John Doe has a seizure. What good is an ECG?
Episode 141

May 12, 2014


Download the 2014 UMEM ECG Competition and test yourself!

Answers coming soon. 


Be systematic and consider the differentials when you find an abnormality!

 
Causes of Rightward Axis Deviation
  • Right ventricular hypertrophy
  • Pulmonary HTN - Acute (PE) & chronic lung disease (COPD)
  • Left posterior fascicular block
  • Lateral MI (from Q-waves in lead I)
  • Ventricular ectopy (VT)
  • Hyperkalemia
  • Na2+ channel blocker toxicity
  • Lead misplacement / Dextrocardia
  • Normal thin adults with horizontally positioned hearts
Causes of QRS prolongation
  • BBB (LBBB or RBBB) or paced rhythm
  • Pre-excitation (WPW)
  • Ventricular ectopy
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Nonspecific intraventricular conduction delay (eg. LVH)
  • Na2+ channel blocker toxicity ​
Na2+ channel blocker toxicity
  • Tachycardia (usually)
  • Right Axis Deviation
  • Tall R wave in aVR
  • Tall R in V1 (sometimes)
  • Prolonged QRS
  • Prolonged QTc

Think of cocaine (Na2+ channel blocker) toxicity in pts. with fever & HTN 

 
John Doe has a seizure. What good is an ECG?
Episode 141

May 12, 2014


Download the 2014 UMEM ECG Competition and test yourself!

Answers coming soon. 


Be systematic and consider the differentials when you find an abnormality!

 
Causes of Rightward Axis Deviation
  • Right ventricular hypertrophy
  • Pulmonary HTN - Acute (PE) & chronic lung disease (COPD)
  • Left posterior fascicular block
  • Lateral MI (from Q-waves in lead I)
  • Ventricular ectopy (VT)
  • Hyperkalemia
  • Na2+ channel blocker toxicity
  • Lead misplacement / Dextrocardia
  • Normal thin adults with horizontally positioned hearts
Causes of QRS prolongation
  • BBB (LBBB or RBBB) or paced rhythm
  • Pre-excitation (WPW)
  • Ventricular ectopy
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Nonspecific intraventricular conduction delay (eg. LVH)
  • Na2+ channel blocker toxicity ​
Na2+ channel blocker toxicity
  • Tachycardia (usually)
  • Right Axis Deviation
  • Tall R wave in aVR
  • Tall R in V1 (sometimes)
  • Prolonged QRS
  • Prolonged QTc

Think of cocaine (Na2+ channel blocker) toxicity in pts. with fever & HTN 

 
Need some more practice with AV blocks?
Episode 140

May 5, 2014


Take Home Points

  1. Find out what the atrium is doing (map out p-waves)

  2. Find out what the ventricle is doing
  3. Figure out the relationship between them (PR-interval) 
The answer usually lies in the PR-interval!
 
  • ​Check out more cases of AV block by watching this previous episode

  • Biphasic T-waves (i.e. Wellens syndrome) are indicative of ischemia.

  • New biphasic T-waves in the inferior leads, may be indicative of RCA lesions. 

Need some more practice with AV blocks?
Episode 140

May 5, 2014


Take Home Points

  • When interpreting difficult rhythms, always do these three things:
  1. Find out what the atrium is doing (map out p-waves)

  2. Find out what the ventricle is doing
  3. Figure out the relationship between them (PR-interval) 
The answer usually lies in the PR-interval!
 
  • ​Check out more cases of AV block by watching this previous episode

  • Biphasic T-waves (i.e. Wellens syndrome) are indicative of ischemia.

  • New biphasic T-waves in the inferior leads, may be indicative of RCA lesions. 

What’s a better predictor of ACS than the ECG?
Episode 139

April 28, 2014



References:

Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454

Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077

Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377

What’s a better predictor of ACS than the ECG?
Episode 139

April 28, 2014


Most important predictors of ACS

  • History is still the key predictor!
    • ​Chest pain associated with the following is concerning
      • ​Radiation
      • Diaphoresis
      • Vomiting
      • Exertion
  • ​​​​Get serial ECGs when history is concerning or patient has persistant pain

References:

Body R, Carley S, Wibberley C, et al. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–286. PMID: 20036454

Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. PMID: 16304077

Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280(14):1256–1263. PMID: 9786377

2 patients, 20 mins, tons of pearls!
Episode 138

April 21, 2014



You can find several more cases of STEMI vs. Pericarditis here!
2 patients, 20 mins, tons of pearls!
Episode 138

April 21, 2014


STEMI vs. Pericarditis

  • Clinical signs & symptoms are often unreliable
  • First troponin can also be unreliable
  • 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 “check mark 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…CATH!

 

You can find several more cases of STEMI vs. Pericarditis here!
"Kitchen syncope" revealed!
Episode 137

April 14, 2014


Want more
ECG training + CME credit?
 
The Advanced ECG Workshop
is available at emedhome.com

7+ hours of video & 10 CME credits! 

Want to go to Hong Kong?

The International Conference on Emergency Medicine

is in Hong Kong on July 10, 2014

Go to www.icem2014.org for more info

AV Blocks…the key to the diagnosis is the PR-interval!

  • Lengthening of the PR = Mobitz I
  • Constant PR = Mobitz II (Usually has wide QRS)

"Kitchen syncope" revealed!
Episode 137

April 14, 2014


Want more
ECG training + CME credit?
 
The Advanced ECG Workshop
is available at emedhome.com

7+ hours of video & 10 CME credits! 

Want to go to Hong Kong?

The International Conference on Emergency Medicine

is in Hong Kong on July 10, 2014

Go to www.icem2014.org for more info

AV Blocks…the key to the diagnosis is the PR-interval!

  • Lengthening of the PR = Mobitz I
  • Constant PR = Mobitz II (Usually has wide QRS)

What’s the opposite of Wellen’s waves?
Episode 136
What’s the opposite of Wellen’s waves?
Episode 136

April 7, 2014


Hypokalemia

  • Prolonged QT (Due to U waves)
  • ST-segment depression 
  • Biphasic T-waves (Down then up, unike Wellen’s waves)
  • PVC’s, ventricular arrhythmias

Differential for Prolonged QT-intervals

  • Hypokalemia (due to U-wave)

  • Hypomagnesemia
  • Hypocalemia
  • Hypothermia
  • Acute coronary syndromes / ischemia
  • Increased intracranial pressures
  • Nachannel blocking drugs
  • Congenital
 
Quick Bedside Calculation of QT interval
T-waves should typically 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 (half way between the R-waves), as shown below.

Check out our previous episodes on #Hypokalemia
New T-wave inversions = ACS, right? Hmmm…
Episode 135
New T-wave inversions = ACS, right? Hmmm…
Episode 135

March 31, 2014


PE’s often produce ECG changes that mimic cardiac ischemia & frequently elevate troponins. 
 
Simultaneous TWI’s in anteroseptal & inferior leads = PE until proven otherwise. 
 
ECG findings in Pulmonary Embolism
  • Sinus Tachycardia (only in 30-50%)
  • SIQIII or SIQIIITIII, a.k.a. Rightward Axis (not sensitive or specific)
  • New RBBB or incomplete RBBB
  • Superventricular tachydysrhythmias
  • Ventricular dysrhythmias
  • ST-segment  elevations or depressions
  • New TWI’s, especially in anteroseptal +/- inferior leads = Acute Pulmonary Hypertension = PE until proven otherwise!

Check out more cases here, #PulmonaryEmbolism
Lightheaded 12 YO: Deadly or Benign?
Episode 134

March 24, 2014

Want more
ECG training + CME credit?
 
is now available @ emedhome.com
 

7+ hours of instruction & 10 CME credits! 


Hypertrophic cardiomyopathy
  • Can’t miss cause of #syncope
  • Common cause of sudden death in young males
  • ECG abnormalities are typical
    • ​High voltage
    • Deep narrow Q waves
Want more practice, so that you don’t miss this?
This video has more details about Hypertrophic Cardiomyopathy
Lightheaded 12 YO: Deadly or Benign?
Episode 134

March 24, 2014


Want more
ECG training + CME credit?
 
is now available @ emedhome.com
 

7+ hours of instruction & 10 CME credits! 


Hypertrophic cardiomyopathy
  • Can’t miss cause of #syncope
  • Common cause of sudden death in young males
  • ECG abnormalities are typical
    • ​High voltage
    • Deep narrow Q waves
Want more practice, so that you don’t miss this?
This video has more details about Hypertrophic Cardiomyopathy
22 YO with a STEMI? Maybe…maybe not!
Episode 133

March 17, 2014


Go through the ECG systematically!
Use a stepwise approach or you will miss something
 

Go through the following steps every time:

  1. Rate and Rhythm
  2. Axis
  3. Intervals
  4. Enlargement
  5. Ischemia & Infarction 

​​Recognize abnormalities and consider the differentials that explain them

 

Short QT-Interval Differential

  • Hypercalcemia (STE is not uncommon)
  • Digoxin Toxicity
  • Congenital 
22 YO with a STEMI? Maybe…maybe not!
Episode 133

March 17, 2014


Go through the ECG systematically!
Use a stepwise approach or you will miss something
 

Go through the following steps every time:

  1. Rate and Rhythm
  2. Axis
  3. Intervals
  4. Enlargement
  5. Ischemia & Infarction 

​​Recognize abnormalities and consider the differentials that explain them

 

Short QT-Interval Differential

  • Hypercalcemia (STE is not uncommon)
  • Digoxin Toxicity
  • Congenital 
Pericarditis part deux: You make the call!
Episode 132

March 10, 2014


 

First, make sure you are not missing an acute MI!

  • Do you remember the factors that strongly suggest STEMI? If not, review them here

  • STEMI patients commonly have ventricular arrhythmias and very rarely have atrial dysrhythmias

  • New onset atrial fibrillation or flutter in a patient with ST-elevation favors Pericarditis 

 
Nothing in medicine is 100%…including the ECG 
When in doubt, do serial ECG’s, ECHO, Consult & Cath!

References:

Bainey KR, Bhatt DL. Acute pericarditis: appendicitis of the heart? Mayo Clin Proc. 2009;84(1):5–6. PMID: 19121246

Pericarditis part deux: You make the call!
Episode 132

March 10, 2014


Did You Miss Part I? Start HERE 
 

First, make sure you are not missing an acute MI!

  • Do you remember the factors that strongly suggest STEMI? If not, review them here

  • STEMI patients commonly have ventricular arrhythmias and very rarely have atrial dysrhythmias

  • New onset atrial fibrillation or flutter in a patient with ST-elevation favors Pericarditis 

 
Nothing in medicine is 100%…including the ECG 
When in doubt, do serial ECG’s, ECHO, Consult & Cath!

References:

Bainey KR, Bhatt DL. Acute pericarditis: appendicitis of the heart? Mayo Clin Proc. 2009;84(1):5–6. PMID: 19121246