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

Pericarditis vs. STEMI, Subtle Clues Part I
Episode 131

March 3, 2014


Young people can have MI’s!
Know the subtle ECG differences between STEMI & Pericarditis 

 

First, make sure you are not missing an acute MI

Look for factors that strongly favor STEMI:

  1. Reciprocal ST-segment depression in any leads (except aVR & V1)
  2. Horizontal or convex upward ST-segment morphology 
  3. STE in lead III> the STE in lead II ​​​​​​​​
Also, look for other factors that favor STEMI:
NO factors that suggest STEMI? Consider pericarditis

Look for factors that strongly favor pericarditis:

  1. Pronounced PR-segment depression in multiple leads
  2. Pericardial friction rub
Also, look for other factors that favor pericarditis:
When in doubt, do serial ECG’s, ECHO, and consider cath!

For more practice, check out previous episodes on this important topic
Pericarditis vs. STEMI, Subtle Clues Part I
Episode 131

March 3, 2014


Young people can have MI’s!
Know the subtle ECG differences between STEMI & Pericarditis 

 

First, make sure you are not missing an acute MI

Look for factors that strongly favor STEMI:

  1. Reciprocal ST-segment depression in any leads (except aVR & V1)
  2. Horizontal or convex upward ST-segment morphology 
  3. STE in lead III> the STE in lead II ​​​​​​​​
Also, look for other factors that favor STEMI:
NO factors that suggest STEMI? Consider pericarditis

Look for factors that strongly favor pericarditis:

  1. Pronounced PR-segment depression in multiple leads
  2. Pericardial friction rub
Also, look for other factors that favor pericarditis:
When in doubt, do serial ECG’s, ECHO, and consider cath!

For more practice, check out previous episodes on this important topic
Beware this really wide complex tachycardia!
Episode 130
February 24, 2014
Bizarre rhythm that is REALLY wide?
Consider tox/metabolic causes and treatment with Ca2+ & NaHCO3-

Differential for Wide QRS

  • Ventricular Ectopy
  • Paced Beats
  • Bundle Branch Block
  • Pre-excitation (WPW)
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Medications - Na2+ channel blocking toxicity (i.e. TCA’s & Anti-arrhythmics)
  • Nonspecific intraventricular conduction delay (ex. from LVH)
 

ECG findings in Hyperkalemia

  • Peaked T-waves
  • Widening of the QRS (often marked)
  • Prolonged PR-interval
  • Flattening and eventual loss for p-waves
  • Tachydysrrhythmias
  • Advanced AV Blocks and sinus pauses
  • Fascicular & Bundle Branch Blocks
  • Pseudo ACS with ST-segment changes
  • Sine wave morphology

Check out this previous video on Regular Really Wide Complex Tachycardia


Beware this really wide complex tachycardia!
Episode 130
February 24, 2014
Bizarre rhythm that is REALLY wide?
Consider tox/metabolic causes and treatment with Ca2+ & NaHCO3-

Differential for Wide QRS

  • Ventricular Ectopy
  • Paced Beats
  • Bundle Branch Block
  • Pre-excitation (WPW)
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Medications - Na2+ channel blocking toxicity (i.e. TCA’s & Anti-arrhythmics)
  • Nonspecific intraventricular conduction delay (ex. from LVH)
 

ECG findings in Hyperkalemia

  • Peaked T-waves
  • Widening of the QRS (often marked)
  • Prolonged PR-interval
  • Flattening and eventual loss for p-waves
  • Tachydysrrhythmias
  • Advanced AV Blocks and sinus pauses
  • Fascicular & Bundle Branch Blocks
  • Pseudo ACS with ST-segment changes
  • Sine wave morphology

Check out this previous video on Regular Really Wide Complex Tachycardia


Beware this really wide complex tachycardia!
 
Episode 129
Beware this really wide complex tachycardia!
 
Episode 129
February 24, 2014
When looking at a bizarre rhythm that is REALLY wide…
Consider tox/metabolic causes and treatment with Ca2+ & NaHCO3-

Differential for Wide QRS

  • Ventricular Ectopy
  • Paced Beats
  • Bundle Branch Block
  • Pre-excitation (WPW)
  • Metabolic/Electrolytes (acidosis, hyperkalemia)
  • Medications - Na2+ channel blocking drug toxicity (i.e. TCA’s & Anti-arrhythmics)
  • Nonspecific intraventricular conduction delay (ex. from LVH)
 

ECG findings in Hyperkalemia

  • Peaked T-waves
  • Widening of the QRS (often marked)
  • Prolonged PR-interval
  • Flattening and eventual loss for p-waves
  • Tachydysrrhythmias
  • Advanced AV Blocks and sinus pauses
  • Fascicular & Bundle Branch Blocks
  • Pseudo ACS with ST-segment changes
  • Sine wave morphology

Check out this previous video on Regular Really Wide Complex Tachycardia


When the computer calls it Pericarditis…
Episode 128
February 10, 2014

PR depression is NOT specific for Pericarditis!

Pericarditis vs. STEMI

  • First, make sure you are not missing an acute MI by looking for factors strongly associated with STEMI. Ask yourself:

    • Is there reciprocal ST-segment depression in any leads (except for aVR and V1)? If yes, it’s a STEMI. If not,…

    • Is the ST-segment morphology convex or horizontal? If yes, it’s a STEMI. If not,…

    • Is the STE in lead III> the STE in lead II? If yes, it’s a STEMI.

    • Are there new Q waves? (Need old ECG) If yes, it’s likely a STEMI.

    • Is there a QR-T or check mark sign? If yes, it’s likely a STEMI.

  • If the answer to all those questions is NO, then you can consider the possibility of it being pericarditis.

    • Is there pronounced PR-segment depression in all leads? If so, it’s possibly pericarditis.

    • Is there a pericardial friction rub? If so, it’s possibly pericarditis​.

Do you remember what the check mark sign is? If not check out this previous episode and the links on that page for more cases. 

When the computer calls it Pericarditis…
Episode 128
February 10, 2014

PR depression is NOT specific for Pericarditis!

Pericarditis vs. STEMI

  • First, make sure you are not missing an acute MI by looking for factors strongly associated with STEMI. Ask yourself:

    • Is there reciprocal ST-segment depression in any leads (except for aVR and V1)? If yes, it’s a STEMI. If not,…

    • Is the ST-segment morphology convex or horizontal? If yes, it’s a STEMI. If not,…

    • Is the STE in lead III> the STE in lead II? If yes, it’s a STEMI.

    • Are there new Q waves? (Need old ECG) If yes, it’s likely a STEMI.

    • Is there a QR-T or check mark sign? If yes, it’s likely a STEMI.

  • If the answer to all those questions is NO, then you can consider the possibility of it being pericarditis.

    • Is there pronounced PR-segment depression in all leads? If so, it’s possibly pericarditis.

    • Is there a pericardial friction rub? If so, it’s possibly pericarditis​.

Do you remember what the check mark sign is? If not check out this previous episode and the links on that page for more cases. 

The myth of Medusa & stone heart revealed…
Episode 127
February 3, 2014
Bizarre rhythm? Think about hyperkalemia!
 Knowing all the variations of ECG findings in hyperkalemia saves lives.
 
ECG finding associated with hyperkalemia:
  • Peaked T-waves
  • Widening of the QRS
  • Prolonged PR
  • Flattening and eventual loss for p-waves
  • Advanced AV Blocks and sinus pauses
  • Pseudo ACS, new BBB’s, ST-segment changes
  • Sine wave morphology
In digoxin-intoxicated humans, IV calcium does not seem to cause malignant dysrhythmias or increase mortality. Evidence does not support the historical belief that calcium administration is contraindicated in digoxin-toxic patients. 

 

Reference

Levine M, Nikkanen H, Pallin DJ. The Effects of Intravenous Calcium in Patients with Digoxin Toxicity. J Emerg Med. 2011;40(1):41–46. Pubmed Link

The myth of Medusa & stone heart revealed…
Episode 127
February 3, 2014
Bizarre rhythm? Think about hyperkalemia!
 Knowing all the variations of ECG findings in hyperkalemia saves lives.
 
ECG finding associated with hyperkalemia:
  • Peaked T-waves
  • Widening of the QRS
  • Prolonged PR
  • Flattening and eventual loss for p-waves
  • Advanced AV Blocks and sinus pauses
  • Pseudo ACS, new BBB’s, ST-segment changes
  • Sine wave morphology
In digoxin-intoxicated humans, IV calcium does not seem to cause malignant dysrhythmias or increase mortality. Evidence does not support the historical belief that calcium administration is contraindicated in digoxin-toxic patients. 

Search the site to watch more videos on the bizarre ECG manifestations of #hyperkalemia
 

Reference

Levine M, Nikkanen H, Pallin DJ. The Effects of Intravenous Calcium in Patients with Digoxin Toxicity. J Emerg Med. 2011;40(1):41–46. Pubmed Link