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20 EKGs You Should Know
Susan P. Torrey, MD, FACEP, FAAEMAssociate Professor of Emergency Medicine
Tufts University School of Medicine
Faculty, Baystate Medical Center
Springfield, Massachusetts
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20 EKGs you should know
• Chest pain presentations• Syncope• Palpitations• Metabolic/miscellaneous
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1. 45-year-old man with one hour of chest pain radiating to his back.
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Isolated posterior wall MI
• Posterior MI usually with inferior• 5% MIs - isolated posterior wall
• Acute posterior wall MI– ST-segment depression V1-3
• As MI evolves:– Upright T waves V1-3
– Tall R waves V1-2
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2. 78-year-old dairy farmer with one hour chest pain associated with sweating.
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Critical Left Main Artery Disease
• Wellens described association with:– ST-segment depression ≥ 8 leads– ST-segment elevation in lead aVR
• Especially if ST-elevation in aVL
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3. 36-year-old woman, 3 weeks post-partum, with 30 min chest pain which has resolved.
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Wellens’ warning
• Left anterior descending (LAD)• Associated with either:
– Biphasic T waves anterior leads– Deeply inverted T waves
– Change from initial normal EKG– During pain-free interval– Normal enzymes
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four hours after chest pain
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4. 53-year-old man with acute MI who received thrombolytic therapy one hour ago.
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Accelerated Idioventricular Rhythm
• Beats 1-3 are idioventricular• Note emergence of P before #3• Beats 4-6 are sinus• Beat 7 is a fusion beat
1 2 3 4 5 6 7 8
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5. 35-year-old man with chest pressure all day, worse with inspiration and position.
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Pericarditis
• Acute phase diffuse ST-elevation– Maintains convex upward shape– Often ST-elevation in II > III (reverse true with MI)
• PR segment depression in II (elevation in aVR)
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6. 40-year-old man being evaluated for syncope earlier that day.
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Brugada syndrome
• Hereditary sudden death• Sodium-channel mutation
• Downsloping ST in V1-2
• If family hx sudden death, or hx syncope
• EP study and AICD
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7. 48-year-old woman with shortness of breath after experiencing syncope.
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EKG signs of acute PE
• New RBBB• S1Q3T3
• T wave inversion in V1-3– Correlates with severity of PE
S1Q3T3
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Her CT angiogram…
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8. 45-year-old man with “worst headache of his life” associated with vomiting.
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CNS effect
• Diffuse T wave inversion – impressively deep• Asymmetric with bulging ascending portion• +/- prominent U waves and QT prolongation
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Other causes of deep T wave inversion
• Ischemia/subendocardial infarction• Ventricular pacing (memory T waves)• Apical hypertrophic cardiomyopathy• Takotsubo cardiomyopathy• Acute pulmonary embolism
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9. 65-year-old woman collapses 3 days after experiencing severe back pain.
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Subacute inferior-posterior MI
• Tall R wave in V1– RBBB – QRS > 0.12– WPW, type A – δ wave– RVH – right axis– Old post MI – old inf MI
• Small complexes?– tamponade
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10. 75-year-old woman with syncope in church – asymptomatic when lying flat.
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Pacemaker failure
• QRS at 24/min• P waves at 75/min• Pacer spikes at 72/min
– Failure of sensing and of capture
↑ ↑ ↑ •↑ • • •
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11. 60-year-old man with weakness and “heart racing” – no prior history.
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Atrial flutterwith 2:1 AV conduction
• When the rate is 150/minute, always think of 2:1 atrial flutter.
• With AV blocking agents…
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12. 36-year-old man with palpitations and near syncope. History of palpitations.
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The scariest atrial fib you’ll ever see…
• Avoid typical AV blocking agents– Adenosine– β-blockers– Calcium-channel blockers– Digoxin
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Wolff-Parkinson-White Syndrome
• After cardioversion– note δ wave = WPW
• After ablation of bypass– no longer has WPW
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13. 28-year-old woman with frequent episodes of “SVT” treated in ED.
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Signs of AVRT (WPW)
Prolonged RP interval
QRS alternans
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after cardioversion…
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14. 50-year-old woman with “heart jumping” but no syncope.
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Blocked PAC
The most common cause of a pause in sinus rhythm is a blocked PAC.
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15. 68-year-old woman with chronic atrial fibrillation.
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Ashman’s phenomenon
• Repolarization proportional to preceding R-R• Thus, with long R-R followed by short R-R
– Portion of conducting system may be refractory (usually RBBB)
• Long…short…weird
V1
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16. 25-year-old man with ESRD who missed last hemodialysis session.
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Hyperkalemia
• Peaked T waves of hyperkalemia– Symmetrical and narrow-based
• Then ↑ QRS complex and ↓ P wave– sine wave of severe hyperkalemia
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17. 70-year-old woman with weakness. Meds include hydrochlorothiazide.
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EKG signs of hypokalemia
• U waves appear, and• T waves diminish
May appears as ↑ QT interval• ST-segment depression “rollercoaster”
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18. 70-year-old man with metastatic lung cancer who is lethargic.
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19. 30-year-old homeless man found outside during winter – unresponsive.
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Osborne waves of hypothermia
• Osborne waves appear < 32°C.• Size correlates inversely with temperature.
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20. 22-year-old man found unresponsiveby roommate.
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EKG signs of TCA toxicity
• Sinus tachycardia• Prolongation QRS complex• Prolongation QTc interval• Rightward shift of terminal 40 msec QRS axis
– Increase amplitude of R wave in aVR
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after Rx with NaBicarb…