EKG/ECG Practice

[Sdiver]

Trapper John had mentioned in another thread about putting up some more EKG/ECG strips.

So let's start with this one ....

Here is the ECG from our 63 yo F patient complaining of neck and arm pain... BEFORE you jump in and write STEMI (that is too obvious), I want to know what you think the RHYTHM is.

I'm NOT going to give you Pt. Hx or scenario, just read the rhythm and give me your interpretation.

Be as precise and specific as possible.

[miclo18d]

Took me a few minutes to realize what a STEMI is. It's been about 7 years since I looked at a strip so it seems they have some new terms like ST elevated myocardial infarction. We called it the "tombstone" sign.

As I had taken 12 leads for guys physicals, we never had to learn how to read them and sometimes doctors would give us classes on them. I never could remember which angle I was looking at, so never really got the feel for reading the 12 lead.

That said, the only other thing I was seeing was the pr interval seems a bit long. 1st degree AV block?

[PedOncoDoc]

That said, the only other thing I was seeing was the pr interval seems a bit long. 1st degree AV block?

I agree with that assessment - the PR interval appears long but fixed, without any dropped p waves.

[Trapper John]

First thing that struck me was the inverted T-wave in lead I. The second is what appears to be a broad T-wave in all leads, and elevated S-T interval (short S-T interval with a long S-T segment?) The obvious MI aside, I get the impression of a left ventricular hypertrophy too.

Is this patient on digoxin? I am thinking there may be some pharmacological induced ECG changes too, but not sure.

[Sdiver]

First thing that struck me was the inverted T-wave in lead I. The second is what appears to be a broad T-wave in all leads, and elevated S-T interval (short S-T interval with a long S-T segment?) The obvious MI aside, I get the impression of a left ventricular hypertrophy too.

Is this patient on digoxin? I am thinking there may be some pharmacological induced ECG changes too, but not sure.

In this thread, don't worry about meds or Hx or Dx, just give me your interpretation of the posted strip.

Remember, be as precise and specific as possible in reading it off. ;)

[Trapper John]

In this thread, don't worry about meds or Hx or Dx, just give me your interpretation of the posted strip.

Remember, be as precise and specific as possible in reading it off. ;)

FTFSI :eek: Just couldn't help myself :D

[adal]

Rate = 52, rhythm=reg, PRI= >.20 about .28 seconds, QRS = <.12, Every QRS has a P, Every P has a QRS, Elevation >3mm in leads II, III, AvF. Invereted T in I, V1, V2, AvR, AvL.

Sinus Brady W/ 1st Degree HB and Inferior STEMI

I think. ;)

There are numerous sites to learn / re-learn about EKG.

http://www.slideshare.net/Jedimurl/12-leads-made-easy-2725398
http://www.emergencyekg.com/interactive_learning.cfm

[Sdiver]

FTFSI :eek: Just couldn't help myself

Now worries. It happens. :D


I agree with that assessment - the PR interval appears long but fixed, without any dropped p waves.

Correct, there are no dropped P waves, but ... has anything else dropped or is there anything "extra" that cane be seen ???


Rate = 52, rhythm=reg, PRI= >.20 about .28 seconds, QRS = <.12, Every QRS has a P, Every P has a QRS, Does it ???Elevation >3mm in leads II, III, AvF. Invereted T in I, V1, V2, AvR, AvL.

Sinus Brady W/ 1st Degree HB and Inferior STEMI

I think.

There are numerous sites to learn / re-learn about EKG.

http://www.slideshare.net/Jedimurl/12-leads-made-easy-2725398
http://www.emergencyekg.com/interactive_learning.cfm

It's always good to practice up on EKGs and these are a couple of good sites to do so on.

Not reading/practicing on strips, you could miss a thing or two. ;)

*HINT .... Get your calipers out. :munchin

[MR2]

*HINT .... Get your calipers out. :munchin

First thing that I did - you owe me for a new LED screen...

[adal]

Sooo....I don't and probably won't ever own a pair of calipers. :)

Now I see my error.

3rd degree HB. That explains the brady better.

It is hard to see without a longer strip that I would usually run in conjunction with a 12 lead. It's hard to dx off that short run the 12 lead uses.

[Sdiver]

First thing that I did - you owe me for a new LED screen...

*Sigh* ... Okay. :rolleyes:

That's why I use a EKG ruler or a piece of paper with marks on it.

[Trapper John]

Sooo....I don't and probably won't ever own a pair of calipers. :)

Now I see my error.

3rd degree HB. That explains the brady better.

It is hard to see without a longer strip that I would usually run in conjunction with a 12 lead. It's hard to dx off that short run the 12 lead uses.

You've done this before haven't ya? :D Kidding aside - very good analysis. But, I thought complete HB gives the classic camel hump T-wave presentation?

I still say left ventricular hypertrophy. Possible LBB. Need to hit the books on this one some more. I wonder if the absent Q wave in lead 1 is significant? :confused:

[PedOncoDoc]

You've done this before haven't ya? :D Kidding aside - very good analysis. But, I thought complete HB gives the classic camel hump T-wave presentation?

I still say left ventricular hypertrophy. Possible LBB. Need to hit the books on this one some more. I wonder if the absent Q wave in lead 1 is significant? :confused:

3rd degree heart block has consistent intervals between p waves and between QRS complexes that are independent from each other, hence the recommendation to get out the calipers. When taking exams on which I had to analyze rhythms I would take a piece of paper and place a mark above 2 consecutive p waves and move from p-wave pair to p-wave pair to see if they were consistent, and would do the same for the QRS complexes.

I would've preferred to see a longer rhythm strip in conjunction with the 12-lead to firm up this diagnosis - sometimes the switch from lead to lead on the printout can make identifying 3rd degree block more difficult than it should be.

[Red Flag 1]

1

[adal]

3rd degree heart block has consistent intervals between p waves and between QRS complexes that are independent from each other, hence the recommendation to get out the calipers. When taking exams on which I had to analyze rhythms I would take a piece of paper and place a mark above 2 consecutive p waves and move from p-wave pair to p-wave pair to see if they were consistent, and would do the same for the QRS complexes.

I would've preferred to see a longer rhythm strip in conjunction with the 12-lead to firm up this diagnosis - sometimes the switch from lead to lead on the printout can make identifying 3rd degree block more difficult than it should be.

Yeah, Sdiver and I had this chat on another forum. :( I may have jumped the gun a bit. However, with a longer strip it would be easier. I have been looking at my pts EKG strips with renewed vigor, however.

I use paper strips also, if... I have the time. Most of the time I'm on my way to a cath lab with the obvious stuff and we try to work in the extra credit when we can.

This was a great example of slow down and do it like we are SUPPOSED to. :)

[Sdiver]

Here's the moment you've all been waiting for .... the answer.

In addition to the obvious STEMI, which is indeed an Inferior wall MI (as seen in leads II, III, and aVF, at least 3, possibly 4 mm elevation) this was/is a 2nd degree type I AVB, with 2:1 conduction and periods of 3:2, otherwise known as wenckebach.

Here's the same strip with marks pointing out the P-waves that "march out" with regularity. In lead I, you can see the P waves sitting on the down-ward slope of the T-wave with a dropped QRS. But the next p-wave associated with a QRS is right on time and on target.

Also, look at leads V1-V6. Notice anything "extra" ???
Is that a PVC or a PAC ???
Does it make a difference in your interpretation ???
Should you be concerned about it ???

Yes, the main focus is the STEMI and this person should be in a Cath-Lab ASAP, but as Adel pointed out, this is the kind of strip that one needs to slow down, take your time and hit the basics.

Heart blocks are a bitch to read sometimes. Everyone can pick out a 1st degree, and 3rds are relatively "easy", it's the two different types of 2nd degrees that throw people off.

[Sdiver]

What are the types of heart block?

First-degree heart block (also called first-degree AV block). The electrical impulses are slowed as they pass through the conduction system, but all of them successfully reach the ventricles. First-degree heart block rarely causes any symptoms or problems, and well-trained athletes may have this. Medications can contribute to the condition. No treatment is generally necessary for first degree heart block.

Type I second-degree heart block (also known as Mobitz Type I second-degree AV block or Wenckebach AV block). In this condition, the electrical impulses are delayed further and further with each heartbeat until a beat is skipped entirely. The condition generally is not as serious as type II second-degree heart block, but it sometimes causes dizziness and/or other symptoms. Normal people may sometimes have this when they are sleeping.
Type II second-degree heart block (Mobitz Type II second-degree AV block) is also a condition in which some of the electrical impulses are unable to reach the ventricles. This condition is less common than Type I, but is generally more serious. In some cases, a pacemaker is implanted to treat the abnormally slow heartbeat that may result from this condition.

Third-degree heart block (also known as complete heart block or complete AV block) is when none of the electrical impulses can reach the ventricles. When the ventricles, (lower chambers), do not receive electrical impulses from the atria (upper chambers), they may generate some impulses on their own called functional or ventricular escape beats. Ventricular escape beats, natural backup signals, usually are very slow, however, and cannot generate the signals needed to maintain full functioning of the heart muscle.

Bundle Branch Block is when electrical impulses are slowed or blocked as they travel through specialized conducting tissue in the ventricles.

http://arrhythmia.org/heartblock.html

[miclo18d]

As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.

[Trapper John]

Thanks for the tutorial SDiver. Great exercise for the ol' noggin to think about things that I haven't thought about in years. Good therapy for the CRS syndrome too. :D

[The Lunchbox]

As far as the STEMI goes I recall someone telling me that without S/Sx that elevated ST can be indicative of PRIOR MI. That once damage has been done it's permanent and therefore shows up on an EKG.

Again I've been out of the game for awhile and as I gain more FOG status with each day, my CRS keeps actin' up.

Your post got me thinking about persistence of ST segment changes post MI and I found this abstract about it.

http://www.ncbi.nlm.nih.gov/pubmed/1124714

Their conclusions were..."We concluded that (1) the natural history of S-T segment elevation after myocardial infarction is resolution within 2 weeks in 95 percent of inferior but in only 40 percent of anterior infarctions; (2) S-T segment elevation persisting more than 2 weeks after myocardial infarction does not resolve; (3) persistent S-T segment elevation is associated with clinically more severe myocardial infarction; and (4) in patients with coronary artery disease, persistent S-T segment elevation after myocardial infarction is a specific but insensitive index of advanced asynergy."

[wook]

Great ECG and discussion!

It looks like the elevation is greater in III than II, which would definitely make me want to get a right sided ECG to evaluate for the inferior AMI (often a more proximal lesion of the right coronary artery). With the heart block and brady, thinking it is a right coronary artery lesion since in 80% of the population, this arterty feeds the AV Node.

[regularamymedic]

Extreme Sinus Bradycardia; 3rd Degree (Complete) Heart block w/ Inferior/lateral STEMI.

HR seems to be less than 40.

[rricht]

Sinus bradycardia with 1st degree AV block and premature junctional contractions.

[ender18d]

Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.

[wook]

Alright here's a scenario for you based on a patient I saw not that long ago. Some inconsequential details have been changed.

19yo previously healthy young female PV2 is having a wild night out, gets drunk, and passes out on a dance floor. Seems pretty straightforward but something about the abruptness of the way she face planted rubs you the wrong way so you get an EKG and some labs. ETOH level is ~200. Currently drunk but not complaining of anything.

Additional questions? (Even if you are struggling with the EKG, what sorts of questions should you be asking?)

Thoughts?

MDs and the like hang back on this one before giving the game away.

Nice!! Great case and very important diagnosis to catch (if it's what I think it is)!


Wook

[miclo18d]

All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?

[ender18d]

All the questions I want to ask are mimicked by drunkeness/hangover...
Headache? Dizzy? Nauseous?

Or am I going down the wrong street?

Quick approach to transient loss of consciousness:

1. Is it syncope or is it seizure?
Convulsions (can be present for either but if prolonged more likely seizure)?
Post ictal period?
Incontinence?
Tongue biting?
Seizure history?

2. Is it syncope **AND?**
Syncope plus other symptoms can have a huge differential. In the right context, syncope AND abdominal pain could be AAA. Syncope AND dyspnea could be PE. Syncope AND headache could be SAH. Syncope and pregnant could be ectopic. Figure out if there are other concerning symptoms.

3. Red flags for syncope.
If you set aside syncope with significant and/or ongoing associated symptoms for a moment, almost all scary causes of syncope are cardiac. So some red flags that should scare you point to cardiac causes of syncope:
-Pain. Along the lines of #2, benign syncope should not hurt.
-“Lights out” with no prodrome. Suspect this if injured in fall esp.
-Syncope during exertion. Passing out after exertion is not uncommon, but during exrtion should scare you.
-history of cardiac disease
-family history of sudden cardiac or unexplained death
-Patient is elderly
-new/unexplained murmur

**So back to our patient:
1. No historical features to suggest seizure.
2. No associated symptoms not explained by ETOH. Neg HCG.
3. A few big red flags: she went out quickly with no prodrome and possibly (story fuzzy) while dancing. Her father died in his 30’s in his sleep and no one was ever sure why.

[ender18d]

So most of the MDs have PMd me and identified the rhythm, and I think no one else is going to wade in, so the answer:

This patient had Brugada Syndrome, a channelopathy that can predispose patients to arrhythmia and sudden cardiac death. Its an autosomal dominant genetic disorder, and this is likely what claimed her father's life. The EKG findings of Brugada are not always present (you can have a normal prior EKG) and Brugada "attacks" can be precipitated by alcohol use. This patient's EKG normalized when she sobered up.

She was admitted to Cardiology for an AICD placement.

Brugada has different forms, but should be considered in a syncopal patient with EKG findings of ST elevation in V1-3, especially if combined with T wave inversion as seen in this EKG.

If y'all want to keep going I have some other good real patient syncope scenarios for you.

[Trapper John]

As the namesake for my nomme de plume would say, "Finest Kind!" :D

Seriously, Thank you all for contributing to this discussion!

[miclo18d]

Way above my pay grade!

Put a GSW in front of me and I’ll make you proud!