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ECG Abnormalities_Part 21

Saturday, July 21, 2012

69 year old female with a past history of breast cancer presents with dyspnea on exertion and dizziness. Her vital signs are BP 80/40, HR 120, RR 24, and oxygen saturation 88% on room air. Physical exam revealed crepitations at the left lung base, distant heart sounds, and elevated jugular venous pressures especially with inspiration. Her ECG is given below. Also provided is a simultaneous recording of her arterial line pressue tracing and inspirometer.
What are the abnormal ECG findings?
What is the diagnosis?

ANSWER

The ECG findings are:
1) Sinus tachycardia
2) Low voltage
3) PAC (2nd beat from the last on rhythm strip)
4) Poor R wave progression

Diagnosis is cardiac tamponade. Malignancy is the most common cause for a pericardial effusion resulting in increased intrapericardial pressures causing the right atrium and right ventricle to collapse in diastole.This results in hypotension and tachycardia and can be life threatening. The ECG findings of cardiac tamponade include low voltage on the ECG and "electricle alternans" where each QRS complex alternates from normal voltage to low voltage.Arterial line pressue tracing shows her systolic blood pressure dramtically drop with inspiration.This phenomenon which occurs in cardiac tamponade is called "pulsus paradoxus" and can be measured non-invasively using a blood pressure cuff.

ECG Abnormalities_Part 20

Monday, June 25, 2012

A 65 year old male patient with end-stage COPD gets admitted to the ICU with respiratory failure. He was found to have the below ECG:

What are the ECG findings?
What is the treatment for this heart rhythm disorder?

ANSWER

The ECG findings include: 1) Multifocal atrial tachycardia (three distinct P wave morphologies) 2) Incomplete right bundle branch block 3) Poor R wave progression 4) PVCs

Multifocal atrial tachycardia (aka MAT) is an irregularly irregular, tachycaric rhythm in which many foci in the atium chaotically fire acting as the pacemaker of the heart instead of the sinus node. The atrial rate is not as fast as in atrial flutter or atrial fibrillation, so normal AV synchrony can occur. When the rhythm has 3 distinct P wave morphologies and the heart rate is not fast, the term "wandering atrial pacemaker" or WAP is used.

 The treatment of multifocal atrial tachycardia is aimed at the underlying cause. In this case it would be to treat the COPD exacerbation and respiratory failure. The only medication that has been used to treat MAT is verapamil with only marginal success. No anticoagulation is needed for MAT in contrast to atrial flutter/fibrillation since the atrium are contracting well, but simply originating in different areas.

ECG Abnormalities_Part 19

Wednesday, April 27, 2011

 You are the house officer on call for the telemetry floor and a nurse calls you with an abnormal rhythm seen on telemetry. The patient was admitted 2 days previously for a congestive heart failure exacerbation. He denies any symptoms including chest pain, palpitations, lightheadedness, or shortness of breath. Vital signs are normal. You ask for a 12-lead ECG which is below:


You go back to sleep and are soon called again for another abnormal rhythm seen on the same patient which is intermittently occurring. The patient is still asymptomatic and vital signs are still normal. Another 12-lead ECG is obtained which is below:


What are the ECG abnormalities?

ECG Abnormalities_Part 18

Saturday, January 29, 2011


A 60 year old male who is a known patient with type 2 diabetic mellitus and hypertension presents to your clinic and has the below ECG:
What are the ECG abnormalities?
What is the differential diagnosis of this ECG finding?

ECG Abnormalities_Part 17

Sunday, December 12, 2010

A 21 year old healthy female comes to the clinic with complaints of intermittent palpitations. These episodes can last from seconds to minutes and are associated with lightheadedness, diaphoresis, and occassionally chest pain. Her ECG is below:

What is the Abnormality in ECG 1?

In the clinic she has one of these episodes and an ECG is performed:

What is the Abnormality in ECG 2?

ECG Abnormalities_Part 16

Friday, November 26, 2010

An 87 year old male with a history of coronary artery disease has the below ECG:

What is the Abnormality?

ECG ANSWER

The ECG findings include:

1) Normal sinus rhythm with first degree AV block
2) Right bundle branch block (RBBB)
3) Left anterior fascicular block (LAFB or left anterior hemiblock or LAHB)
4) PVC

ECG Abnormalities_Part 15

Sunday, November 21, 2010

A 58 year old male with a history of  DM, hypertension, and dyslipidemia presents with substernal chest pressure for 30 minutes. The pain began at rest,severe in nature, was mild to begin with then increased in intensity, is worse with exertion, radiates to his left arm, is not pleuritic or positional, and is associated with diaphoresis, shortness of breath, and nausea.
His temperature is 37.2, blood pressure 90/50mmhg, heart rate 100/bpm, respiratory rate is 16/min. No jugular venous distension is present, he is tachycardic and an S4 heart sound is present. No murmurs are heard. His lungs are clear to auscultation. The rest of his exam is normal.


What is the diagnosis?

ECG ANSWER

The ECG findings include:

1) Normal sinus rhythm
2) Poor R wave progression (possibly indicated an anterior wall infarct - age undetermined)
3) Old inferior wall infarct (indicated by Q waves in inferior leads)
4) Biphasic T waves in leads V1 - V4 possibly consistent with ischemia

ECG Abnormalities_Part 14

Wednesday, November 17, 2010

A 72 year old male receives a routine ECG which is below. His electrolytes are normal.

Identify the Abnormality in this ECG strip?

ECG ANSWER

Normal sinus rhythm with a first degree AV block

The PR interval in this ECG is very long, about 380 milliseconds (normal is 120 - 200 ms or 0.12 - 0.20 seconds). A P wave preceeds each QRS complex, thus this is 1st degree AV nodal block.

ECG Abnormalities_Part 13

Saturday, November 13, 2010

An 82 year old male with a history of hypertension presents to the clinic with a complaint of generalized weakness for 3 days. No chest pain, shortness of breath, dyspnea on exertion, lower extremity edema, paroxysmal nocturnal dyspnea, orthopnea, palpitations, or dizziness. He takes lisinopril and hydrochlorothiazide for his hypertension.

His temperature is 37.0, blood pressure 100/50 mmHg, heart rate 155 bpm, respiratory rate is 16/min. No jugular venous distension is present, he is tachycardic and irregularly irregular on cardiac exam without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is below

What Is the Abnormality in this ECG?

ECG ANSWER


The ECG findings include:

1) Atrial fibrillation with rapid ventricular response
2) PVC(Premature ventricular contraction)

Atrial fibrillation occurs when the atrial conduction becomes chaotic and very fast. The atrial rate increases to around 400-600 beats per minute. When this occurs, the amplitude of the P waves markedly decrease. Frequently, the P waves are not able to be detected at all, however at times a coarseness of the baseline of the ECG occurs reflecting the fibrillatory atrial activity. Not all of the 400-600 atrial action potentials per minute are conducted to the ventricles otherwise ventricular fibrillation would occur. Instead, the AV node is able to block a good number of beats usually resulting in a ventricular rate between 120-180 in the absence of AV blocking medications. Due to the chaotic atrial activity, varying block of the atrial action potentials at the AV node occurs resulting in an irregularly irregular rhythm.

ECG Abnormalities_Part 12

Sunday, November 7, 2010

A 68 year old male with a past history of chronic atrial fibrillation presents to the emergency room with a complaint of nausea, vomiting, generalized abdominal pain, and generalized weakness. No fevers or chills. No diarrhea, constipation, melena, or other signs of gastrointestinal bleeding. He does not know his medications. He states his vision has been slightly yellow tinged recently.

His temperature is 37.0, blood pressure 90/50, heart rate 55, respiratory rate is 16. No jugular venous distension is present, he is bradycardic and irregularly irregular on cardiac exam without any murmurs. His lungs are clear to auscultation. His abdominal exam is completely normal. The rest of his exam is normal.

His ECG is below:

 Identify the Abnormality?

ECG ANSWER

The ECG findings include:

1) atrial fibrillation with bradycardia
2) ST segment depression consistent with digoxin effect

The ECG shows a downsloaping ST segment depression in multiple leads that are shaped like the "reverse check mark sign" or a "scooped out" appearance. This pattern is typical of digoxin. This may occur at normal digoxin levels in some people, but becomes more common as the digoxin level increases.

ECG Abnormalities_Part 11

Friday, November 5, 2010

A 38 year old female presents to the emergency department with a complaint of palpitations for 2 hours. She complains that she has intermittently had palpitations for years, but always lasting for minutes only. These palpitations are associated with mild dizziness and shortness of breath. No chest pain occurs.

Her temperature is 37.0, blood pressure 90/50, heart rate 190, respiratory rate is 16. No jugular venous distension is present, she is tachycardic and regular on cardiac exam without any murmurs. Her lungs are clear to auscultation. The rest of her exam is normal.
Identify this ECG rhythm?


ECG ANSWER

The ECG findings include:

Narrow complex tachycardia - most likely AV nodal rentry tachycardiaa (AVNRT)

The ECG shows a narrow-complex tachycardia that is regular.No flutter waves are seen. In leads V3 - V6 a P wave can be seen just after the QRS complex making this rhythm a "short-PR" tachycardia. Remember the most common short-PR tachycardia is AV nodal rentry tachycardia.

ECG Abnormalities_Part 10

Sunday, October 24, 2010

A 86 year old male with no significant past medical history to clinic with a complaint of generlized weakness, dizziness, and dyspnea on exertion. Mild lower extremity edema, paroxysmal nocturnal dyspnea, and orthopnea are present. No chest pain has occured. He is not taking any medications.

His temperature is 37.0, blood pressure 80/40mmHg, heart rate 40/BPM, respiratory rate is 16/min. Mild jugular venous distension is present, he is bradycardic and regular without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is below:

Identify the Abnormality in this ECG strip?


ECG ANSWER

The ECG findings include:Junctional rhythm

A junctional rhythm occurs when the SA node is not able to generate an action potential and AV node acts as the main pacemaker of the heart. In this instance, the P wave morphology (normally generated when the SA node fires causing atrial depolarizaion) will be altered since its origin is no longer at the SA node and is instead at the AV node. The direction of conduction to the atria in a junctional rhythm is considered "retrograde" since it is traveling up the atria from the AV node instead of down the atria from the SA node. This results in an inverted P wave in lead II (normally upright in sinus rhythm) and an upright P wave in aVR (normally inverted in sinus rhythm).
Depending on the exact location of the pacemaker in a junctional rhythm, the P wave location may vary. If it occurs slightly above the AV node (low atrium), then the P wave will actually occur slightly before the QRS complex is seen. This will result in the P wave appearing just before the QRS, but PR interval will be short (< 0.12 ms). If the pacemaker occurs at the junction, the P wave and QRS complex may be exactly overlying and you may not be able to identify any P waves at all. If the pacemaker occurs lower in the junction, the QRS complex may actually occur before the P wave (the P wave will be seen after the QRS complex). In this case a retrograde P wave can be identified just before the QRS complex with a short PR interval, thus the pacemaker is located high in the AV node or perhaps in the low atrium. Causes of a junction rhythm include chronic degeneration of the SA node (termed "sick sinus syndrome"), hypoxia, myocardial ischemia, hyperkalemia, digoxin toxicity, elevated vagal tone, and medications known to supress the SA node (beta-blockers and non-dihydropyradine calcium channel blockers).

ECG Abnormalities_Part 09

Monday, October 18, 2010

A 50 year old male with no past medical history presents to the emergency room with sudden onset severe chest pain. The pain is 10/10, substernal, sharp in nature, worse with deep inspiration, not positional or reproducible, and associated with shortness of breath and dizziness but no excessive sweating , nausea, or vomiting.

His temperature is 37.0, blood pressure 80/40, heart rate 110, respiratory rate is 28. His oxygen saturation is 88% on room air. He appears in mild distress, no jugular venous distension is present, he is tachycardic and regular without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is given below:

What is the Abnormality in this ECG Strip


ECG ANSWER

The ECG findings include:
1) Sinus tachycardia
2) S1Q3T3 pattern consistent with acute cor pulmonale (acute right ventricular strain) a.k.a. the "McGinn-White sign"

The diagnosis is pulmonary embolism
The patient's clinic scenario of pleuritic chest pain, tachycardia, and hypoxia should raise a high clinical suspicion for pulmonary embolus. Also, his chest pain was sudden onset and severe unlike that of myocardial ischemia. Aortic disection can cause sudden-onset severe chest pain as well, however usually the patient is hypertensive and not necessarily hypoxic.

ECG Abnormalities_Part 08

Wednesday, October 13, 2010

A 53 year old male with a history of uncontrolled hypertension is found unresponsive at the side of the street and is brought to the emergency room.

His temperature is 37.0, blood pressure 190/100, heart rate 50, respiratory rate is 8. He is unrepsonsive on physical exam. Heart and lung exams are normal. Laboratory studies including electrolytes and troponin levels are all normal.

His ECG is below:

What is the abnormality in this ECG strip?

ECG ANSWER

The ECG findings include:
1) Normal sinus rhythm
2) Marked T wave inversions and prolonged QT interval

Answer: A CT scan of the brain is needed. His clinical picture and ECG findings are consistent with an acute central nervous system abnormality. Patients with subarachnoid hemorrhages, intracranial hemorrhages, and less commonly severe ischemic strokes have ECGs that reveal deep, symmetric T wave inversions and QT prolongation. Less commonly, carotid endarterectomy can result in this ECG pattern chronically.

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