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ECG OF THE WEEK

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Each Week we put up one ECG case for you....because it's easier to learn from cases.
The ECG of the week is FREE to everyone. To become an expert at ECG's join the Cardiac Bootcamp Course. It's a great way to Learn!
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A 22 yo male with lethargy and palpitations

27/4/2021

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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?
Picture
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?
  1. What is the diagnosis?​
  2. What is the potential cause in this patient?
  3. If this patient went into Torsades de Pointes, following cardioversion with electricity, would you treat with:​
    1. Amiodarone or
    2. ​Magnesium?
  4. What are the causes generally?​
  5. What conditions is this ECG pattern mistaken for?
​....answers are below.
This is the classic ECG of hypokalaemia. It has the 4 classic changes:
  1. ST segment Depression
  2. Inverted T waves
  3. Large U waves
  4. Prolonged PR Interval
Beware here as there is no prolonged QT, but a long QU due to the prominent U waves.
​See the ECG Below for these changes. The patient's potassium was 1.1 mmol/L
Picture

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:
  • High carbohydrate meal
  • Rest following Exercise
  • High Na Content Foods
  • Sudden Change in Temperature
Clinical Diagnosis is made by:
  • Episodes of Paralysis
  • Low K during attacks but normal between
  • Triggers
  • Familial History
Patients tend to develop a progressive myopathy over time.

If this patient went into Torsades de Pointes, following
cardioversion with electricity, what would you treat with?

Picture
Obviously we would need to treat the hypokalaemia. However rapid correction of hypokalaemia can result in ventricular arrhythmias and asystole.
Usually patients with hypokalaemia also have hypomagnesaemia. Magnesium is modulator of K+ ion transport.
​Therefore GIVE MAGNESIUM.

What are the Causes and What ischaemic condition is it
​
sometimes mistaken for?

Go to the Hypokalaemia section of the cardiac Course and see more cases, causes and what it is mistaken for.
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ST Elevation in Non-Contiguous Leads: What do we do with that?

6/4/2021

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In this blog we again look at why serial ECGs are important and how to approach a particular ECG variant, where there may be some ST elevation, but not in contiguous leads. We introduce The South African Flag Sign.
CASE
​A 54 yo male presents with left sided chest pain that radiates into his jaw. He has vomited once.
His past medical history includes:
  • Diabetes
  • Hypercholesterolaemia
  • An AMI 10 years ago
  • Hypertension
This is a great case presented recently at EMCORE by Prof Louise Cullen who has allowed me to use her slides here.
​His first ECG is shown below. Describe and interpret the ECG.
Picture
Sinus rhythm
Rate 78
Axis: Normal
Narrow complex QRS
ST segments: 
  • ? ST elevation I and aVL
  • T wave inversion lead III
Intervals: Borderline prolonged PR
​Anything else?

Let me ask you this question: Is this a fast rule out candidate? Can we apply ADAPT criteria for rapid rule out? We will need two high sensitivity troponins 2 hours apart and then apply the TIMI Score.
​I can tell you that once he has all these risk factors and has had a previous AMI, he is being referred! This is not a rapid rule out patient.
Picture

TIMI Score

The 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.
His first troponin is normal and he has a followup ECG 20 minutes later. Describe and interpret now:
Picture
Not much has changed here. Perhaps there is more ST elevation in lead I and certainly aVL. T waves are still inverted in lead III, perhaps some ST depression in III.

The patient has a serial troponin and at 3 hours the troponin is raised, (30ng/L normal is < 20ng/L)
A further ECG is done at 6 hours: Describe and interpret.
Picture
Now we see some ST elevation in I and aVL, with ST depression in III.
A further ECG is done and shown below. The Troponin is now raised at 472ng/L.
How is this ECG different?
Picture
Perhaps we can now see some ST elevation in I and aVL and even in V2. Perhaps the ST depression in III is a little reduced.
The TIMI Score has now increased to 4 and predicts about a 20% chance of MI or ischaemia or all-cause mortality.

The patient was taken to the cath lab and an occluded Diagonal artery was found, for which he had successful PCI.

So the question here is is, without the 6 hour troponin and the fact that there is no ST elevation in contiguous leads, this might be one of those ECG we miss. We need to look at this particular pattern in the ECG. ​
ECG Pattern for High lateral infarct ie 1st Diagonal.
In 2015 Durant et al published a case report of a patient with a characteristic ST elevation in NON contiguous leads, with an acute diagonal occlusion. This is the ECG.
Picture
We clearly see the ST elevation in I, aVL and V2 and ST depression in II, III and aVF.
Littman in response to this, discussed the South African Flag sign as a way of memorizing the changes in a high lateral infarct..
The ECG changes were:
  • ST Elevation in I, aVL and V2 and
  • ST Depression in lead III​
Picture
We can apply this same sign to out patients ECG as follows:
Picture
The SOUTH AFRICAN FLAG SIGN. Remember it, as it can help identify the subtle and non-contiguous changes of a high lateral infarct. For members of the HOMEcardiac bootcamp self study course, go to the section on subtle ischaemia, for more examples.
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    Author

    Dr Peter Kas
    ​Emergency Physician

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