Pearls From Cases Flashcards
What must you consider in a pt with sob, Dyspnea and syncope? What additionally?
PE Pericardial effusion
What defines low voltage? Low voltage (especially if new) + tachycardia think what?
QRS complexes < 15mm in leads I, II, III combined Or QRS amplitudes in V1+V2+V3 < 30mm Pericardial effusion
AHA circulation 2004 chemo drugs and SEs, author is Yeh (cardiovascular complications) What drug causes cardiac vasospasm?
5-FU
What are the 5 things that can cause diffuse STE?
Large acute MI —> Reciprocal depression Pericarditis Vasospasm Ventricular aneurysm —> Q waves from old MI Early Repol —> dx of exclusion, look for fishhooks (looks like J wave)
Pt that has AFib that presents with bradycardia and appears regular, what must you think of?
Digoxin toxicity —> look for Salvador Dali sloping ST segment
How does Digoxin make the rhythm regular in AFib?
Blocks AV node, it becomes a Junctional escape rhythm (40-60)
What is Contraindicated in Digoxin toxicity with hyperkalemia? What is this called?
Calcium —> Stone Heart
LBBB what is present in leads V1-V3? What about in lead I, V5, V6?
Deep wide S, absent R wave No Q wave
What is appropriate discordance in LBBB (Also in pacemakers)? Where QRS goes down what should you see?
QRS goes up should see ST depression ST elevation
What is excessive discordant ST elevation in LBBB for MI?
Discordance ST elevation >/= 5mm I.e. if QRS goes down and you have > 5mm of ST elevation This is Sgarbossa criteria C —> Not validated
What is Sgarbossa Criteria A? B?
Concordant ST elevation >/= 1mm in any lead Concordant ST depression >/= 1mm in V1, V2, V3 ONLY
What is the Revised Sgarbossa C?
ST elevation > 25% than the S wave in their discordance
What is the 1st marker on EKG in someone with active Chest Pain that could be having acute inferior wall STEMI? Then what?
Inverted T wave in aVL ST depression
T wave height greater than ENTIRE height of QRS could mean what? Do what?
Early cardiac ischemia Get a REPEAT EKG This is a called a type 2 hyperacute T wave
DDx long QTc (> 500ms)?
HypoK HypoMg HypoCa Hypothermia Na blocking drugs Elevated ICP
What are the only 2 etiologies that prolong the QT d/t via prolonged ST?
Hypothermia HypoCalcemia
What is intermittent WPW?
Sinus rhythm with a normal beat then a WPW beat (short PR with delta Wave and subsequent long QRS) Can cause flipped T waves in general
How to diagnose Right axis Deviation? What are the main ddx for RAD + STE?
Large S wave in lead I PE, HyperK and Na channel blocking drugs
PE can produce STE in what leads?
Rightward leads —> aVR, V1, V2, III
Signs of right heart strain?
Tall RV1 RAD T wave inversions (anteroseptal and inferior leads) ST changes in V1, V2, aVR, III
Patient with NEW weakness think about what? Can cause what?
HyperK and Rhabdo —> get a CK STE
STE + RAD think about what?
1 —> HyperK Na Channel blocking drugs Acute Pulm HTN (PE)
STE in lead V1, V2, aVR with a RAD think immediately of what?
HyperK
What is the treatment for symptomatic PVCs?
Beta-Blockers (IV metoprolol)
What factors strongly suggest STEMI over Pericarditis?
STD in any leads except V1 or aVR STE in III > II Horizontal or convex upwards of STE
What is Spodick’s Sign? Indicates what?
Downsloping of the TP segment Pericarditis
Sgarbossa Criteria?
How to tell STEMI vs Pericarditis?
Pt that has lead V1, V2 concerning for Brugada but not 100% clear picture, what can you do to confirm?
Move leads 1-2 interspaces higher
What are signs of early cardiac ischemia?
T wave inversion in aVL
Hyperacute T waves - T wave height > qrs height or straightening of T wave
When deciding if a pt has AFib, where to check P waves first?
why?
Lead V1
Sitting right over the RA
What is most commonly misdiagnosed as AFib?
Mobitz Type 1
Whenever you have grouped or clumped beats (regularly irregular) in the rhythm strip it is indicating what?
Mobitz type 1 or PAC
T wave alternas with long QT can lead to what?
QTc > what level?
Torsades or sudden cardiac arrest
> 500
Patient with deep T Wave inversions and prolonged QT interval has what?
Inc ICP
Patient with RBBB, what should you NEVER see?
where to look?
STE, you should see ST depression
V1, V2
What rate is VTach is usually seen?
If it is kinda slow what can kill the pt?
Needs to be GREATER than 130 (maybe 120)
Na channel blocker like amio, procainamide, lidocaine if the underlying problem is hyperK
What can you do to helpdiagnose if you suspect HyperK mimicking VTach on EKG?
give 1 amp NaHCO and the rhythm will change
what is the DDx for STE in V1, V2, aVR?
STEMI
But also: HyperK and PE
How to tell if a pt with a Pacemaker is having a STEMI?
Sgarbossa A - Concordant STE in ANY lead
B - Concordant STD in V1-V3
C - Discordant STE > 5mm in ANY lead
How to Dx LBBB on ekg?
look at V1, usually no Q wave, Very small r wave, then deep S wave that is negatively deflected
QRS > 120
lead V5-V6 has RsR’ and no Q wave
What is BRASH syndrome?
Bradycardia
Renal Failure
AV nodal blockers (BB or CCB)
Shock
HyperKalemia (mild)
how to treat BRASH?
treat the hyperKalemia with 2g Calcium gluconate even if K is mild (5-6.5)
RAD (or big S wave in lead I) with STE in leads aVR, V1, V2 what must you strongly consider?
PE
TCA overdose EKG findings?
tachycardia
tall R wave in aVR
RAD
long QT
Wide QRS
DDx long QT?
DDx wide QRS?
DDx Right Axis Deviation?
What degrees is RAD?
90-180
EKS and ACS chart indicating when to go to CATH lab
What are the only 2 things that cause a prolonged QT because of a prolonged ST segment?
Hypocalcium
Hypothermia
What must you check before you call an EKG a STEMI?
when does this commonly occur?
Check the QRS length, it may just be part of QRS and not STEMI
RBBB patterns
Narrow complex regular tachycardia, what are the possibilities?
Sinus tachy
SVT
Atrial flutter 2:1 (rate of 150 +/- 20)
What is the Bix Rule?
T wave that is poky/sharp (P wave buried in T wave) exactly bw 2 QRS complexes means you probably have atrial flutter
What leads to look for in Benign Early Repol?
What is a characteristic pattern?
what makes you think it is more likely a STEMI?
V1 - V4 Only
Fishhook
Shark takeoff from J point
What does LV aneurysm look like?
STE lead V1, V2
Q waves leads V1-V4
NO recipricol changes
How do you determine if it is a junctional rhythm?
rate is around 40 with narrow QRS
No P waves OR short PR
How to tell if it is Mobitz I, Mobitz II, or 3rd degree heart block?
If PR interval is changing then it is 3rd degree
Large T wave inversions (MC in anterolateral leads) + QT prolongation think what?
what else may they have?
ICH
STE
Pt with atypical chest pain/ongoing chest pain with most unremarkable EKG, what lead may show T Wave changes that are concerning?
New upright T wave V1
Describe VTach rate
If not VTach bc of rate, what is it?
due to what?
> 120
AIVR
Usually reperfusion
What are the Lewis leads for?
Place where?
Give the DDx of RAD
Pt with wide complex tachycardia with a rate below 120, what is it?
Means what?
Treat how?
Accelerated Idioventricular rhythm
Reperfusion rhythm (usually after giving lytics)
Observe!
How to treat stable pt with nonsustained VTach?
Treat underlying cause
Beta Blockers
Amiodarone
How to calculate ventricular rate if the machine is not giving it to you?
count up all the QRS complexes and multiply by 6
each ekg is 10 seconds (10x6 is 60 seconds so 1 minute)
What leads mimic STEMI in massive PE?
V1, V2
then aVR
then finally lead III
Treatment of sustained VTach that is stable?
Class I recomendation: Shock Cardioversion 250 or 360J
Class IIa - Procainamide
Class IIb - Amio
Difference bw “generic” Polymorphic VTach vs Torsades?
Generic has Normal QT
where to look for STD in inferior MI?
aVL
Inverted U wave in lateral leads (V4-V6) indicates what?
LAD occlusion - ischemic heart disease
93% specific
What is required to Dx BER?
If it does not, called what?
S wave or J wave in BOTH leads V2 and V3
Terminal QRS distortion - means STEMI
