V6. This occurs because the entire heart is reversed.

Our patient’s Chest X-ray is below.

2018 11-4 CXR.jpg

As you can see, the heart is reversed and on the right side of the body. Additionally, you can see the liver on the left side and the stomach bubble on the right side. This represents complete situs inversus. This is why the patient’s EKG is essentially reversed.

EKG of the Week 2018 10-7

This EKG comes courtesy of Dr. O’Halloran and Dr. Litvak.

A 74 year old female presents to the emergency department with Chest pain and SOB. She had an anterior wall STEMI 1 month prior and had stents placed. At the time of evaluation in the ED she is asymptomatic. Her EKG is below.

2018 10-7.jpg

 

1.    What does the EKG demonstrate?

2.    What can cause these EKG findings?

ANSWER:

The EKG shows ST elevations and Q waves in Leads V1-V6.

In the acute setting this would be consistent with an evolving anterior wall MI. One month after a STEMI, these findings can be caused a left ventricular aneurysm.

 

The EKG demonstrates ST elevations in leads V1-V6 with Q waves in the same leads. There are no reciprocal depressions. This pattern in a patient >2 weeks after a STEMI suggests a ventricular aneurysm. This is a potential complication of an MI. The most common location of a ventricular aneurysm is the anterior wall.

 

The patient had an echocardiogram which showed paradoxical movement of the left ventricular wall.

 

Patients with LV aneurysm are at risk for ventricular arrhythmias and sudden cardiac death.

EKG of the Week 2018 9-9

This EKG comes courtesy of Dr. Yousseff.

A 25 year old male presented to participate in an elective research study. He had no complaints. A screening EKG was performed.

Vital Signs: Pulse – 50, R -16, BP 120.70.

His EKG is below.

2018 9-9.jpg

1.       What is the rhythm?

2.       How would you manage this patient?

ANSWER:

The rhythm is 3rd degree AV block. In this patient it turned out to be congenital.

This patient is asymptomatic. In asymptomatic congenital complete AV block, no specific treatment is needed.

 

The EKG demonstrates a bradycardia with dropped P waves, regular R-R intervals and irregular P-R intervals. This is consistent with 3rd degree AV block.

In congenital 3rd degree AV block, treatment depends on whether or not the patient has structural cardiac abnormalities. If the echocardiogram demonstrates structural abnormalities of the heart, treatment includes placement of a permanent pacemaker. If there are no structural abnormalities and the patient is asymptomatic, pacemaker placement can be delayed.

In this patient, he remembered being told as a child that he had “some kind of block in his heart”. He in fact had congenital 3rd degree AV block. His echo was normal. So, placement of a pacemaker was delayed. Ultimately most of these patients become symptomatic at some point in their life and they then require pacemaker placement.

The algorithm below is helpful for diagnosing bradyarrhythmias.

Bradycardia algorithm.jpg