Random ECGs 2

Dr Chris Cresswell

Emergency Physician

2015

62 year old with chest pain

Elderly patient, CP, ST elevation peaked Ts = ischaemia till proved otherwise

10 minutes later

• This is one of the reasons we do repeat ECGs– Another one is Wellen’s syndrome where the ECG with CP can look

normal, but the ECG when the pain has resolved may show marked anterior T wave inversion. Associated with critical LAD stenosis

22 F low GCS, no Hx available

Slightly wide complex. Dominant R in aVR

= Na channel blockade eg tricyclic

Went on to have a seizure then a wide complex tachy

Mx?

NaHCO3 1-2 mmol/kg boluses q5min til QRS < 120ms

Intubate and hyperventilate

(I don’t know if that doc came back to work)

82 F with CP and borderline low BP

How will you manage this, including important negatives?

Inferior MI +/- posterior MI

Aspirin (+/- other anticoagulents)

Fentanyl

Avoid morphine and GTN

May need fluid load to improve LV filling

Revascularisation

72 F with 1 hour CP

Same patientR sided ECG

Confirms RV infarct

Could also have done posterior leads which may or may not have shown a posterior STEMI

14 year old with CP

Looks like T wave inversion in I and avLBut P waves inverted in IDifferent morphology in I and V6 (look at the same area of heart)= incorrect lead placement

82 M diarrhoea x 8Palpitation

ICD firing repeatedlyTerrified

What is going on?What are you going to do?

Run of wide complex tachyOverdrive pacing

Then resolvesFrom Hx ICD also defibrillating him

Do not turn the ICD/pacemaker off! He needs itCheck electrolytesGive magnesium as QTc looks longGive antiarrhythmic – eg amiodarone (procainamide better if available in your country)Analgesia +/- sedation

85 M with 1 hour of chest pain

Anterior sepatal STEMI + inferior ischaemia(inferior leads are not the reciprocal leads

of the septal leads)

Aspirin (+/- other anticoagulants/antiplatelet agents)Analgesia

Revascularisation

70 F Palpitation for 2 hours, slight chest discomfort

Hx PAF and thyrotoxicosisAnxious and tremulous for a few days

Inferior STEMI and fast AF (AF with RVR)

What are you going to do?

Inferior STEMI and fast AF (AF with RVR)

What are you going to do?

IV beta blocker (eg 2.5mg metoprolol)IV steroid eg 100mg hydrocortisone

Electrical cardioversion (eg 20mg propofol (or 1mg midazolam) and 20mg of ketamine

100 J synchronised

OopsHypoperfusion from tachycardia

Now hypoperfusion from bradycardia

What now?

Support blood pressure with fluids if needed

Aspirin and reperfusion

(had RV infarct also)

18 year old with glandular fever for 2 weeks, dry, sore, miserable HR noted

to be 170

No p wavesregular

Narrow complex

Symptomatically better with IV fluids, and analgesia

No response to vagal manouevresRx adenosine (these days I would use diltiazem)

65 M CP

10 minutes later, pain free

Wellen’s syndrome – critical LAD stenosisDo not put on treadmill – they tend to drop dead

50 F found collapse at supermarketDecr GCS, hypotensive

K 9.8Died in ED as not treated for hyper KWas known to be a dialysis patient

81 F palpitation, light headed for 3 hours. BP 110/50

SVT ? Atrial flutter

Electrically cardioverted

Crap

What do you do now?

If conscious and no chest pain: nothing, hope it improves

If decr LOC: CPR +/- electrical or chemical pacing (eg 1mg of adrenalin in 1L saline dripping freely and titrated to effect, change to eg isoprenaline ASAP)

In patient improved spontaneouslyDr sent for clean underwear

45 F dialysis patient10 minutes into cardiac arrest

Assume hyperK

Continue CPR (unless advance directive)Rx Calcium gluconate 1g = 10ml of 1% repeat q 5minNaHCO3 2mmol/kgInsulin (actrapid) 10u and 50ml of 50% dextroseIV salbutamol 250µg

Intubate and PEEP as often pulmonary oedema from volume overload

Urgent dialysis

19 F with CP, no palpitation

Short PRDelta waves

WPWIncidental finding

T wave inversion aVL is concerning

92 F CP -> false teeth + palpitationNo cardiac Hx

Fast AF – presumed newIschaemic changes

Including ST elevation aVR and widespread ST depressionBP 102/60 -> 92/50

What are you going to do?

UnstableZap her

50µg fentanyl100J - synchronised

Screamed like a banshee for 5minutesThese days I give 10-20mg propofol(or 1mg of midazolam) + 10-

20mg ketamine for the elderly

Pain free (10 minutes after the zap)

56 M. Hx AF

Atrial flutter with variable block

Post 20mg IV diltiazem

78 F Weakness, collapse, nauseated, dizzy

Diarrhoea for a week. Hx AF. BP 141/52

78 F Weakness, collapse, nauseated, dizzy

Diarrhoea for a week. Hx AF. BP 141/52

Slow, irregular, no p waves, narrow complex= very slow AF

Diarrhoea for a week -> renal impairmentCreat 152 (GFR 29)

K 6.8 (3.4-5.2)Digoxin 3.14 (0.6-2.0)

Mx?

IV fluidDigoxin FAB eg Digibind or DigiFAB2 vials

Indications controversial:Digoxin level > therapeutic range + symptoms and signseg nausea, bradycardia, increased automaticity, hyperK

Don’t retest the digoxin level as assay measures free and bound digoxin -> no use

85F chest pain

Inferior STEMI +/- posterior and RV infarct

R sided and posterior ECG didn’t show posterior or RV infarcts

AspirinAnalgesia (still be cautious with GTN

and morphine)Revascularise -> thrombolysed

Chest pain worse, BP OKBugger

What now

Hearts do lots of funky things during or post revascularisation

• Support them through it• Fentanyl for pain• Fluid for hypotension• Electricity for fast VT or VF• Don’t treat idioventricular rhythms (slow VT, wide complex,

rate less than, say, 120

Some ECGs from Life in The Fast Lane