Activate or Wait?
46 year-old male with 1 hour of crushing central chest pain. Hx of HTN, morbid obesity, and heavy tobacco use. EKG #1
Activate the cath lab or monitor and why?
YES, this patient has an anteroseptal lesion due to occlusion of the proximal LAD.
ST elevation in V1-V3, Reciprocal depression in II, aVF, and V5-V6
What electrolyte derangements do you expect to see on labs and why?
Hypokalemia
Prominent U waves, long QU interval and widespread ST depression
77 year-old male comes to the ED complaining of palpitations and fatigue that started this morning. Review EKG #7.
What is the diagnosis and why?
Atrial flutter with variable block
A 65 year-old female is evaluated in the ED for chest pain that began why she was attending a funeral. Coronary angiography did not demonstrate any obstruction. EKG #2
What is the most likely diagnosis and what findings support this?
A. Long QT syndrome
B. Microvascular coronary artery disease
C. Resolved STEMI
D. Stress induced cardiomyopathy
Bonus: What are the most common abnormal EKG findings in this diagnosis?
D. Stress induced cardiomyopathy
Findings supported by symptoms onset during period of stress, normal angiogram, persistent EKG changes. (+positive troponin)
Most common location is ST elevations in the anterior precordial leads, followed by deep T wave inversions with prolonged QT interval.
A 63 year-old woman is admitted to the ICU with respiratory failure. Review EKG #5.
Which of the following abnormalities is demonstrated in this patient's EKG?
A. Atrial fibrillation
B. Junctional Tachycardia
C. Wandering atrial pacemaker
D. Multifocal atrial tachycardia
D. Multifocal atrial tachycardia
What distinguishes MAT from Wandering Atrial Pacemaker?
A 38 year-old female is evaluated for fatigue and palpitations. Blood pressure is 110/75, heart rate is 38 bpm. Review EKG #8
Which of the following is the most likely cause of this patient's symptoms?
A. Long QT syndrome
B. Premature ventricular contractions
C. Sinus node dysfunction
D. WPW
Bonus: Where is the abnormality arising?
B. PVCs
EKG demonstrates bigeminal PVCs with only about 1/2 of them conducting fully leading to patient's symptoms.
Bonus: QRS complex tells us where the PVC is arising - right ventricular origin show LBBB pattern and left ventricular origin shows RBBB. V1 is primarily used to distinguish this.
A 69 year-old male was admitted to a rural hospital after 1 hour history of substernal chest pain. He was given thrombolytics. Review EKG #3.1 is on arrival. EKG #3.2 is post thrombolytic therapy.
When should this patient undergo angiography?
A. Before discharge
B. Immediately on arrival at PCI capable institution
C. No coronary angiography indicated after thrombolytics
D. Coronary CT angiography during hospital admission
Bonus: Where was the lesion?
A. Patient should undergo coronary angiography before discharge.
Coronary angiography is indicated 3-24 hours post thrombolytic administration. This patient had improvement of EKG and resolution of symptoms indicated restored myocardial perfusion.
A 40 year-old woman is evaluated for hypotension and dyspnea. She is currently being treated for breast cancer. Blood pressure is 100/70, pulse is 170 bpm. Heart sounds are distant. Review EKG #6.
Which of the following is the most likely diagnosis, and what EKG features support this?
A. ACS
B. Cardiac tamponade
C. COPD
D. Pulmonary embolism
Bonus: What is the physiologic and/or anatomic cause of this EKG finding?
EKG is concerning for electrical alternans, caused by the motion of the heart in the pericardial fluid. Compensatory tachycardia helps to support this concern.
18 year-old male is brought to the ED by ambulance following a generalized seizure at home. He has further witnessed seizure en route in the ambulance. In the ED he is comatose with a GCS of 3 and poor respiratory effort with symmetrically dilated pupils. BP is 70/40. See EKG #9
Describe the abnormal EKG features? What is the most likely cause of this patient's presentation and EKG findings?
A. Doxpein overdose
B. Digoxin overdose
C. Lexapro overdose
A. Doxepin overdose
TCA causes hypotension, tachycardia, seizures, broad complex dysrhythmias,. Cardiotoxic physiology is seen due to blockade of myocardial fast channels, inhibition of potassium channels, and myocardial depression. Also hists muscarinic M1, histamine H1, and alpha 1. Dose dependent risk is noted with TCA.