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
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

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


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

Pacemakers & Acidosis
Episode 124
January 13, 2014

Can pacemakers prevent syphilis? Find out here! 


ECG findings in 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
Really wide QRS? Always consider Hyperkalemia/Acidosis & Overdose
Don’t be misled by pacers,which may not work well in acidosis!
Pacemakers & Acidosis
Episode 124
January 13, 2014

Can pacemakers prevent syphilis? Find out here! 


ECG findings in 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
Really wide QRS? Always consider Hyperkalemia/Acidosis & Overdose
Don’t be misled by pacers,which may not work well in acidosis!

Knowing this stuff saves lives! For more practice check out…#Hyperkalemia
Himalayan T waves
Episode 123
Himalayan T waves
Episode 123
January 6, 2014

You’ll never look at the mountains the same way again


Himalayan T waves 

  • Giant broad and spiked T waves 
  • Associated with syncope & seizures (due to torsades)
  • Think of congital long QT (Jervell and Lange-Nielsen syndrome)
  • Can also be seen in severe hypokalemia 

Check out this link for a case of congenital long QT with Himalayan T waves and a QTc of 900ms! ​

Also, search these tags for more practice with #T-waves & #Prolonged-QT

Low Voltage QRS Differential
Episode 122
December 30, 2013

Electrocardiographic voltagemia. What’s the significance?

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”
    • Myxedema (severe hypothyroidism)
    • Infiltrative diseases (Amyloid, Sarcoid)
    • End stage cardiomyopathy
  • Conduction blockage
    • Fluid/Effusion (pericardial or pleural)
    • Fat (obesity)
    • Air (COPD)
Don’t rely only on electrical alternans to diagnose pericardial effusions.
Low voltage + Tachycardia = Pericardial effusion until proven otherwise!
Low Voltage QRS Differential
Episode 122
December 30, 2013

Electrocardiographic voltagemia. What’s the significance?

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”
    • Myxedema (severe hypothyroidism)
    • Infiltrative diseases (Amyloid, Sarcoid)
    • End stage cardiomyopathy
  • Conduction blockage
    • Fluid/Effusion (pericardial or pleural)
    • Fat (obesity)
    • Air (COPD)
Don’t rely only on electrical alternans to diagnose pericardial effusions.
Low voltage + Tachycardia = Pericardial effusion until proven otherwise!
ECG findings in Hypothermia
Episode 121
December 23, 2013

Elderly patient found down. Better know this for the Boards! 


Osborn waves (a.k.a. J waves)
  • positive deflections at junction between the QRS complex and ST-segment
  • repolarization abnormality caused by exaggerated outward K+ current
  • usually observed in patients with hypothermia
ECG findings in Hypothermia
  • Osborn waves
  • Sinus brady, junctional rhythm
  • Prolongation of all intervals
  • Slow irregular Afib
  • Ventricular fibrillation
  • Asystole
ECG findings in Hypothermia
Episode 121
December 23, 2013

Elderly patient found down. Better know this for the Boards! 


Osborn waves (a.k.a. J waves)
  • positive deflections at junction between the QRS complex and ST-segment
  • repolarization abnormality caused by exaggerated outward K+ current
  • usually observed in patients with hypothermia
ECG findings in Hypothermia
  • Osborn waves
  • Sinus brady, junctional rhythm
  • Prolongation of all intervals
  • Slow irregular Afib
  • Ventricular fibrillation
  • Asystole
How to identify MI in paced rhythms
Episode 119
December 9, 2013

Can you read ischemia with a pacemaker???


You can diagnose MI in paced rhythms!

  • Paced rhythms cause ST-segment & T wave changes that can make the identification of acute MI difficult

  • Patients with paced rhythms can be expected to have ST segment & T wave changes that are discordant to the direction of the QRS complex

    • ​This is normal & referred to as the “Rule of Appropriate Discordance”

  • ST-segment deviations that are concordant (in same direction) to the QRS complex are abnormal

Sgarbossa’s criteria can be used to diagnose MI,

in the setting of both paced rhythms & LBBB

Here is what to look for:

     1. Concordant ST elevation ≥ 1mm in any single lead

     2. Concordant ST depression ≥ 1mm in either V1, V2, or V3

     3. Excessively discordant ST elevation ≥ 5mm in any lead


​Do you remember what the Modified Sgarbossa rule is & how to use it?

If not, check out …The Modified Sgarbossa Rule


References

Sgarbossa EB. Recent advances in the electrocardiographic diagnosis of myocardial infarction: left bundle branch block and pacing. Pacing Clin Electrophysiol. 1996;19(9):1370–1379. Pubmed Link

Sgarbossa EB, Pinski SL, Gates KB, Wagner GS. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol. 1996;77(5):423–424. Pubmed Link

Maloy KR, Bhat R, Davis J, Reed K, Morrissey R. Sgarbossa Criteria are Highly Specific for Acute Myocardial Infarction with Pacemakers. West J Emerg Med. 2010;11(4):354–357. Pubmed Link

Schaaf SG, Tabas JA, Smith SW. A patient with a paced rhythms presenting with chest pain and hypotension. JAMA Intern Med. 2013. Epub ahead of print. Pubmed Link
How to identify MI in paced rhythms
Episode 119
December 9, 2013

Can you read ischemia with a pacemaker???


You can diagnose MI in paced rhythms!

  • Paced rhythms cause ST-segment & T wave changes that can make the identification of acute MI difficult

  • Patients with paced rhythms can be expected to have ST segment & T wave changes that are discordant to the direction of the QRS complex

    • ​This is normal & referred to as the “Rule of Appropriate Discordance”

  • ST-segment deviations that are concordant (in same direction) to the QRS complex are abnormal

Sgarbossa’s criteria can be used to diagnose MI,

in the setting of both paced rhythms & LBBB

Here is what to look for:

     1. Concordant ST elevation ≥ 1mm in any single lead

     2. Concordant ST depression ≥ 1mm in either V1, V2, or V3

     3. Excessively discordant ST elevation ≥ 5mm in any lead


​Do you remember what the Modified Sgarbossa rule is & how to use it?

If not, check out …The Modified Sgarbossa Rule


References

Sgarbossa EB. Recent advances in the electrocardiographic diagnosis of myocardial infarction: left bundle branch block and pacing. Pacing Clin Electrophysiol. 1996;19(9):1370–1379. Pubmed Link

Sgarbossa EB, Pinski SL, Gates KB, Wagner GS. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol. 1996;77(5):423–424. Pubmed Link

Maloy KR, Bhat R, Davis J, Reed K, Morrissey R. Sgarbossa Criteria are Highly Specific for Acute Myocardial Infarction with Pacemakers. West J Emerg Med. 2010;11(4):354–357. Pubmed Link

Schaaf SG, Tabas JA, Smith SW. A patient with a paced rhythms presenting with chest pain and hypotension. JAMA Intern Med. 2013. Epub ahead of print. Pubmed Link