Download 20 EKGs You Should Know

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
20 EKGs you should know
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Chest pain presentations
Syncope
Palpitations
Metabolic/miscellaneous
1. 45-year-old man with one hour of chest
pain radiating to his back.
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
2. 78-year-old dairy farmer with one hour
chest pain associated with sweating.
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
3. 36-year-old woman, 3 weeks post-partum,
with 30 min chest pain which has resolved.
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
four hours after chest pain
4. 53-year-old man with acute MI who
received thrombolytic therapy one hour ago.
Accelerated Idioventricular Rhythm
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2
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4
5
6
Beats 1-3 are idioventricular
Note emergence of P before #3
Beats 4-6 are sinus
Beat 7 is a fusion beat
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5. 35-year-old man with chest pressure all
day, worse with inspiration and position.
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)
6. 40-year-old man being evaluated for
syncope earlier that day.
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
7. 48-year-old woman with shortness of
breath after experiencing syncope.
EKG signs of acute PE
• New RBBB
• S1Q3T3
• T wave inversion in V1-3
– Correlates with severity of PE
S1Q3T3
Her CT angiogram…
8. 45-year-old man with “worst headache of
his life” associated with vomiting.
CNS effect
• Diffuse T wave inversion – impressively deep
• Asymmetric with bulging ascending portion
• +/- prominent U waves and QT prolongation
Other causes of deep T wave inversion
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Ischemia/subendocardial infarction
Ventricular pacing (memory T waves)
Apical hypertrophic cardiomyopathy
Takotsubo cardiomyopathy
Acute pulmonary embolism
9. 65-year-old woman collapses 3 days after
experiencing severe back pain.
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
10. 75-year-old woman with syncope in
church – asymptomatic when lying flat.
Pacemaker failure
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• QRS at 24/min
• P waves at 75/min
• Pacer spikes at 72/min
– Failure of sensing and of capture
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11. 60-year-old man with weakness and
“heart racing” – no prior history.
Atrial flutter
with 2:1 AV conduction
• When the rate is 150/minute, always think
of 2:1 atrial flutter.
• With AV blocking agents…
12. 36-year-old man with palpitations and
near syncope. History of palpitations.
The scariest atrial fib you’ll ever see…
• Avoid typical AV blocking agents
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Adenosine
β-blockers
Calcium-channel blockers
Digoxin
Wolff-Parkinson-White Syndrome
• After cardioversion
– note δ wave = WPW
• After ablation of bypass
– no longer has WPW
13. 28-year-old woman with frequent
episodes of “SVT” treated in ED.
Signs of AVRT (WPW)
Prolonged RP interval
QRS alternans
after cardioversion…
14. 50-year-old woman with “heart jumping”
but no syncope.
Blocked PAC
The most common cause of a pause in
sinus rhythm is a blocked PAC.
15. 68-year-old woman with chronic atrial
fibrillation.
Ashman’s phenomenon
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
16. 25-year-old man with ESRD who missed
last hemodialysis session.
Hyperkalemia
• Peaked T waves of hyperkalemia
– Symmetrical and narrow-based
• Then ↑ QRS complex and ↓ P wave
–  sine wave of severe hyperkalemia
17. 70-year-old woman with weakness.
Meds include hydrochlorothiazide.
EKG signs of hypokalemia
• U waves appear, and
• T waves diminish
 May appears as ↑ QT interval
• ST-segment depression  “rollercoaster”
18. 70-year-old man with metastatic lung
cancer who is lethargic.
19. 30-year-old homeless man found outside
during winter – unresponsive.
Osborne waves of hypothermia
• Osborne waves appear < 32°C.
• Size correlates inversely with temperature.
20. 22-year-old man found unresponsive
by roommate.
EKG signs of TCA toxicity
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Sinus tachycardia
Prolongation QRS complex
Prolongation QTc interval
Rightward shift of terminal 40 msec QRS axis
– Increase amplitude of R wave in aVR
after Rx with NaBicarb…