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Instructors' Collection ECG: Acute Anterior M.I. and Ventricular Fibrillation

Submitted by Dawn on Tue, 04/04/2023 - 15:11

The Patient:   This series of ECGs is from a 65-year-old woman who was complaining of a sudden onset of chest pain, nausea, and weakness. She stated that the pain increased on inspiration.  She reported a history of non-insulin-dependent diabetes mellitus (NIDDM). 

ECG No. 1, 14:46:  This ECG includes V4Right, V8 and V9 in place of V4, V5, and V6.  The rhythm is sinus at 91 beats per minute.  The PR interval is within normal limits, as is the QRS duration.  The QTc is WNL as well.  The frontal plane axis is also WNL.  The three standard chest leads show an early transition of R waves in V2.   There are noticeable ST and T wave abnormalities:

slight ST elevation in I and aVL with ST depression in II, III, and aVF.  In chest pain, possible M.I., STD should be presumed to be reciprocal in nature.  V1 has slight STE with a coved upward (frowning) appearance.  V2 has more noticeable STE, with a tall, wide-based T wave. This is called a “hyperacute T wave”.  We will have to evaluate V4 – V6 on ECG No. 2. 

V4 Right has no ST elevation, and V8 and V9 have ST depression (reciprocal to the anterior leads).  So far, we have all the signs of acute anterior wall M.I. 

Dr A Röschl's picture

Why is this not second degree AVB Type II and no high grade AVB

Submitted by Dr A Röschl on Sat, 06/03/2023 - 04:32

(Image 1) Why is there no second-degree AVB  Mobitz type II and no high-grade AV block? To the first question: Basically, second-degree AV block Mobitz type II is rare. The two ECG patterns that can easily be confused with Type II Mobitz block are: blocked/non-conducted PACs and second-degree AVB Mobitz type I (Wenckebach). (Image 2) You have to compare the PR duration before the pause and after it. With the naked eye, the difference is often difficult to recognize, a pair of calipers does a good job here.

Dr A Röschl's picture

Atypical Atrial Flutter

Submitted by Dr A Röschl on Fri, 06/02/2023 - 05:47

Why is this left atrial atypical atrial flutter (ECG 1)? Atrial fibrillation can be excluded because nice flutter waves (all look the same) can be clearly identified. With typical right atrial flutter, the reentry circle runs counterclockwise and we see typical saw tooth patterns in the inferior leads (negative flutter waves). The flutter waves are positive in V1 (ECG 2). With typical right atrial flutter with a clockwise reentry circle, the flutter waves in the inferior leads are positive.

Dr A Röschl's picture

Junctional Escape Rhythm, Very Slow

Submitted by Dr A Röschl on Wed, 05/31/2023 - 02:02

This ECG comes from a 75 yo man who had 2 syncopes in the past few weeks. The 12-lead-EKG at the family doctor showed an inconspicuous finding. Here you can see a section of the patients Holter ECG. There is a very slow junctional escape rhythm. How can this be recognized?

Dr A Röschl's picture

Second degree AVB Mobitz Type II

Submitted by Dr A Röschl on Sat, 05/27/2023 - 01:35

This ECG is from an 80-year-old lady who has collapsed or had sycopal episodes several times. The ECG comes from a Holter monitor. She has arterial hypertension and coronary artery disease. The ECG shows a second-degree, Mobitz Type II AV block. In both types of AVB, the PP intervals are usually the same.

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Welcome Dr. Andreas Roeschl

Submitted by Dawn on Wed, 05/24/2023 - 12:23

Welcome to Dr. Andreas Roeschl, who is a cardiologist and ECG instructor in Germany.  He will have a recurring blog on the Guru, contributing his knowledge about ECG and teaching, along with ECGs from his collection.  His ECGs are digitized and beautiful quality for reproduction, and his contributions will be a great asset to any student or teacher of ECG.  Dr. Ken Grauer and I want you to feel free to ask us and Dr. Roeschl any questions you have about ECG or teaching ECG.  That is the mission of this website - to make it easier for instructors to teach.

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ECG Basics: Ventricular Fibrillation Seen In Twelve Leads

Submitted by Dawn on Fri, 05/19/2023 - 15:07

This is an image of ventricular fibrillation as seen in all twelve standard leads simultaneously.  This is cardioplegic ventricular fibrillation, occurring as the heart is stopped during cardiopulmonary bypass for open heart surgery.  Each channel (horizontal strip) is run during the same ten-second period.  Our thanks to Dr. Andreas Röschl from Germany for contributing this image.

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ECG Basics: Second-degree AV Block, Type I

Submitted by Dawn on Wed, 02/02/2022 - 13:43

This two-lead rhythm strip shows a normal sinus rhythm at about 63 bpm.  The P waves are regular. After the sixth P-QRS, there is a non-conducted P wave.  The normal rhythm then resumes.  The two most common reasons for a non-conducted P wave in the midst of a normal sinus rhythm are 1) non-conducted PAC, and 2) Wenckebach conduction. The first is easy to rule out.  The non-conducted P wave is not premature, so it is not a PAC.  The second one is a little harder when we only have a short strip to look at.  We are conditioned to look for progressively-prolonging PR intervals until a QRS is "dropped".  In this case, the progression is in very tiny increments that are hard to see unless you zoom in and measure.  But they ARE progressively prolonging.  An easy hack:  measure the last PRI before the dropped beat and the first one after the pause.  You will see that the cycle ends on a longer PRI (about .28 seconds) and the new cycle starts up with a PR interval of about .20 seconds.  Fortunately, this conduction ratio will have very little effect on the patient's heart rate.

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Ask The Expert

Submitted by Dawn on Fri, 10/01/2021 - 14:38

Dr. Jerry W. Jones, MD, FACEP, FAAEM has graciously shared with us his four-part article on the topic of “Delays & Blocks Involving the Bundle Branches”.

Dr. Jones is a talented instructor who makes difficult topics easy.  Please feel free to post your comments and questions for Dr. Jones and our other ECG Gurus. 

Click THIS LINK for a downloadable pdf of Part 1: Non-Specific Intraventricular Conduction Delays. 

Click THIS LINK for a downloadable pdf of Part 2: Left Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 3: Right Bundle Branch Block.

Click THIS LINK for a downloadable pdf of Part 4: The Fascicles of the Left Bundle Branch 

Dawn's picture

ECG Glossary from Dr. Ken Grauer

Submitted by Dawn on Sat, 06/08/2019 - 14:16

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

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Dr. Ken Grauer Glossary

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