1. 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

2. 20 EKGs you should know Chest pain presentations Syncope Palpitations
Metabolic/miscellaneous

3. 1. 45-year-old man with one hour of chest pain radiating to his back.

4. 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

5. 2. 78-year-old dairy farmer with one hour chest pain associated with sweating.

6. 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

7. 3. 36-year-old woman, 3 weeks post-partum, with 30 min chest pain which has resolved.

8. 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

9. four hours after chest pain

10. 4. 53-year-old man with acute MI who received thrombolytic therapy one hour ago.

11. 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

12. 5. 35-year-old man with chest pressure all day, worse with inspiration and position.

13. 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)

14. 6. 40-year-old man being evaluated for syncope earlier that day.

15. 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

16. 7. 48-year-old woman with shortness of breath after experiencing syncope.

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

18. Her CT angiogram…

19. 8. 45-year-old man with “worst headache of his life” associated with vomiting.

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

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

22. 9. 65-year-old woman collapses 3 days after experiencing severe back pain.

23. 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

24. 10. 75-year-old woman with syncope in church – asymptomatic when lying flat.

25. 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

26. 11. 60-year-old man with weakness and “heart racing” – no prior history.

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

28. 12. 36-year-old man with palpitations and near syncope
year-old man with palpitations and near syncope. History of palpitations.

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

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

31. 13. 28-year-old woman with frequent episodes of “SVT” treated in ED.

32. Signs of AVRT (WPW)
Prolonged RP interval
QRS alternans

33. after cardioversion…

34. 14. 50-year-old woman with “heart jumping” but no syncope.

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

36. 15. 68-year-old woman with chronic atrial fibrillation.

37. 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

38. 16. 25-year-old man with ESRD who missed last hemodialysis session.

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

40. 17. 70-year-old woman with weakness. Meds include hydrochlorothiazide.

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

42. 18. 70-year-old man with metastatic lung cancer who is lethargic.

43. 19. 30-year-old homeless man found outside during winter – unresponsive.

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

45. 20. 22-year-old man found unresponsive by roommate.

46. 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

47. after Rx with NaBicarb…