Identify the abnormal findings
ECG #1
Clinical Context: Patient presenting with dyspnea followed by witnessed syncope in the ED.
- NSR with RBBB (rsR i V1-V2)
- TWI in V1-V6 and II, III, avF
- S1Q3T3
- Patient ended up having a massive pulmonary embolism so the above findings likely represent R heart strain
ECG #2
Clinical context: Altered Mental Status
- Significant artifact
- Bradycardia - sinus vs. junctional but hard to tell. Less likely atrial fibrillation as rhythm appears regular.
- There is a pause between 5th and 6th beats likely representing a sinus pause
- Osborn waves (terminal positive deflection of QRS) seen in II, III, avF, V4-V6
- This patient ended up having a rectal temp of < 90 degrees F
ECG #3
Clinical context: chest pain
- This is concerning for STEMI / OMI
- Inferior STE (II, III, avF) with reciprocal STD (I, avL)
- STE III > II could mean RV MI
- Lateral STE (V5-V6)
- V2 depression could indicated posterior involvement
ECG #4
Clinical Context: History of CHF presenting with dizziness
- Regular wide complex tachycardia concerning for ventricular tachycardia
- Rate a little less than 150 bpm
- QRS > 160 ms
- Consider SVT with aberrancy but high pre-test probability for VT given CHF
- Patient became unstable and successfully converted via DCCV
ECG #5
Clinical Context: palpitations
- This is an irregular rhythm but there appears to be atrial activity (see lead V1)
- Atrial rate is about 200 bpm (see lead V1), so this is an atrial tachycardia
- The p waves do not original from SA node as they are inverted in avF and upright in aVR
- There are multiple p waves per qrs complex but the p:qrs ratio varies so this is atrial tachycardia with variable conduction
ECG #6
Clinical context: chest pain
- Anterior STEMI/ OMI
- STE and hyperacute T waves V1-V4
- Note you may not always see reciprocal STD in an anterior MI especially without lateral involvement
ECG #7
Clinical Context: med refill, chest pain is obtained on ROS but no active chest pain.
- This is a LBBB (QRS > 120ms, monophasic R waves in I, V6) but does it meet Smith modified Sgarbossa criteria? There are no concordant STE anywhere and no concordant STD in V1-V3 but are there excessively discordant STE? (≥ 25% the preceding S wave). Let’s set the ECG at half standard to better visualize.
- Here you can measure out that none of the STE in V1-V4 are ≥25% the preceding S wave. A troponin was sent and it was negative.
ECG #8
Clinical context: young male < 30 years with chest pain for months
- There are subtle < 1mm STE in I, avL, V4-V6. Could this be a lateral MI? These same leads also have J waves (terminal upright deflection of the QRS) which could indicate early repolarization
- Troponins came back negative
ECG #9
Clinical Context: dizziness
- Marked Bradycardia and AV dissociation concerning for third degree av block
- RBBB
ECG #10
Clinical Context: medication refill, BP 170 systolic
- LVH by peguero lo presti (S wave in V4+ deepest S wave ≥ 28mm)
- Left atrial enlargement (LAE) via p-mitrale (wide p wave) in the inferior leads and biphasic p ave in V1 with large negative component
ECG #11
Clinical Context: chest pain, history of HTN not on medictations
- Anterior- Lateral MI in the setting of LVH
- LVH - by peguero Lo presti (S wave in V4 + deepest S wave ≥ 28mm)
- STEMI: STE in I, avL that are concordant to QRS complex, STE in V2 that is convex in morphology, III/avF V5-V6 STD+TWI could be reciprocal changes and repolarization abnormality from LVH
ECG #12
Clinical Context: headache and dizziness
- LBBB: Wide QRS+monophasic R in I and V6, super high voltage
- The STE are impressive but when you compare them to the QRS complexes, they are ≤ 25% the depth of the preceding S wave
- This does not meet Smith modified Sgarbossa criteria
- AV Dissociation/3rd degree AVB
- P waves and qrs complexes do not communicate
- There are varying PR intervals
- P waves at fixed rate - 72 bpm
- QRS complexes at fixed rate - 36 bpm
- P:QRS > 1
ECG #13
Clinical Context: abdominal pain
- At first glance this may look like av dissociation but there are grouped beats (2 or 3 complexes together) so this is likely 2nd degree av block (other ddx include SA block or PAC pattern like trigeminy).
- Look closely at V1, the PR interval starts off pretty long and progressively get so long that it occurs on the T wave making this type 1.
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This post is for education and not medical advice.
