ECG etc… (Miscellaneous ECGs) Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center

Objectives Describe the following miscellaneous ECGs: –Lead reversal –Dextrocardia –Hypothermia –Pericarditis –Cardiac Tamponade –Wolff-Parkinson-White –Pulmonary embolism Practice, practice, practice!!!

Limb lead reversal Inverted P and QRS in lead I

Chest lead reversal Tall precordial R waves

Normal ECG

Dextrocardia Negative P and QRS in lead I and aVL Reverse R wave progression (differential: lead reversal)

Hypothermia Osborn or “J” waves (arrows) Baseline interference from shivering (others: sinus brady, QT prolongation, junctional rhythm, ventricular fibrillation, asystole)

Hypothermia

Pericarditis Diffuse ST elevations Typically, no reciprocal changes PR displacement

Pericarditis

Cardiac Tamponade Tamponade Triad (specific, not sensitive): 1.Sinus tachycardia 2.Low voltage QRS 3.Electrical alternans

Wolff-Parkinson-White WPW Triad: 1.Short PR interval 2.Wide QRS 3.Delta wave

A. Fib with WPW

Pulmonary Embolism Clues: Sinus tachycardia S1Q3T3 pattern Incomplete RBBB with R precordial T wave inversions

PE

Lets’ practice!

EKG 1

EKG 2

EKG 3

EKG 4

EKG 5

EKG 6

EKG 7

EKG 8

Brugada syndrome Defined in 1992 by brothers Pedro and Josep Brugada in J Am Coll Cardiol Rare condition associated with sudden cardiac death (SCD) or ventricular fibrillation/polymorphic VT in structurally normal hearts Mean age of presentation: years; male predominance (notably in SE Asia where it is endemic) Familial with autosomal dominant inheritance Clinical presentation: syncope or SCD is most common initial event; typically occurs in sleep or in early morning ECG criteria: ST segment elevation in V1-V3 with characteristic RBBB pattern Defect in sodium channel gene (SCN5A) on chromosome 3 Lifetime risk of SCD Consider ICDs; refer for genetic counseling

The End