ECG PRACTICE CASES:
PART 3—SPECIAL CASES
Megan Chan, PGY-1
UHCMC 2015
http://thepracticalpsychosomaticist.com/2013/04/01/qtc-interval-prolongation-andantipsychotics-by-elysha-elson-pharm-d-mph/
84 Y/O FEMALE WITH SYNCOPE
DIAGNOSIS?
WHAT CAUSES LOW VOLTAGE QRS?
Sinus Bradycardia (HR 40) with Low Voltage QRS
Incomplete RBBB
(RSR’ in V1 but no deep S in V6)
LOW VOLTAGE QRS
Amplitude of QRS is < 5mm in limb leads &
< 10mm in precordial leads
 Etiology
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Pericardial effusion
Hyperinflation of lungs (e.g. COPD, pneumothorax)
Pericarditis (2/2 less activated muscle)
Obesity
Generalized edema
Severe ischemic disease
Infiltrative diseases (e.g. amyloidosis)
Thyroid disease
Pleural effusion
Post-open heart surgery
WHAT TREATMENT WOULD YOU RECOMMEND?
Sinus Bradycardia (HR 40) with Low Voltage QRS
Incomplete RBBB
(RSR’ in V1 but no deep S in V6)
WHAT TREATMENT WOULD YOU RECOMMEND?
Pacemaker Placement
INDICATIONS FOR CARDIAC PACEMAKERS
Sinus node dysfunction
 Mobitz Type II heart block
 Complete heart block
 Symptomatic bradyarrhythmias
 Tachyarrhythmias (e.g. recurrent/sustained SVT)
 Hypersensitive carotid sinus syndrome
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http://www.circ.ahajournals.org/content/97/13/1325.full
65 Y/O MALE AT A FOLLOW UP VISIT
DIAGNOSIS?
PVC
P waves
Pacer spikes
Ventricular pacing with PVC
(P waves indicate atrial tracking,
LBBB pattern typical unless biventricular pacing)
COMPARED TO…
http://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_atrial_pacing.png
ATRIAL PACING
Normal QRS interval
http://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_atrial_pacing.png
59 Y/O FEMALE WITH SOB
DIAGNOSIS?
S1Q3T3
NSR with R axis deviation (Left posterior hemiblock)
http://www.usfca.edu/fac-staff/ritter/Image74.gif
WHAT IS YOUR CLINICAL DIAGNOSIS?
S1Q3T3
NSR with R axis deviation (Left posterior hemiblock)
S1Q3T3
ECG finding that indicates right heart strain
 Thus differential diagnosis should include PE
and Pulmonary HTN (which this pt had)
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http://ems12lead.com/wp-content/uploads/sites/42/2010/11/S1Q3T3.jpg
65 Y/O MALE ON A NEW MEDICATION
DIAGNOSIS?
http://www.jem-journal.com/article/S0736-4679(00)00312-7/fulltext
DIGITALIS EFFECT
Scooping T waves
U waves
http://www.jem-journal.com/article/S0736-4679(00)00312-7/fulltext
68 Y/O FEMALE WHO COLLAPSES
DIAGNOSIS?
http://sitemaker.umich.edu/ecgtutorial/ventricular_tachycardia
MONOMORPHIC VT
>30 second run = Sustained VT
http://sitemaker.umich.edu/ecgtutorial/ventricular_tachycardia
75 Y/O MALE WITH COPD
DIAGNOSIS?
http://www.emedu.org/ecg/searchdr.php?diag=SVT
MULTIFOCAL ATRIAL TACHYCARDIA
Irregular rhythm with varying P wave morphology
& PR intervals
http://www.emedu.org/ecg/searchdr.php?diag=SVT
60 Y/O UREMIC PATIENT
DIAGNOSIS?
http://www.heartpearls.com/tag/ecg-in-pericarditis
PERICARDITIS
Diffuse concave ST elevations
Diffuse PR depressions
http://www.heartpearls.com/tag/ecg-in-pericarditis
53 Y/O MALE WITH SOB AND INTERMITTENT CP
DIAGNOSIS?
http://en.wikipedia.org/wiki/Pericardial_effusion
ELECTRICAL ALTERNANS
Beat-to-beat alternation is relatively specific of pericardial
effusion usually with cardiac tamponade.
http://en.wikipedia.org/wiki/Pericardial_effusion
55 Y/O MALE WITH DIZZINESS
DIAGNOSIS?
http://pages.mrotte.com/wpw/
WOLFF-PARKINSON-WHITE
Delta wave, Short PR interval
Preexcitation syndrome through accessary pathway that
bypasses AV node.
http://pages.mrotte.com/wpw/
65 Y/O DIALYSIS PATIENT
DIAGNOSIS?
http://www.emedu.org/ecg/volts.htm
http://www.emedu.org/ecg/crapsanyallans.php
30 Y/O FEMALE ON FUROSEMIDE
DIAGNOSIS?
HYPOKALEMIA
U waves
(increased susceptibility for Torsades)
ST depressions also associated (not seen here)
50 Y/O MALE WITH NEPHROLITHIASIS
DIAGNOSIS?
http://1.bp.blogspot.com/-ieVzYvG1LNM/UpXKeiy9dUI/AAAAAAAAA8Q/KpkJk2EV0Zk/s1600/ATC5.png
HYPERCALCEMIA
Hypercalcemia: Shortened QT
Hypocalcemia: Prolonged QT
http://www.angelfire.com/un/al6a/presentation/REsearch/electrolyte_and_metabolic_abnorm.htm
Hypothermia: “Osborn wave” (arrow)
Amiodarone: prolonged QT
TCA: QRS/QT prolongation with sinus tach
Intracranial bleed: “CVA T-wave pattern” =
deep, wide T wave inversions
https://www.studyblue.com/notes/note/n/cardiology-ecg/deck/3113605
REFERNCES
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Agabegi SS, Agabegi ED. Step up to Medicine, 3rd ed.
2013. Lippincott Williams & Wilkins. Philadelphia,
PA.
Gomella LG, Haist SA. Basic EKG reading. In:
Clinician’s Pocket Reference. McGraw-Hill; 2007.
http://flylib.com/books/en/2.569.1.27/1/. Accessed Nov
18, 2014.
Longo DL, Fauci AS, Kasper DL, et al.
Electrocardiography. In: Harrison’s Principles of
Internal Medicine, 18th ed. 2012. McGraw Hill. New
York, NY.
University of Illinois at Chicago. Online ICU
Guidebook. 2013.
http://chicago.medicine.uic.edu/UserFiles/Servers/Ser
ver_442934/Image/1.1/residentguides/final/icuguidebo
ok.pdf. Accessed December 1, 2014.