Cancer patient with diffuse STE
Episode 164

October 20, 2014



Reference:

Yeh E, Macfarlane P, Tong A, Lenihan D, et al. Cardiovascular Complications of Cancer Therapy: Diagnosis, Pathogenesis, and Management. Circulation. 2004;109:3122-3131. Pubmed Link
Cancer patient with diffuse STE
Episode 164

October 20, 2014


Differential Diagnosis for Diffuse ST-Elevation


Want more learn more about the emergent causes of diffuse STE?

Check out the links about & this previous episode…​http://tmblr.co/Zls-wvGjwFeF


Reference:

Yeh E, Macfarlane P, Tong A, Lenihan D, et al. Cardiovascular Complications of Cancer Therapy: Diagnosis, Pathogenesis, and Management. Circulation. 2004;109:3122-3131. Pubmed Link
43 year old female with near-syncope & a subtle ECG diagnosis!
Episode 163
43 year old female with near-syncope & a subtle ECG diagnosis!
Episode 163

October 13, 2014


Quick Bedside Calculation of QT interval
T-waves should end before the midpoint of the R-R interval.
Beware of a prolonged QT-interval when the T-wave ends after the midpoint of the R-R interval.
 
Differential for Prolonged QT-intervals caused by a prolonged T wave
  • Hypokalemia & Hypomagnesemia
  • Acute coronary syndromes
  • Increased intracranial pressures
  • Na+ channel blocking drugs
  • Congenital
What are the only 2 things that prolong the QT-interval specifically by stretching the ST-segment?
  1. Hypocalcemia
  2. Hypothermia

Want more learn more about the ECG & electrolytes? Check these out…​

23 year old female with chest pain
Episode 162

October 6, 2014



You can find several more cases of STEMI vs. Pericarditis here!
 
23 year old female with chest pain
Episode 162

October 6, 2014


STEMI vs. Pericarditis

  • Clinical signs & symptoms are often unreliable
  • STEMI’s DO occur in young patients
  • ECG machine interpretation is not to be trusted!
  • Know the differences in ECG findings & use a stepwise approach

Step 1. Factors that rule-in STEMI:

  • Reciprocal ST depression in any leads (except aVR & V1)
  • Horizontal or convex upward ST-segment morphology 
  • STE in lead III> the STE in lead II ​​​​​​​​
  • R-T sign or “checkmark sign
  • Q-waves that you know are new​​

Look for the factors that rule in STEMI before thinking pericarditis! 

Step 2. Factors that suggest pericarditis:

  • Pronounced PR depression in multiple leads 
  • Spodick sign
  • Pericardial friction rub​
  • Pericardial effusion 

When in doubt…do serial ECGs and consider CATH!


You can find several more cases of STEMI vs. Pericarditis here!
 
Can you make a Dx and miss a Dx at the same time?
Episode 161
Can you make a Dx and miss a Dx at the same time?
Episode 161

September 29, 2014


The biggest reason we miss a diagnosis,
is because we make a diagnosis!
Look carefully at the entire ECG
 
To diagnose AV Blocks, always look at the PR interval!
  • If you have not mastered AV blocks yet, practice by reviewing these cases

Emergent treatment of bradycardias is based on the ventricular rate, not the AV block or atrial rate!


Did you miss the Dx because you made the Dx? 
Learn more about inferior STEMI here
THIS case of torsades needs no treatment!
Episode 160
THIS case of torsades needs no treatment!
Episode 160

September 22, 2014


Artifact is not uncommon!

True VT / Polymorphic VT / Torsades (PVT with prolonged QT) vs. Artifact

  • Look at the patient!
    • ​If unstable, don’t hesitate to assume the worst!
    • If stable, look for normal beats within the rhythm

Check out this previous episode for more: Another case of torsades?
67 yo DOE. Piece of cake!
Episode 159
67 yo DOE. Piece of cake!
Episode 159

September 15, 2014


Large PE’s commonly cause T-wave inversions.

New TWI’s in anteroseptal & inferior leads = PE until proven otherwise. 


Check out more cases here #PulmonaryEmbolism
Patient found down with WCT
Episode 158
Patient found down with WCT
Episode 158

September 8, 2014


Causes of QRS prolongation
  • Ventricular ectopy
  • BBB (LBBB or RBBB) or paced rhythm
  • Pre-excitation (WPW)
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Medication toxicity ​
  • Nonspecific intraventricular conduction delay (eg. LVH)
​What about the causes of Really Wide QRS complexes?
  • Think of toxicologic and metabolic (hyperkalemia & severe acidosis) causes
  • Consider Calcium and Sodium Bicarbonate therapy before antiarrhythmics

Do your remember your differentials for Right Axis Deviation? How about the classic findings of TCA toxicity?

Knowledge + advocacy saves lives
Episode 157
Knowledge + advocacy saves lives
Episode 157

September 1, 2014


YOU MUST BE THE EXPERT AT READING ECG’s!

Don’t assume that your consultants know more than you!

Knowledge of ECGs & advocacy for patients will save lives! 


Want to make sure you never miss these type of cases? Check out these links and save a life…

aVR, the forgotten lead you need to remember

Why Brugada syndrome needs an EP study

Why you should care when things are totally RAD
Episode 156

August 25, 2014


Don’t ignore the AXIS!

Can’t Miss Causes of Rightward Axis Deviation in the ED
  • Na2+ channel blocker toxicity
  • Pulmonary HTN - Consider PE
Other Causes of Rightward Axis Deviation
  • Hyperkalemia
  • Ventricular ectopy (VT)
  • Lateral MI (from Q-waves in lead I)
  • Left posterior fascicular block
  • Right ventricular hypertrophy
  • Dextrocardia
Na2+ channel blocker toxicity
  • Tachycardia (usually)
  • Right Axis Deviation
  • Tall R wave in aVR
  • Tall R in V1 (sometimes)
  • Prolonged QRS
  • Prolonged QTc
Why you should care when things are totally RAD
Episode 156

August 25, 2014


Don’t ignore the AXIS!

Can’t Miss Causes of Rightward Axis Deviation in the ED
  • Na2+ channel blocker toxicity
  • Pulmonary HTN - Consider PE
Other Causes of Rightward Axis Deviation
  • Hyperkalemia
  • Ventricular ectopy (VT)
  • Lateral MI (from Q-waves in lead I)
  • Left posterior fascicular block
  • Right ventricular hypertrophy
  • Dextrocardia
Na2+ channel blocker toxicity
  • Tachycardia (usually)
  • Right Axis Deviation
  • Tall R wave in aVR
  • Tall R in V1 (sometimes)
  • Prolonged QRS
  • Prolonged QTc
Another syncope case with a diagnostic ECG
Episode 155

August 18, 2014


Low Voltage Definition
  • QRS amplitudes in limb leads all < 5 mm or in all chest leads < 10mm (specific definition)
  • QRS amplitudes in I+II+III < 15 mm or V1+V2+V3 < 30 mm (sensitive definition)
Low Voltage QRS Differential
  • “Low Power/Weak Battery”
    • Infiltrative diseases (Amyloid, Sarcoid, etc.)
    • End stage cardiomyopathy
    • Myxedema (severe hypothyroidism)
  • Conduction blockage
    • Fluid/Effusion (pericardial or pleural)
    • Fat (obesity)
    • Air (COPD, PTX)

Don’t rely only on electrical alternans to diagnose pericardial effusions.

Low voltage + Tachycardia = Pericardial effusion until proven otherwise!

Another syncope case with a diagnostic ECG
Episode 155

August 18, 2014


Think of these differentials everytime you interpret the ECG of patients with syncope:
Low Voltage Definition
  • QRS amplitudes in limb leads all < 5 mm or in all chest leads < 10mm (specific definition)
  • QRS amplitudes in I+II+III < 15 mm or V1+V2+V3 < 30 mm (sensitive definition)
Low Voltage QRS Differential
  • “Low Power/Weak Battery”
    • Infiltrative diseases (Amyloid, Sarcoid, etc.)
    • End stage cardiomyopathy
    • Myxedema (severe hypothyroidism)
  • Conduction blockage
    • Fluid/Effusion (pericardial or pleural)
    • Fat (obesity)
    • Air (COPD, PTX)

Don’t rely only on electrical alternans to diagnose pericardial effusions.

Low voltage + Tachycardia = Pericardial effusion until proven otherwise!