Identify concerning findings. What is the rhythm and diagnosis?
ECG 1
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CC: Chest pain
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- Rhythm: normal sinus rhythm at ~75
- Concerning findings:
- ST elevations and hyperacute T waves in I, aVL, and V2 (South Africa Flag Sign)
- Reciprocal depressions in II, III, aVF, and V6
- Diagnosis: High Lateral STEMI (likely occlusion of D1 branch of LAD)
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- ST elevations in 2 or more contiguous leads
- Criteria for leads V2-3 vary by age/sex
- ≥ 2.5 mm for males <40
- ≥ 2.0 mm for males 40 or older
- ≥ 1.5 mm for females
- All other leads ≥ 1.0 mm
- More reading: ECG Patterns of OMI
ECG 2
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CC: Chest pain and palpitations
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- Rhythm: regular, narrow-complex tachycardia ~150 without identifiable p-waves
- Concerning findings: lack of p-waves suggests tachyarrhythmia
- Diagnosis: most likely AVNRT but should also consider orthodromic AVRT
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- Sinus tachycardia
- AVNRT
- Orthodromic AVRT
- Atrial flutter (with 2:1 conduction)
- Atrial tachycardia
- More Reading: ECG Exercise 7 - Narrow complex tachycardias
ECG 3
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CC: Bodyaches
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- Concerning findings: peaked T waves, wide QRS, bizarre morphology
- Rhythm: sinus rhythm with 1st degree avb and interventricular conduction delay (IVCD)
- Diagnosis: hyperkalemia (K was 7.7)
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- Peaked T waves
- QRS widening
- P wave flattening
- PR prolongation
- Sinus bradycardia, AV blocks, and junctional escape rhythms
- Bizarre appearance
- Morphology progresses to “sine wave” pattern when QRS merges with T wave and p wave disappears
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- IV Calcium
- Insulin/dextrose, albuterol
- More Reading: Killer K+
ECG 4
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CC: Syncope
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- Rhythm: Sinus rhythm ~60
- Concerning findings: short PR and delta wave (slurred beginning of qrs complex)
- Diagnosis: Wolff-Parkinson-White (WPW) Syndrome
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- Wolff-Parkinson-White (WPW) Syndrome
- Lown-Ganong-Levine (LGL) Syndrome
- Normal variant (especially in children/young adults)
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- Supraventricular arrhythmias
- More Reading: Wolff-Parkinson-White (WPW)
ECG 5
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CC: chest pain and dizziness, history of ESRD on dialysis
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- Concerning findings: diffuse low-voltage QRS, diffuse T-wave flattening
- Rhythm: sinus rhythm
- Diagnosis: Possible pericardial effusion (uremic)
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- QRS amplitude:
- < 5 mm for limb leads
- < 10 mm in precordial leads
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- Pericardial effusion
- Pleural effusion
- Obesity
- Emphysema
- Pneumothorax
- Infiltrative diseases (amyloidosis, sarcoidosis, hemochromatosis)
- Loss of viable endocardium: end-stage dilated cardiomyopathy, prior massive MI
ECG 6
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CC: history of anorexia nervosa presenting with dizziness
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- Sinus rhythm with prolonged Qtc devolving into polymorphic Vtach with Torsades de Pointes morphology
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- Long Qtc devolving into Torsades
- Afib RVR with aberrancy / bundle branch blocks
- Afib with WPW
- Non-torsades Polymorphic VT
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- Always attach pads first
- Defibrillate (if patient is very stable you can skip this but watch them very closely)
- IV mag (give more than you think)
- Fix underlying electrolyte abnormalities (with this story probably hypoK)
- Lidocaine but avoid QT prolonging antiarrhythmics
- Medical chronotropy (eg, isoproterenol) or electric chronotropy (overdrive pacing) speeds up HR and reduces QT
ECG 7
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CC: Syncope
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- Sinus rhythm with Coved STE / QRS morphology in V1-V2 concerning for Brugada syndrome
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- Brugada Type I ECG (as seen here) -> More specific to brugada syndrome
- For diagnosis of brugada syndrome you need Type 1 pattern plus one:
- Previous cardiac syncope or previous cardiac arrest survivor
- 1st degree relative with same ECG pattern
- Family history of sudden cardiac death
- Documented polymorphic VT
- Nocturnal agonal respiration
- Brugada type II ECG (“saddleback” morphology ST elevation) -> Less specific for syndrome
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- Medications/drugs (eg, TCAs, Sodium channel blockers)
- Electrolyte abnormalities (K mostly), Hypothermia or fever
- More Reading: Brugada Pattern
ECG 8
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CC: Chest pain with history of pacemaker (This is a ventricularly paced rhythm -spikes are too small to see)
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- LBBB type pattern
- Excessively high discordant STE (>5 mm and STE higher than 25% of preceding S-wave depth) in V2-V4
- >1mm concordant STE in lead III and some STD in avL
- Anterior MI meeting Smith Modified Sgarbossa Criteria
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- Concordant ST elevation ≥ 1 mm in ≥ 1 lead
- Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
- Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave
- More Reading: ECG Patterns of OMI
ECG 9
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CC: Weakness and dizziness
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- Severe bradycardia, pretty tall T waves v2-3-4, complete AV dissociation
- Complete AV block (grade III), likely ventricular escape rhythm (very slow!) but could also be junctional
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- Pace, external if possible or transvenous
- Consider pharmacologic agents (epi, atropine)
- Check the medication list for triggering agents
- More reading: ECG Exercise 14 - Identify the AV block
ECG 10
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CC: Altered mental status
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- Sinus brady, TWI II,III, AVF V3-4-5-6, and STD V3-4-5,
- RSR vs J-waves (osborn waves) vs STE in QRS all across
- Differential would be
- Acute MI
- Hypothermia - pt was 89F
- Electrolyte abnormalities
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- Hypothermia, hypercalcemia, Brugada type 2, Acute MI, Takotsubo cardiomyopathy, Early repolarization, Myocarditis.
ECG 11
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CC: History of CHF presenting with chest pain and dizziness
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- Regular rhythm, Monomorphic ventricular tachycardia (Absence of LBB/RBBB, extreme axis deviation, RS interval > 100ms in V1-V6, QS wave in V6, )
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- Monomorphic ventricular tachycardia (causes: Ischemic Heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy)
- Antidromic AVRT (WPW): antegrade conduction through the accessory pathways - causes a wide QRS complex. Mainly young patients, patients with h/o WPW.
- SVT with Aberrant conduction (RBBB/LBBB)
- SVT with metabolic disturbance- Hyper K, Sodium channel blockade, severe acidosis.
- Pacemaker-mediated tachycardia / ventricular paced rhythm(can see pacing spike)
ECG 12
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CC: Severe chest pain that resolved upon arrival to the ED
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- Sinus rhythm, right atrial enlargement.
- Wellens Pattern B (type 2 )
- Deeply inverted T wave in V2,V3,V4.
- ECG pattern in pain-free state
- Precordial R wave progression in precordial leads
- Normal troponin
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- Highly specific for critical stenosis of the left anterior descending artery.
- Need serial ECG - High risk for extensive anterior wall MI within days.
- ACS: antiplatelet, statin, nitrate, anticoagulation
- Admission/ transfer for urgent invasive management ie, PCI / revascularization /stenting
ECG 13
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CC: Chest pain, syncope, and is on OCPs
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- Sinus tachycardia, S1T3, TWI III, avF V1-V6.
- S wave in V6-pulmonary disease pattern.
- Diagnosis: Right heart strain from Pulmonary embolism
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- Sinus tachycardia
- Complete or incomplete RBBB
- Right ventricular strain pattern(TWI in the right precordial leads +/- inferior lead)
- Right axis deviation: extreme RAD, b/w 0 to -90 degrees. Can give an appearance of LAD/”pseudo left axis”.
- Dominant R wave in V1(less than 5%)- signs of RV dilation
- Right atrial enlargement(P pulmonale)
- S1Q3T3 pattern.
- Clockwise rotation -shift of R/S transition point towards V6 with persistent S wave in V6
- Atrial tachyarrhythmias - Afib, flutter, atrial tachycardia. Nonspecific ST-segment and T-wave changes
- More reading: ECG findings in Pulmonary Embolism
ECG 14
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CC: History of ablation as a teenager and currently on coumadin now with chest pain
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- Tachycardia, irregular rhythm, wide QRS complex,
- Rate: Over 300 bpm/
- Irregular rhythm
- WPW with Afib with pre-excitation
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- Afib with aberrant conduction (BBB)
- Pre-excited A Fib (AF with accessory pathway, WPW)
- Aflutter with variable AV conduction and aberrancy.
- Multifocal atrial tachycardia with aberrancy
- Hyperkalemia /drug toxicity
- V fib
- Polymorphic vtach /torsades de pointes
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- AV nodal blocking drugs.
- More reading: Wolff-Parkinson-White (WPW)
ECG 15
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- Sinus tachycardia, widened QRS, Dominant R wave in aVR, prolonged QT.
- Rate: nearly 150 bpm.
- TCA overdose.
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- Cardiac monitor, Airway management, may need intubation.
- IV Sodium Bicarb
- For seizure: Benzos
- Hypotension: Fluid, pressors.
- Avoid class 1A and 1C, beta blockers
- More reading: ECG in Toxicology
This post is for education and not medical advice.