Welcome to the start of a new series here at EMS 12-Lead. With the ECG Mixtapes we’ll compile some of the week’s best ECG’s from around the world of social media and #FOAMed. As High Fidelity taught us, “The making of a great compilation tape, like breaking up, is hard to do and takes ages longer than it may seem.” Please dig deeper into the cases that interest you.
Pick of the Week
This week’s top pick comes from Mohd Faried over at the EKG Club on Facebook.
The patient, a 58 year old female, presented with chest pain x 1 hour with diaphoresis and signs of heart failure. This ECG shows sinus tachycardia, a (presumed) new RBBB, severe ST-depression in the inferior leads, and towering ST-elevation in aVR—which add up to quite a poor prognosis. It is important not to mistake the profound ST-changes in the limb leads for an extremely wide QRS (> 240 ms); the QRS in this tracing is really about 170 ms.
Now, despite common teaching, most cases of diffuse ST-depression with ST-elevation in aVR are not caused by acute occlusion of the left main coronary and often do not require immediate catheterization (for a lot more on this topic check out this post). The tracing above is unique for two reasons:
- The magnitudes of the ST-deviations in the limb leads are huge (though this can be seen in patients without obstructive coronary artery disease too).
- There are almost no ST-deviations in V1–V4.
This pattern is sometimes seen when anterior and posterior ST-elevation cancel each-other out and seems consistent with a true acute occlusion of the LMCA (a “left-main STEMI”). A patient with this ECG needs the cath lab now and, even with immediate intervention, the disease carries a very high mortality.
In this case the patient was intubated for worsening pulmonary edema and prepped for immediate angiography but, as often happens with these presentations, she did not survive long enough to make it to cath.
For more examples of true LMCA occlusion and a collection of ECG’s that share some of the features I describe, check out this post from our site.
Our Favorite Blogs
Dr. Steve Smith provides an in-depth discussion of a challenging wide complex tachycardia over at his eponymous ECG Blog.
Dawn Altman over at ECG Guru proves that you can spot a STEMI in a patient with a pacemaker.
Dr. John Larkin at ECG of the Week dissects a STEMI with anterior “tombstones” and almost no limb leads changes. Be warned! Some anterior STEMI’s look perfectly normal in the limb leads—typically those with mid-LAD lesions.
Dr. Arnel Carmona at ECG Rhythms shows you how the onset and offset of a wide complex tachycardia can be used to easily discern VT from SVT.
Dr. Susan Torrey’s blog, Torrey EKG, explains why this otherwise healthy 48 year old male is bradycardic.
Float Nurse posts a lot of quick, interesting, and accurate arrhythmia self-tests using real-world rhythm strips. Check out the latest one and make sure you have your basic arrhythmias down-pat before your next ACLS exam!
The Best of Social Media
How low can you go? Over at the Facebook group 12 Lead ECG – I’ve Got the Rhythm, Cam Warren shares a tracing from a patient who was conscious and alert with a heart rate of 17 bpm!
12-Lead ECG – I’ve Got the Rhythm hosts another “Oh no! Too Slow!” rhythm with this case of tachy-brady syndrome from Luca Alfatti.
And yet one more bradycardia! This time a type II AV-block from Dr. Michelle Connolly on Twitter.
Twitter brings us another spot-diagnosis arrhythmia with this beautiful ventricular tachycardia from Chris Evers.
Speaking of VT… Don’t get distracted by this patient’s runs of tachycardia and miss the underlying cause. Make sure you check out the comments for more information on this interesting and instructive case from Kris Barraclough over at 12-Lead ECG – I’ve Got the Rhythm on Facebook.
Here’s a challenging one from our good friend Dr. Rohin Frances on Twitter. A 70 year old female with a history of schizophrenia and this ECG—can you spot the abnormality? Make sure you check out the serial ECG’s! Further discussion is also available in the EKG Club on Facebook.
Here’s a subtle finding that’s vital to spot! At a glance the ECG looks normal, but there’s trouble brewing… From Dr. Sergio Pinski over on Twitter.
And finally, here’s a facinating case from Dr. James Cranley on Twitter. A 31 year old female undergoes a liver transplant but suffers a bout of ventricular tachycardia soon after extubation. Her pre-op and post-VT ECG’s are shown below. What’s going on? Follow the link for the discussion.
I hope you find the cases interesting and take the time to check out the links to their original posts. Look forward to our next installment of the ECG Mixtape series returning again in a week!