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Instructors' Collection ECG of the WEEK, August 29, 2014 ____ Extensive Anterior Wall M.I. With Recent Inferior Wall M.I.

Fri, 08/29/2014 - 19:15 -- Dawn

This 88-year-old woman was brought to the Emergency Department in cardiogenic shock.  Very little is known of her past medical history, but it was relayed to the EMS responders that she had been ill for about four days, when she became much worse.

This ECG shows a large, acute anterio-lateral wall M.I., as evidenced by the ST ELEVATIONS in V2 through V6, Leads I and aVL.  To make matters worse, there are PATHOLOGICAL Q WAVES in Leads V2 through V6.  Pathological Q waves indicate areas of necrosis.  Because the myocardium facing the positive electrode is not electrically active, we "see through" the dead tissue to the myocardium on the opposite side of the heart.  Pathological Q waves could be thought of as "reciprocal R waves".  This represents a great deal of dead myocardium, which will be akinetic - not moving.

To make matters worse, she has pathological Q waves in the INFERIOR WALL as well, in Leads II, III, and aVF.  Her ST segments in those leads are flattened and possibly slightly elevated, but not much.  There are no reciprocal ST depressions in I and aVL, because they are affected by the anterior - lateral wall M.I., and are elevated.

The accompanying photos show her left coronary artery angiogram indicating severe coronary artery disease and a "missing" left anterior descending artery.  This is due to a proximal lesion that occurred around the area of the first diagonal artery, cutting off blood flow to a very large part of her anterior-lateral wall.  The photo of the right coronary artery shows a very tight lesion which is allowing some blood to pass.  The Interventionalist felt that this represented a resolving 100% occlusion (remember, she had been sick for four days).  As the blood clot broke up, blood flowed again, lowering the ST segments.  Unfortunately, permanent damage had already been done, and she had Q waves in the inferior wall also.  This leaves very little of her heart beating, and it is easy to understand why she presented in shock.  She suffered cardiac arrests several times during the procedure, and was managed with a balloon pump and ventilator.

Unfortunately, this type of injury is not survivable, and she died in the CVICU a few hours after her procedure. She contributes to our education by demonstrating the cumulative effects of M.I., especially when permanent damage occurs.  For a look at her ventriculogram, to understand the devastating effects of these injuries, go to our You Tube channel.

ECG Basics: Atrial Flutter With 2:1 Conduction Ratio

Thu, 07/17/2014 - 17:40 -- Dawn

One of the most frequently misdiagnosed rhythms, atrial flutter with 2:1 conduction often masquerades as sinus tach.  Sinus tach usually has an obvious cause, such as exercise, severe hypovolemia, or age less than 6 months.  Atrial flutter usually produces flutter waves (P waves) at a rate of 250 - 350 per minute.  Therefore, a 2:1 conduction ratio would result in a heart rate of about 125 - 175 bpm).  

Often, students are taught about atrial flutter using an electronic rhythm generator or a book with limited illustrations, and they become acustomed to seeing atrial flutter with 3:1 or 4:1 conduction.  The flutter waves are very easy to see in such a situation.  However, the AV node, if not affected by medication, is usually well able to conduct at a rate of 150 or more.  Therefore, the physiological block that protects us from extreme rates will keep the heart rate around 150 bpm in atrial flutter.

This is a single rhythm strip.  It can be VERY helpful to look at multiple leads to look for flutter waves.  See this week's Instructors' Collection ECG of the WEEK for the SAME patient's 12-Lead ECG.  Also, your students should be reminded that sinus rhythms, including sinus tach, tend to change rates based on the needs of the patient.  For example, as a patient is treated for his/her condition, the rate may improve by slowing.  Conversely, if the condition becomes worse, or the patient is stressed, the rate may increase.  Atrial flutter, like all re-entry tachycardias, tends to stay at a steady rate unless the conduction ratio changes.

Show your students that the flutter waves are CONTINUOUS.  That is, they don't pause for the QRS.  The second illustration shows the flutter waves highlighted, to aid in seeing the continuous line of flutter waves.

jer5150's picture

Jason's Blog: ECG Challenge for the months of July and August, 2014.

This is an ECG I performed a couple of years ago on an asymptomatic 83-year old man as an outpatient procedure. 

The computer interpreted this as:  "Marked sinus bradycardia [with] Frequent Premature ventricular complexes".  IS THE COMPUTER CORRECT?  Is there more than one plausible interpretation?  What is the differential diagnosis?

ECG Teaching Series: ST Elevation M.I.

Sat, 06/21/2014 - 15:23 -- Dawn

This series shows the evolution of ECG changes in anterior wall M.I. secondary to occlusion of the proximal left anterior descending artery.  The patient is an 88-year-old woman with chest pain.  She was designated a "cardiac alert" from the field by paramedics.  Her proximal LAD was opened and stented in the cath lab.  We do not have follow-up information on her.

The first ECG in the series, titled "12-Lead 3", shows ST elevation at the J point in V1 through V3.  In addition, the T waves are "hyperacute" - tall, broad, and asymmetrical. This can be an early, transient sign of myocardial injury.  Slight reciprocal depressions are seen in the inferior leads.  Lead V4 has a T wave inversion that is out of place with the progression of the T waves in V3 and V5.  Lead placement may be to blame.  Hyperacute T waves in a patient with chest pain should be taken very seriously.

The second ECG, titled "12-Lead 4", shows continued elevation at the J point in Leads V1 through V3, with a lessening of T wave amplitude.  In addition, Lead aVL is showing some T wave changes. The T wave is biphasic, and may be about to become inverted.  This is not an improvement!  V1 through V3 show us the anterior-septal wall, and an M.I. here indicates occlusion in the LAD.  Leads I and aVL show the high lateral area of the anterior wall, and damage here is an indicator that the occlusion is proximal.

The third ECG, titled "12-Lead 5", shows a "maturing" of the ST segment elevation.  Even though there is some significant artifact, we can see that the ST segment in V1 is coved upward, and the ST segment in V2 is flat.  Both shapes are abnormal, and a sign of CAD.  The T waves have become less pronounced, but V2 looks as if the T wave may become inverted in the near future.  V3 looks improved in this image.

The patient's clinical symptoms did not improve during these ECG changes.  Hyperacute T waves are not a definitive sign of STEMI, but they provide a highly visible warning that may catch attention.  They definitely are an indication to run serial ECGs, as these paramedics did.

 

THE MOST COMFORTABLE SHIRT YOU WILL EVER WEAR

Wed, 01/15/2014 - 20:55 -- Dawn

THIS WILL BE YOUR FAVORITE SHIRT!

This is not an ordinary tee shirt.  It is made of the smoothest, most comfortable lightweight fabric, which is moisture-wicking and has a sun-protective UPF of 30.  And, it is wearable art, featuring the work of ALYSSA BEAN.  If you work in a cath lab, and wear lead aprons all day, you will love the feel of this shirt. The fabric keeps you warm in cold environments and cool in warm temperatures.  It is great for sports, boating, beach, and layering.

The ECG Guru is committed to providing high-quality resources for ECG instructors and students FREE of CHARGE and FREE of COPYRIGHT.  We do rack up some expenses keeping the website going.  We came up with the idea of fund raising while also providing a product that we know our members and visitors will LOVE. 

Go to the STORE to learn more about this shirt.

Broken Heart

Click to open: 
Heart Art, Broken Heart, Heart Leaf Illustration

Looking for an illustration for your presentation or packets?

Photograph by Alyssa Bean.  May be used free of charge and free of copyright in instructional setting.  Please contact the artist at Dawn.ECGGuru@gmail.com for any commercial use.

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