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EKG #1

1. What is the rhythm?


a. V-Tach
b. A-Fib
c. A-flutter
d. normal
EKG #1

1. What is the rhythm?


a. V-Tach
b. A-Fib
c. A-flutter
d. normal
Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex


Regular ST ST w/ BBB
SVT SVT w/ BBB
Atrial flutter VT
Irregular A-fib A-fib w/ BBB
A-flutter w/ variable A-fib w/ WPW
conduction VT
MAT

4
EKG #2

1. What does this EKG represent?


a. pericarditis
b. myocarditis
c. digitalis effect
d. infero postero lateral wall ST-elevation MI
EKG #2

1. What does this EKG represent?


a. pericarditis
b. myocarditis
c. digitalis effect
d. infero postero lateral wall ST-elevation MI
Cardiac Location of Event

7
EKG #3

1. What is the rhythm?


a. V-Tach
b. A-Fib
c. A-flutter
d. normal
EKG #3

1. What is the rhythm?


a. V-Tach
b. A-Fib
c. A-flutter
d. normal
Ventricular Tachycardia
 Rate 110 -250 bpm
 Wide complex (>0.12 – 3 small blocks)
 Regular
 AV dissociation
 Extreme Right Axis Deviation + Upright MCL-1

I II III

MCL-1
EKG #4

1. What does this EKG represent?


a. sinus bradycardia
b. sinus tachycardia
c. 2nd degree AV block
d. complete heart block
EKG #4

1. What does this EKG represent?


a. sinus bradycardia
b. sinus tachycardia
c. 2nd degree AV block
d. complete heart block
Blocks
 AV blocks
 First degree block
• PR interval fixed and > 0.2 sec
 Second degree block, Mobitz type 1
• PR gradually lengthened, then drop QRS
 Second degree block, Mobitz type 2
• PR fixed, but drop QRS randomly
 Type 3 block
• PR and QRS dissociated

13
EKG #5

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
EKG #5

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
EKG #6

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
EKG #6

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
Bundle Branch Blocks
 Turn Signal Theory

1 2 3

LBBB

RBBB
EKG #7

1. What does this EKG represent?


a. V-fib
b. A-fib
c. Supraventricular tachycardia
d. normal
EKG #7

1. What does this EKG represent?


a. V-fib
b. A-fib
c. Supraventricular tachycardia
d. normal
Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex


Regular ST (HR < 150) ST w/ BBB
SVT (HR > 150) SVT w/ BBB
Atrial flutter (HR = 150) VT
Irregular A-fib A-fib w/ BBB
A-flutter w/ variable A-fib w/ WPW
conduction VT
MAT

21
EKG #8

19 year old
male with
complaints
of
palpitations

1. What would you do next based on this EKG?


a. Reassure and discharge
b. Refer for electrophysiology study
c. Begin a beta-blocker
EKG #8

19 year old
male with
complaints
of dizziness
and
palpitations

1. What would you do next based on this EKG?


a. Reassure and discharge
b. Refer for electrophysiology study
c. Begin a beta-blocker
EKG #9

1. The therapy of choice is:


a. Thrombolytics
b. Cath and PCI
c. NSAIDs and Colchicine
EKG #9

1. The therapy of choice is:


a. Thrombolytics
b. Cath and PCI
c. NSAIDs and Colchicine
Pericarditis
 PR segment depression, usually in lead II

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EKG #10

This patient is a 50 year old man who presented to the ED with chest tightness
and is noted to be markedly hypotensive on exam. What is your therapy
for BP restoration? A. Dopamine B. IVF bolus C. Balloon pump
EKG #10

This patient is a 50 year old man who presented to the ED with chest tightness
and is noted to be markedly hypotensive on exam. What is your therapy
for BP restoration? A. Dopamine B. IVF bolus C. Balloon pump
What about the right side?
RV infarcts
Occur in conjunction with inferior MIs

 Move V4 to the
right side same
location
 5th intercostal
space anterior
axillary

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Acute MI with RV involvement

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Acute MI with RV involvement
 IVF to increase filling pressures
 Inotropes to follow IVF loading
 RV - VAD

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EKG #11

This patient is 40 year old woman with pleuritic chest pain and
breathlessness. What is the diagnostic test of choice?
a. Echo
b. CTA
c. CXR
EKG #11

This patient is 40 year old woman with pleuritic chest pain and
breathlessness. What is the diagnostic test of choice?
a. Echo
b. CTA
c. CXR
S1Q3T3 pattern is only second to D-dimer
EKG #12

1. What does this EKG represent?


a. V-fib
b. A-fib
c. A-flutter
d. V- tach
EKG #12

1. What does this EKG represent?


a. V-fib
b. A-fib
c. A-flutter
d. V- tach
EKG #13

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
EKG #13

1. What does this EKG represent?


a. V-fib
b. left bundle branch block
c. right bundle branch block
d. normal
EKG #14

1. What does this EKG represent?


a. Pericarditis
b. Myocardial infarction
c. Early Repolarization
EKG #14

1. What does this EKG represent?


a. Pericarditis
b. Myocardial infarction
c. Early Repolarization
Classic findings

1. J-point “notching”

2. Concave-up ST segment
(smiley face)

3. ST segment elevation
from baseline in V2-V5,
typically <3mm

4. Large, symmetrically
concordant T-waves in
leads with STE

42
Classic findings

1. J-point “notching”

2. Concave-up ST segment
(smiley face)

3. ST segment elevation
from baseline in V2-V5,
typically <3mm

4. Large, symmetrically
concordant T-waves in
leads with STE

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Can we tease it out?
 The degree of ST segment elevation is thought to be
indirectly proportional to the degree of sympathetic tone

 Inother words, the more relaxed the patient, the more


pronounced the ST segment elevation (and vice versa)

 Ifyou truly want to test your patient, get their heart rate up
and look at the ST segment
44
HR 64 HR 83

The ST segment is NOT fixed in pts w/ BER and changes from EKG
to EKG and with the degree of sympathetic strain

On the right, note the complete resolution of the ST elevation


but maintenance of the J-point notching in V4 46

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