20 EKGs You Should Know Susan P. Torrey, MD, FACEP, FAAEM Associate Professor of Emergency Medicine Tufts University School of Medicine Faculty, Baystate Medical Center Springfield, Massachusetts

20 EKGs you should know Chest pain presentations Syncope Palpitations Metabolic/miscellaneous

1. 45-year-old man with one hour of chest pain radiating to his back.

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

2. 78-year-old dairy farmer with one hour chest pain associated with sweating.

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

3. 36-year-old woman, 3 weeks post-partum, with 30 min chest pain which has resolved.

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

four hours after chest pain

4. 53-year-old man with acute MI who received thrombolytic therapy one hour ago.

Accelerated Idioventricular Rhythm 1 2 3 4 5 6 7 8 Beats 1-3 are idioventricular Note emergence of P before #3 Beats 4-6 are sinus Beat 7 is a fusion beat

5. 35-year-old man with chest pressure all day, worse with inspiration and position.

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)

6. 40-year-old man being evaluated for syncope earlier that day.

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

7. 48-year-old woman with shortness of breath after experiencing syncope.

EKG signs of acute PE New RBBB S1Q3T3 T wave inversion in V1-3 Correlates with severity of PE S1Q3T3

Her CT angiogram…

8. 45-year-old man with “worst headache of his life” associated with vomiting.

CNS effect Diffuse T wave inversion – impressively deep Asymmetric with bulging ascending portion +/- prominent U waves and QT prolongation

Other causes of deep T wave inversion Ischemia/subendocardial infarction Ventricular pacing (memory T waves) Apical hypertrophic cardiomyopathy Takotsubo cardiomyopathy Acute pulmonary embolism

9. 65-year-old woman collapses 3 days after experiencing severe back pain.

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

10. 75-year-old woman with syncope in church – asymptomatic when lying flat.

Pacemaker failure QRS at 24/min P waves at 75/min ↑ ↑ ↑ •↑ • • • QRS at 24/min P waves at 75/min Pacer spikes at 72/min Failure of sensing and of capture

11. 60-year-old man with weakness and “heart racing” – no prior history.

Atrial flutter with 2:1 AV conduction When the rate is 150/minute, always think of 2:1 atrial flutter. With AV blocking agents…

12. 36-year-old man with palpitations and near syncope 12. 36-year-old man with palpitations and near syncope. History of palpitations.

The scariest atrial fib you’ll ever see… Avoid typical AV blocking agents Adenosine β-blockers Calcium-channel blockers Digoxin

Wolff-Parkinson-White Syndrome After cardioversion note δ wave = WPW After ablation of bypass no longer has WPW

13. 28-year-old woman with frequent episodes of “SVT” treated in ED.

Signs of AVRT (WPW) Prolonged RP interval QRS alternans

after cardioversion…

14. 50-year-old woman with “heart jumping” but no syncope.

The most common cause of a pause in sinus rhythm is a blocked PAC.

15. 68-year-old woman with chronic atrial fibrillation.

Ashman’s phenomenon Long…short…weird V1 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

16. 25-year-old man with ESRD who missed last hemodialysis session.

Hyperkalemia Peaked T waves of hyperkalemia Symmetrical and narrow-based Then ↑ QRS complex and ↓ P wave  sine wave of severe hyperkalemia

17. 70-year-old woman with weakness. Meds include hydrochlorothiazide.

EKG signs of hypokalemia U waves appear, and T waves diminish  May appears as ↑ QT interval ST-segment depression  “rollercoaster”

18. 70-year-old man with metastatic lung cancer who is lethargic.

19. 30-year-old homeless man found outside during winter – unresponsive.

Osborne waves of hypothermia Osborne waves appear < 32°C. Size correlates inversely with temperature.

20. 22-year-old man found unresponsive by roommate.

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

after Rx with NaBicarb…