19
Jan
2017

Monthly EKG Quiz

Hey guys — read the EKG above to the best of your ability and the resident with the best explanation wins a prize [and glory]!

A 56 year old M p/w VF cardiac arrest — here is his EKG post code…

10 Responses

  1. Mohammad Selim

    1-ST elevation in III, aVF, with reciprocal changes in I, aVL (Inferior STEMI)
    2- ST elevation in V1 + ST depression in V2 + elevation III >II (Right ventricular infarction)
    3- ST depression in V3-V6 could represent multi-Vessel disease.
    4- Heart rhythm doesn’t follow certain pattern, irregular, hard to distinguish P wave. Most likely A fib given all what I mentioned.
    5- RAD

  2. Luay Sarsam

    Atrial fibrillation. Inferior and V1 ST elevation. ST elevation in lead III HIGHER THAN lead II with receprocal changes in lateral leads with R less than S in AVL which makes it likely to be RCA. Also V1 ST elevation which could be RV infarction so makes me think it is proximal RCA.

  3. Faysal

    Rythm is Atrial fibrillation, there is ST segment elevation in V1 with ST depression in V2, this is specific sign for right ventricular inferct, this is supported by the ST elevation particularly in the lead iii which is also sign for right ventrular tansmural infarction, add to that the right axis deviation.
    I would send serial troponins and compare it with the previous EKG, also I’ll contact cardiology for possible cath. Or if they are not available and the trops are high with these new changes I’ll start tPA

  4. Nagarjuna R Gujjula

    EKG:
    – Rate is 108 ( even though it’s irregular, rate can be determined by calculating number of QRS complexes in 10 second strip times 6)
    – Rhythm looks irregular
    – P waves cannot be seen in lead II, possible Atrial fibrillation
    – QRS complexes looks narrow
    – ST segments are elevated in Leads III( > 2 mm ), AvF ( 1 mm) and V1 ( >2 mm) , concerning for transmural infarction of Right ventricular region, possibly RCA involvement, supported by reciprocal changes such as ST depressions in leads I, aVL, V2-V6.
    – inverted T waves in Leads I and aVL, reciprocal changes
    – Axis looks normal
    – Possible Delta wave in most of the precordial leads in the EKG concerning for WPW pattern, with A Fib in background, possibly A Fib with RVR might have caused rapid ventricular activation bypassing AV Node which might have led patient to end up in V Fibrillation causing patient to crash and with such rates with possible underlying CAD, might have caused STEMI. ( I might be wrong!)

  5. Rabie

    St elevation in the inferior leads 
Inf MI
 Reciprocal ST depression in lead 1 and Avl
 St elevation in v1 may be Rt myocardial infarction need Rt sided ECG 
??And obviously A.feb

  6. Ali nayfeh

    St elevation in inf leads iii,aVF with reciprocal changes in the lat leads.
    Afib
    St elevation in v1 with st depression in v2/v3

  7. Dr. Smer

    Great input everyone, Dr. Abu Hazeem it looks like you need to buy more than one caliber for this ECG…! Just to recap

    1. Rhythm is AF with RVR ( complication of MI)

    2. Inferior STEMI, ST elevation in lead III > II, typical for RCA more than LCx and the vice versa

    3. ST elevation in V1 and ST depression in V2-3 is typical for RV infarction, which means this is proximal RCA occlusion before the origin of the acute marginal artery that supplies RV. As Rabie said, it’d be good idea to get right sided ECG.

    From a clinical perspective, DO NOT give Nitro to such patients. Nitro decreases pre-load and RV infarction patients are pre-load dependent, it could cause HYPOTENSIOIN.

    Few points to clarify,

    I’m not sure how RAD related to MI..! Please enlighten us

    Remember, if this patient has delta wave (WPW), he would be going very fast, 250 bpm or more. Because you bypass the AV node (which is like traffic light with speed limit road), and go through the accessory pathway (highway with no speed limit)

    With this ECG, you don’t even need cardiac enzymes, you can take it to the bank. You call Cardiology to take patient to CATH LAB ASAP. Remember every minute means muscle, you don’t wanna delay therapy for blood test, which probably won’t change your management.

    Lateral ST depression, could be related to inferoposterior MI if the RCA is dominant and in this patient it was RCA dominant circulation with both posterior descending artery (PDA) and posterolateral (PL) artery coming from RCA. Cath showed proximal occluded RCA 100%.

    Again, good job everyone.

  8. Mahmoud Abu Hazeem

    All good answers and it’s tough choice, but since Nagarjuna is the only one who picked up on the Delta waves the prize goes to him. Thanks everyone for participating and hope to see you again with the next quiz.

So, what do you think?

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