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ACEM fellowship > ECGs > Flashcards

ECGs Flashcards

1
Q

LMCA occlusion

A

Widespread ST depression
ST elevation > 1mm aVR
ST elevation in aVR > V1

Can also be due to post cardiac arrest, severe anaemia/hypoxia, triple vessel disease

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2
Q

LAD occlusion

A

ST elevation aVR > 1mm
ST elevation often also in V1-3
Widespread ST depression

Can also be severe triple vessel disease

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3
Q

Raised ICP

A

Giant cerebral T wave inversion in multiple leads
QT prolongation
Bradycardia

Diffuse ST elevation (STEMI mimic)
General rhythm disturbance

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4
Q

Right heart strain pattern

A 
Right axis deviation
RBBB
S1 Q3 T3
Dominant R wave in V1
T wave inversion V1-4 and III
Persistent S wave V6
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5
Q

PE changes

A

Sinus tachycardia most common 44%
Right ventricular strain - T wave inversion V1-4 and inferior leads 34%
S1 Q3 T3 20%
RBBB associated with increased mortality 18%
RAD 16%
P pulmonale 9%
Persistent S wave V6 8%
Atrial tachycardias 8%
Dominant R wave V1
Non specific ST and T wave changes in 50%

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6
Q

Wolff Parkinson White

A 
Delta waves (look in inferior leads)
Short PR interval < 120
QRS prolongation > 110
ST segment and T wave discordant changes
Pseudo infarction pattern due to negatively deflected delta waves
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7
Q

Hypertrophic cardiomyopathy

A

Left ventricular hypertrophy
Deep narrow dagger like Q waves lateral +/- inferior leads (1, aVL, V5-6)
Often non specific ST/T wave abnormalities

Clinical features - presyncope/syncope, palpitations, chest pain, pulmonary congestion

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8
Q

Brugada

A 
Coved ST elevation > 2mm in > 1 of V1-3 followed by negative T wave
Must also have one of the following clinical criteria:
- documented VF or polymorphic VT
- FH sudden death < 45
- syncope
- nocturnal agonal respiration
- other family members with ECG changes
- VT induced

Can be unmasked by fever, hypothermia, ischaemia, hypokalaemia, alcohol, cardiac drugs

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9
Q

Irregular supraventricular tachycardia

A

Atrial origin, narrow complex

  • atrial fibrillation - no p waves, variable rate
  • atrial flutter with variable block - no p waves, saw tooth pattern
  • multifocal atrial tachycardia - at least 3 distinct p wave morphologies in same lead
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10
Q

Regular supraventricular tachycardia

A 
Sinus tachycardia
Atrial tachycardia
Atrial flutter with fixed AV block
AV nodal re-entrant tachycardia (classical SVT - regular 140-280, narrow complex, buried p waves so appear absent)
AV re-entrant tachycardia (WPW)
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11
Q

Regular broad complex tachycardia

A

VT
SVT with aberrant conduction due to BBB
SVT with aberrant conduction due to WPW

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12
Q

VT vs SVT ECG features (if clinical features/doubt then treat as VT!!)

A

Absence typical LBBB or RBBB morphology
Extreme axis deviation
Very broad complexes > 160
AV dissociation
Capture beats
Fusion beats
Positive concordance throughout precordial leads
Negative concordance throughout precordial leads
RSR complexes with taller left rabbits ear
Brugada sign
Josephson sign

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13
Q

Irregular broad complex tachycardia

A 
VF
Torsdaes de pointes
Polymorphic VT
AF with WPW
AF with BBB
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14
Q

Mobitz I

A

Wenckebach
Progressive prolongation PR interval culminating in non conducted P wave
P-P ratio remains constant

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15
Q

Mobitz II

A

Intermittent non conducted P waves with PR interval remaining normal

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16
Q

Inferior STEMI

A

ST elevation II, III, aVF
Reciprocal depression aVL

40% STEMIs
20% associated 2nd/3rd degree HB

Avoid nitrates, give fluid, preload dependent
May need paced

17
Q

Right coronary artery lesion

A 
Inferior STEMI
STE III > II
STE also in V1
ST depression > 1mm aVL
ST depression I
  • do right sided leads, ST elevation V4R most specific
18
Q

Posterior STEMI

A

ST depression V1-3 with upright T waves
Tall broad R waves V1-3
Dominant R wave V2

Do posterior leads - STE can be 0.5mm

19
Q

What to think if narrow complex tachycardia rate 150

A

Atrial flutter with 2:1 block (elderly, IHD)
SVT
AV reentry in WPW
Sinus tachycardia

20
Q

What to look for in syncope

A
  • Too fast - VT, VF, torsades
  • Too slow - sinus bradycardia, pauses, heart block (Mobitz II or 3rd degree)
  • Pump failure - MI, PE
  • Electrical problems - electrolytes (hypo/hyperkalaemia), pacemaker failure
  • Syncope syndromes - long QT, short QT, WPW, Brugada, HOCM, ARVD
21
Q

Digoxin effect (not toxicity)

A 
Down sloping ST depression (reverse tick)
Flattened, inverted or biphasic T waves
Shortened QTc
PR prolongation
Prominent U waves
22
Q

ECG in digoxin toxicity

A

Can have supra ventricular tachycardia due to increased automaticity or slow ventricular response due to decreased AV conduction or features of both

Most commonly

  • frequent PVCs/bigeminy/trigeminy
  • sinus bradycardia
  • slow AF
  • AV block of any type
  • VT
23
Q

Left axis deviation

A

QRS positive lead I and negative in lead aVF (also in II and III)

Causes
LBBB
inferior MI
LVH
Left anterior fasicular block
Paced rhythm
WPW
24
Q

Right axis deviation

A

QRS positive in aVF (also II and III), negative in I

Causes
Right ventricular hypertrophy
PE
COPD
Left posterior fasicular block
WPW
Hyper kalaemia
Sodium channel blocker toxicity
25
Q

Paediatric ECG

A 
Dominant R in V1 (RSR pattern)
T wave inversion V1-3
May have right axis deviation
Often shorter PR
Can have sinus arrhythmia
26
Q

STEMI mimics

A 
Benign early early repolarisation 
LVH
LBBB
Paced rhythm
Pericarditis
Left ventricular aneurysm
Brugada
Takatsubo
Increased intracranial pressure
27
Q

Causes of long QTc

A 
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
Hypothermia
Myocardial ischaemia
Post ROSC
Raised ICP
Congenital
Drugs - antipsychotics, TCAs, type Ia (procainimide), Ic (flecanide), III (sotalol, amiodarone), citalopram, venlafaxine, quinine, macrolides
28
Q

Arryhthmogenic right ventricular dysplasia

A

Autosomal dominant, second most common sudden cardiac death in young people (after HCM), often associated FH

T wave inversion V1-3 without RBBB
Epsilon wave
QRS widening V1-3
Frequent PVCs
Paroxysmal VT with LBBB morphology (right ventricular outflow tract obstruction)

ACEM fellowship (3 decks)

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