|
This year at the Cardiac Bootcamp face to face course in Sydney we had a fantastic turnout and we went over a huge amount of content in Acute Cardiology and reading ECGs. There were some ECGs that we looked at, as part of the ECG Quiz. Here is one of those ECGs, to test your memory and to reinforce some of the most important things we learnt about this case. A 68 yo woman presented with worsening SOB over the previous 24 Hours. She now also had chest pain and was speaking in very short phrases. She was a smoker, with a past medical history of COPD and hypertension. Her vitals were:
Her blood pressure dropped to 65/32 before peripheral inotropes were commenced. Her ECG and Chest Xray are shown below. What is your diagnosis?   There is a pericardia effusion diagnosed on LOW VOLTAGE CRITERIA. Small complexes and tachycardia = pericardial effusion. The are Sensitive Criteria and Specific criteria for picking low voltage on an ECG. This was all part of the 'SHOCKED' A mnemonic on Cardiac Bootcamp Course, to minimise missed cases. 
0 Comments
A 50 yo male presents with chest pain. His ECG is shown below. What does it show?  Rate: 66
Rhythm: Irregularly irregular, not many P waves, so atrial fibrillation. QRS: Narrow ST-T: The obvious abnormality here is the STE in II, III and aVF with reciprocal changes in aVL. There is also some ST depression in V2-V4. The diagnosis here is an inferior infarction. We need to beware of potential Right Ventricular infarction as well. How do patients with Right Ventricular Infarction present? What does the ECG show? What are the differentials? What is the management of these patients? Isolated right ventricular infarction is rare, but it does occur in 30-50% of cases of inferior infarction. We need to think of the possibility of right ventricular infarction, or we can miss it. The right ventricle is thin walled and is perfused throughout the cardiac cycle, explaining why it is less likely to infarct....... A 48 yo male presents to the emergency department with a complaint of a rapid heart rate. He has been known to be in a rapid rate before(although he is not quite sure of what it is) and has been commenced on Sotalol. He sometimes neglects to take his medication and in this case has not taken it for two days. He has also been drinking heavily the night before. He states that at 7.15 that morning he felt his heart start to race suddenly. His ECG is shown below. What is your diagnosis?  In looking at the diagnosis look at the p-wave axis.
What does the ECG show? What is your management? A 40 yo is brought to the emergency department with the following vitals:
An ECG is done.
 If we use the 'ECG in 20 Seconds Approach' to describe the ECG, we get the following:
Rate/Rhythm 106
A quick clinical pearl for you. One of the important ECG skills to have, is to be able to diagnose a paediatric ECG. Go to the Paediatric ECG page in the course to quickly read on this. There are the important things to know which include:
What about the axis? One of the first things I look at is the AXIS. The paediatric axis should be normal or rightward. If the axis is NORTHWEST, assume a congenital abnormality like a VSD etc. JUST LOOK at aVF. If aVF is NEGATIVE= Congenital until proven otherwise.  Below is an example of this. It is a child with an AV Septal Defect, causing biventricular failure. The ECG should be right heart dominant, but it's both right and left dominant. Look at aVF; it's NEGATIVE. So I know there is a congenital defect. How will these children present. What are the clinical manifestations of this conditions and others? Go to Paediatric Heart Conditions you must know.  Source: Pediatrics in Review A 9 yo girl is brought into the emergency department, following an episode of syncope. She has a current viral illness and looks miserable. She was walking into the Emergency Department with her mother, when she collapsed. She recovered quickly with no post-ictal component but has no memory of the event, although the event was preceded by ‘dizziness’ and diaphoresis. Her past medical history is ADHD, for which she is on no medication. You review her in the triage room as the department is filled to capacity. The vitals are all normal but the child looks tired and has some coryza symptoms. You ask the resident to get the rest of the story and show you an ECG. The resident brings you the ECG shown below. What is your comment on this ECG?  ECG Interpretation At first glance: There is T wave inversion in anterior leads but you would expect this in a young girl. There are however T waves inverted in the lateral leads…….STOP. Let’s go over the ECG in a systematic fashion. Is it sinus rhythm? For it to be sinus, the p wave in II must be upright and the p wave in aVR inverted. This is not the case. Now look at lead I, The p waves are inverted and they should be upright. Two things give you this pattern:
You have the ECG redone. The ECG is shown below. How would you comment on this?  For quite some time I've been less than eager to calculate axis on all ECGs. The one exception that I made is, when there was a RBBB on the ECG, as I would then look for a Fascicular Block. However I have found it more useful than I thought. In this Blog we will look at how to calculate axis and refer you back to the section in the course on ECG Axis to do this in more detail and we will further look at some of the uses. There are many ways to calculate axis;
WHY IS IT IMPORTANT? There was a case we covered in a prior blog of a 70 yo male who presents to the emergency department following a collapse at home. There is no prodrome and he does not remember the incident. His ECG is shown below. What is the diagnosis?  This was an incomplete triphasicular block, with:
The next case is one of an amphetamine overdose. Can the axis help us here? The patient has been in a sinus tachycardia and now he has a wide complex.
 It is a wide complex tachycardia. It has a rate > 120, so it qualifies to continue with my 120CRAM formula for diagnosing VT. It has some of the elements of VT. First thing to say is that amphetamines DO NOT cause Na channel blockade, so it can't be that. What is the axis? It looks like a right axis. Right axis can be cause by ventricular ectopy ie VT. So it can be VT. RBBB doesn't tend to cause a right axis. BUT HyperK+ does and this patient was hyperkalaemic. After being shocked with no result, the patient was treated with bicarb and Ca++ and sinus rhythm was obtained. Axis can help. HOW TO QUICKLY CALCULATE AXIS: Let's use the Quadrant Method We will use leads I and aVF Here is how to perform this:
Let's practice on the ECG below: Using the Quadrant Method the left arm goes up as lead I is positive and the right arm is downas aVF is negative. The resultant positive arm is the left so it is a LEFT AXIS.  For a Video on how to do this and a bit of fun with Donald Trump showing us how to calculate axis, go to the Basic ECG Section.  That's all I've got for you this week....
A 22 yo male presents to the emergency department with a history of lethargy, fatigue and palpitations. He has no chest pain or SOB.
There is no past medical history. The patient believes he feels like this, as he had a big gym workout today. An ECG is done because of the history of palpitations. What is your interpretation? 
Sinus Rhythm at rate of 98bpm
Normal QRS width Widespread ST depression I, II, aVL aVF V1-V6 with abnormal ST segments due to? Intervals: PR is prolonged, Is that a long QT?
This is the classic ECG of hypokalaemia. It has the 4 classic changes:
See the ECG Below for these changes. The patient's potassium was 1.1 mmol/L 
Diagnosis
This patient has Hypokalaemic Periodic Paralysis. It is characterised by muscle weakness of the shoulders and hips associated with hypokalaemia.
Proximal Weakness is usually greater than distal weakness. The respiratory muscles are usually spared, although they may not be. The conditions presents with first attacks in childhood and adolescence. A first attack in someone older than 25 years is almost never this condition, unless it is associated with thyrotoxic periodic paralysis. It has an autosomal dominant inheritance. Attacks are precipitated by:
If this patient went into Torsades de Pointes, following
|
 | TIMI ScoreThe Thrombolysis in Myocardial Infarction Score looks at the likelihood of ischaemic events or mortality in patients with unstable angina or a NSTEMI. It has been used to risk stratify patients presenting with chest pain. Low risk patients have a TIMI score of < 1. Without knowing a first troponin- the patient has a TIMI score of 2- He is not for rapid rule-out. He is getting admitted. Let's look at the case in more detail however and see how it unfolds. The TIMI score will also change as we progress. |
Dr Peter Kas
Emergency Physician
June 2021
May 2021
April 2021
March 2021
February 2021
January 2021
December 2020
November 2020
September 2020
August 2020
July 2020
