Ischaemia

Question 1

think of ischaemia in

Answer 1

1. Widened QRS
2. ST elevation
3. ST depression
4. other causes…

Question 2

6 causes of widened QRS

Answer 2

Bundle branch block

ventricular rhythm

hyperkalaemia

medications (TCA overdose)

paced rhythm

WPW

Question 3

6 causes of ST elevation

Answer 3

1. Benign Early Repolarisation
2. Acute MI
3. Pericarditis
4. LV aneurysm
5. PRintzmetal’s angina (vasospasm)
6. Bundle Branch Block

Question 4

6 causes of ST depression

Question 5

BER is

Answer 5

Benign Early Repolarisation

The majority of ST elevation that we see in the ED

Features to help confirm

Contour - Concave up - smiley face

Anterior leads

No reciprocal changes

No evolution (repeat the ECG)

Often associated with LVH

“Fishhook” contour in V4 (very specific)

Question 6

Fishhook wave

Answer 6

Seen in BER lead V4

• very specific
• ddx hypothermia

Osborne wave (take the patient’s temperature)

Question 7

Which leads are normally elevated in BER

Answer 7

Primarly in the anterior leads V1 - V4

Can be in inferior or lateral leads…

• but high level of vigilance required

Question 8

ST Elevation - Acute MI - features?

Answer 8

Frowny Face Contour

Reciprocal Changes

Continguous leads

Evolution/Change from old ECG

Other Findings of Ischaemia​

Question 9

ST Elevation - Acute MI - features?

Answer 9

Diffuse ST elevation

Benign morphology

PR depression is diagnostic

Clinical presentation..

Question 10

Clinical features of pericarditis?

Answer 10

Stabbling / burning

Worse lying flat

Relieved sitting up

Persistent and prolonged

(guy sleeping with iron buring on his chest, sits up and the iron falls off)

Question 11

what do you use aVR for

Answer 11

Deciding if the rhythm is sinus

Looking for PR elevation in pericarditis

Question 12

LV aneurysm - appearances on ECG

Answer 12

“persistent” ST elevation of anterior leads

Not a true aneurysm, anterior wall doesn’t move but bulges when rest of ventrical contracts

Looks like a STEMI - so call it a STEMI until proven otherwise

No reciprocal changes

Compare with old ECG, get cardiologist involved

Question 13

What is Wellen’s sign?

Answer 13

the presence of biphasic t-waves in the anterior leads in the absence of ST elevation

Question 14

What is takosubo?

Answer 14

Huge emotional stress / adrenergic surge

Can mimic a heart attack

• non-specific changes on ECG with heart failure

But not an ED diagnosis (not our decision to make)

• send to Cath Lab
• if awesome at Echo can have a look.

Question 15

What is Prinzmetal’s angina?

Answer 15

Occurs rarely, and occurs on top of underlying cardiac disease, e.g. tight stenoses.

Send to Cath lab

Thrombolysis - try to defer in the patient that has pain disappear with BB and Nitrates

Consider Heparin

Question 16

Give other ECG changes that require PCI / thrombolysis

Answer 16

Left Bundle Branch Block - Sgarbosa’s Criteria

New RBBB with LAFB

Inferior Wall MI - elevation of any degree in the inferior leads

RV infarction (any ST depression in lead I = sens&spec)

Isolated Posterior MI

Question 17

High risk ECGs that need watching

Answer 17

Wellens

Transient STEMI

Question 18

ACC/AHA Criteria