ECG made easy Part 2 – ECG Quiz
• Presented by: • Dr Randall Hendriks, Interventional Cardiologist – Western Australia
1 ? Axis
1. Left 2. Right 3. Indeterminate ? Axis
1. Left 2. Right 3. Indeterminate ? Axis
1. Left 2. Right 3. Indeterminate
Page 4 ? Axis
1. Left 2. Right 3. Indeterminate
Page 5 ? Axis
1. Left 2. Right 3. Indeterminate
Page 6 ? Axis
1. Left 2. Right 3. Indeterminate
Standard limb lead reversal!
Page 7 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 8 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 9 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 10 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 11 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 12 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 13 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 14 Tachycardia
1. Atrial fibrillation 2. Atrial flutter 3. SVT 4. Sinus tachycardia 5. Junctional
Page 15 Tachycardia
1. Atrial flutter 2. Atrial fibrillation 3. SVT 4. Sinus tachycardia 5. Junctional
Page 16 Tachycardia
1. Atrial flutter 2. Atrial fibrillation 3. SVT 4. Sinus tachycardia 5. Junctional
Page 17 Bradycardia
1. Sinus bradycardia 2. First degree AV block 3. Mobitz Type I (Wenckebach) 4. Mobitz Type 2 5. Complete heart block
Page 18 Bradycardia
1. Sinus bradycardia 2. First degree AV block 3. Mobitz Type I (Wenckebach) 4. Mobitz Type 2 5. Complete heart block
Page 19 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 20 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 21 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 22 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 23 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 24 ST elevation MI
1. Inferior 2. Anterior 3. Lateral 4. Posterior 5. IPL
Page 25 ST elevation – 30 year old Thai man with syncope
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 26 ST elevation – 30 year old Thai man with syncope
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 27 ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 28 ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 29 Palpitations
1. VT 2. SVT with aberrancy
Page 30 ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 31 ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI 2. Normal repolarisation 3. LV aneurysm 4. Pericarditis 5. Brugada syndrome
Page 32 Palpitations
1. Absence of RS? 2. No – next question
Page 33 Palpitations
1. R/S interval > 100msec? 2. Yes - VT
Page 34 Can’t miss-life threatening ECGs
35 Bradycardia and hypotensive in ED
Page 36 Bradycardia and hypotensive in ED
Complete heart block
Page 37
Wolff-Parkinson-White syndrome Palpitations: 20 year old female with presyncope
Page 40 Palpitations: 20 year old female with presyncope
Pre-excited AF
Page 41 Hypokalaemia
Page 42 Broad complex tachycardia – diagnosis?
Page 43 Broad complex tachycardia – diagnosis?
Torsades de Pointes – QT prolongation
Page 44 Hypokalaemia
• Decreased extracellular K – hyperexcitability: re-entrant arrhythmias • Increase amplitude and width of P wave • Prolonged PR interval • T flattening / inversion • ST depression • Prominent U waves • Apparent long QT (QTU fusion) • SVEs, VPBs • SVT (AF, atrial flutter, atrial tachy) • VT, VF and Torsades de Pointes
Page 45 Hyperkalaemia
Page 46 Hyperkalaemia
• Increased extracellular K – reduces myocardial excitability • Repolarisation changes: Peaked T waves • Atrial paralysis: P wave widens and flattens PR prolongation P wave disappears • Conduction abnormality and bradycardia: QRS prolongs / bizarre High grade AV block, junctional and ventricular escape rhythms Sinus brady or slow AF Sine wave (pre terminal) • Cardiac arrest: Asystole VF PEA with bizarre wide QRS
Page 47 Hyperkalaemia
Page 48 Digoxin toxicity – PAT with block and VPBs
Page 49 Bidirectional VT – digoxin toxicity
Page 50 Digoxin toxicity
• Increased automaticity / decreased AV conduction: SVT with slow ventricular response • PVC’s, sinus brady, AF • Any type of AV block • Regularised AF (AF with CHB) • VT (polymorphic or bidirectional)
Page 51 Intracranial haemorrhage
Page 52 Intracranial haemorrhage
• Widespread giant T inversion • QT prolongation • Bradycardia (Cushing reflex – brain stem herniation) • ST elevation or depression • Increased U wave amplitude • ST, junctional, VPBs, AF • (? Hypothalamic stimulation / autonomic dysregulation)
Page 53 Massive pulmonary embolism
Page 54 Massive pulmonary embolism
• Sinus tachycardia • Complete or incomplete RBBB • RV strain T inversion V1-4, II,III,aVF • Right axis deviation • Dominant R V1 • P pulmonale • SI, QIII, TIII in 20% only • Clockwise rotation • Atrial arrhythmias • Non specific ST/T changes
Page 55 Pacemaker malfunction
Page 56 70 year old, chest pain and diaphoresis
Page 57 70 year old, chest pain and diaphoresis
Extensive anterior MI (‘tombstoning” pattern)
Page 58 Ischaemic sounding chest pain
Page 59 Ischaemic sounding chest pain
Wellens’ Syndrome – proximal LAD stenosis
Page 60 LMCA occlusion
Page 61 LMCA occlusion
• Widespread ST depression (leads I, II, V4 – 6) • ST elevation aVR ≥ 1mm • ST elevation aVR ≥ V1
• Can also see in: prox LAD occlusion severe triple vessel disease diffuse subendocardial ischaemia (ie. post resuscitation)
• aVR records electrical activity right upper portion of heart, including RVOT and basal IV septum
Page 62
De Winter’s T wave
Anterior STEMI equivalent ST depression and peaked T waves in precordial leads Seen in ~ 2% acute LAD occlusions Younger / male / hypercholesterolaemia
Code STEMI
Page 64 Middle aged female presents with dyspnoea, prior mastectomy for breast cancer.
Page 65 Middle aged female presents with dyspnoea, prior mastectomy for breast cancer.
QRS alternans – pericardial effusion
Page 66 Ventricular flutter
Page 67 Ventricular flutter
•Continuous monomorphic sine wave •No identifiable P, QRS or T wave •Rate >200 •Extreme form of VT •Rapid degeneration into VF
Page 68 Hypothermia
Bradyarrhythmias (any) Osborn waves (= J waves = positive deflection at J point) Prolonged PR, QRS and QT Shivering artefact VPBs Cardiac arrest due to VT, VF or asystole
Page 69 Hypothyroidism
Bradycardia Low QRS voltage Widespread T wave inversion QT prolongation First degree AV block IVCDs
Myxoedematous deposits in myocardium Decreased SNS activity Less thyroxine – decreased inotropy / chronotropy
Page 70 The End
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