ECG Archive https://www.ecgguru.com/ecg?title= en Instructors' Collection ECG: Regular Really Wide QRS Tachycardia https://www.ecgguru.com/ecg/instructors-collection-ecg-regular-really-wide-qrs-tachycardia <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/instructors-collection-ecg-regular-really-wide-qrs-tachycardia"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/011892%20WCT%2021%20Reg%2C%20really%20wide%20complex%20tach.jpg" width="2180" height="1142" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">    </span></span></strong><span style="font-size: 12.0pt; line-height: 107%;">Unfortunately, this is an old tracing, and we do not have patient information, other than the list of medications the patient has been taking, (Lasix, Capoten, Ntg, and Procardia). Lasix (furosemide) is a potassium – wasting diuretic.<span style="mso-spacerun: yes;">  </span>Capoten (captopril) is an ACE inhibitor.<span style="mso-spacerun: yes;">  </span>Ntg is presumably sublingual nitroglycerine used for angina. Procardia (nifedipine) is a calcium-channel blocker.<span style="mso-spacerun: yes;">  </span>So, we can assume the patient was probably being treated for angina, heart failure, and hypertension.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 8.0pt; line-height: 107%; color: #00b050;"> </span></strong><strong><span style="font-size: 14.0pt; line-height: 107%; color: #00b050;">The ECG</span></strong><strong><span style="font-size: 12.0pt; line-height: 107%;">:  </span></strong><span style="font-size: 12pt; line-height: 107%;">The first impression is that is a regular WIDE COMPLEX TACHYCARDIA.  The ventricular rate is 100 bpm (Starts a little faster at the beginning at 106, then is 100 by the end).  The QRS duration is about 250 ms (.25 seconds) – VERY WIDE.  There appear to be P waves outside the QRS complexes in V1 and aVL, but probably buried in the ST-T of other leads. </span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;"> </span><span style="font-size: 12pt;">We were all taught to treat all wide complex tachycardia (WCT) as VENTRICULAR TACHYCARDIA (VT) until proven otherwise.</span><span style="font-size: 12pt;">  </span><span style="font-size: 12pt;">This is a very good rule, especially in an emergency setting. It pays to take a moment to consider the possibility of REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT) before making a treatment decision.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;"> </span><span style="font-size: 12pt;">An extremely wide QRS can occur because of a number of very concerning reasons, most involving blockade of the sodium channels.</span><span style="font-size: 12pt;">  </span><span style="font-size: 12pt;">Included in this category are:</span></p></div></div></div> Wed, 06 Mar 2024 22:00:00 +0000 Dawn 897 at https://www.ecgguru.com Acute Anterior-lateral STEMI https://www.ecgguru.com/ecg/acute-anterior-lateral-stemi <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/acute-anterior-lateral-stemi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/030123%20Ant-Lat%20MI%201%20Edit.jpg" width="1800" height="781" alt="" /></a></div><div class="field-item odd"><a href="/ecg/acute-anterior-lateral-stemi"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/030123%20Ant-Lat%20MI%202%20%20Edit.jpg" width="1800" height="782" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The Patient:</span></strong><span style="font-size: 12.0pt; line-height: 107%;"><span style="mso-spacerun: yes;">  </span>A 60-year-old man at work. He experienced a sudden onset of substernal chest pain, nausea &amp; vomiting, and dizziness.<span style="mso-spacerun: yes;">  </span>He states the pain is a 5 on 1-10 scale.<span style="mso-spacerun: yes;">  </span>No cardiac history or current medications.</span><strong><span style="font-size: 8.0pt; line-height: 107%; color: #00b050;"> </span></strong></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="font-size: 12.0pt; line-height: 107%; color: #00b050;">The ECGs:<span style="mso-spacerun: yes;">  </span></span></strong><strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">The first ECG</span></strong><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">, taken at 12:30:05, shows a sinus rhythm with ventricular bigeminy. In some leads, you can see the sinus P waves hidden in the beginnings of the PVCs, so we know the underlying sinus rhythm is about 82 bpm.</span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">There is obvious <strong>ST elevation</strong> in V1 through V5, which is the anterior wall, an area perfused by the left anterior descending artery.<span style="mso-spacerun: yes;">  </span>Remember – the ST elevation sign may also show in the PVCs, but because ventricular beats have secondary ST changes of their own, we should assess <strong>only the sinus beats</strong> for ST changes.<span style="mso-spacerun: yes;">  </span></span></p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; color: black; mso-themecolor: text1;">There is also obvious ST elevation in Leads I and aVL.<span style="mso-spacerun: yes;">  </span>This is the high lateral wall, which is perfused by the circumflex and first diagonal arteries, both proximal branches of the left coronary artery.<span style="mso-spacerun: yes;">  </span>So, the involvement of the high lateral wall indicates a proximal lesion in the LCA – not good.<span style="mso-spacerun: yes;">  </span>Leads III and aVF have distinct ST depression – this is a reciprocal change reflecting the ST elevation in Leads I and aVL. </span></p></div></div></div> Sun, 24 Dec 2023 03:15:06 +0000 Dawn 892 at https://www.ecgguru.com Isolated Posterior Wall M.I. https://www.ecgguru.com/ecg/isolated-posterior-wall-mi-0 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/isolated-posterior-wall-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/110923%20PWMI%20isolated%20standard%2012-Lead.jpg" width="1800" height="1135" alt="" /></a></div><div class="field-item odd"><a href="/ecg/isolated-posterior-wall-mi-0"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/110923%20PWMI%20isolated%20Posterior%20Leads%20edit.jpg" width="1800" height="1355" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">This interesting case was provided by Dr. Bojana Uzelac, Emergency Medicine physician. <span style="mso-spacerun: yes;"> </span>We are paraphrasing a translation of her comments here.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The patient</span></strong> is a 50-year-old complaining of chest pain.</p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The ECG</span></strong> shows a rare occurrence – an isolated POSTERIOR WALL MI (PWMI).<span style="mso-spacerun: yes;">  </span>Note that leads V1 through V4 show the usual signs of posterior wall MI.<span style="mso-spacerun: yes;">  </span>We see ST segment depression, which represents a reciprocal view of the ST elevation present on the posterior wall of the left ventricle.<span style="mso-spacerun: yes;">  </span>The relatively tall, wide R waves in V2 and possibly V3 represent pathological Q waves on the posterior wall. (V2 R/S ratio &gt; 1). What is unusual here is that there are no signs of inferior wall MI or lateral wall MI.<span style="mso-spacerun: yes;">  </span>Posterior wall MI usually occurs in conjunction with one of these.</p><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 8.0pt; line-height: 107%;"> </span>PWMI is most often seen as an extension of <strong>inferior wall MI or lateral wall MI,</strong> because of shared blood supply.  Usually, it is the right coronary artery that supplies both the posterior and inferior areas of the left ventricle (about 80% - 85% of the population).  In some individuals, the circumflex artery supplies both areas. Posterior M.I. may also be seen in conjunction with <strong>lateral wall MI</strong>, when the circumflex supplies the posterior and lateral walls.  In the case shown here, <strong>only</strong> the posterior wall is involved.  Most cases of isolated PWMI involve either the circumflex or one of its marginal (OM) branches.  Only about 3.3% - 5% of all MIs are isolated PWMI.</p><p class="MsoNormal" style="text-align: left;" align="left"> </p></div></div></div> Sat, 11 Nov 2023 21:51:23 +0000 Dawn 877 at https://www.ecgguru.com Complete Heart Block or High Grade AVB? https://www.ecgguru.com/ecg/complete-heart-block-or-high-grade-avb <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/complete-heart-block-or-high-grade-avb"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/032007%20Complete%20AVB%20w%20Junctional%20escape%20edit.jpg" width="1800" height="1471" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The patient:</span></strong><span style="mso-spacerun: yes;">  </span>This ECG was obtained from a 91-year-old woman who was complaining of weakness.<span style="mso-spacerun: yes;">  </span>Unfortunately, we have no other information.<span style="font-size: 8pt;"> </span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="color: #00b050;">The ECG:<span style="mso-spacerun: yes;">  </span></span></strong>This ECG has something for your basic students, and even more for the more advanced learners.<span style="mso-spacerun: yes;">  </span>The first thing  that anyone should notice is the slow rate.<span style="mso-spacerun: yes;">  </span>The ventricular rate is around 35 bpm, and regular.<span style="mso-spacerun: yes;">  </span>If the patient is showing signs of poor perfusion, we would stop here and prepare to increase the rate with a temporary pacemaker (transvenous or transcutaneous). Why is the rate so slow?  There is no P wave in front of each QRS, so this is not sinus bradycardia.  Rather, we see P waves at a rate of approximately 100 bpm, wit a very regular rhythm.  Beginners should “march out” the P waves with calipers or by marking a straight edge piece of paper.  There are 15 P waves on this ECG – some are buried within QRS complexes (QRS #3) or T waves (QRS #4).</p><p class="MsoNormal" style="text-align: left;" align="left"> Because there are two distinct, regular rhythms, but they do not track with one another, we know this is possibly <strong>third-degree AV block</strong> (complete heart block).  Another clue is that there are no steady, repetitive PR intervals, which means there is no relationship between the atrial rhythm and the ventricular rhythm.</p><p class="MsoNormal" style="text-align: left;" align="left"> For more advanced learners, it is helpful to try to identify the origin of the escape rhythm.  If it is junctional, the AV block is above the junction.  If the escape is ventricular, the AV block is below the junction.  A junctional rhythm is usually between 40 – 60 bpm, with a narrow QRS.  Ventricular escape rhythms are usually less than 40 bpm and with wide QRS complexes.  <span style="font-size: 8pt; line-height: 107%;"> T</span>his ECG will be a little challenging on this front, because the rhythm has some characteristics of junctional rhythm and of ventricular rhythm.</p></div></div></div> Wed, 11 Oct 2023 21:22:59 +0000 Dawn 873 at https://www.ecgguru.com Pediatric ECG: One month old infant https://www.ecgguru.com/ecg/pediatric-ecg-one-month-old-infant <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/pediatric-ecg-one-month-old-infant"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/091323%20One%20month%20%20ECG%20from%20Cody%20Davis%20on%20Guru%20Edit_0.jpg" width="1800" height="1174" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><strong><span style="font-family: 'Arial',sans-serif; color: #00b050;">The patient:</span></strong><span style="color: black; mso-color-alt: windowtext;"><span style="mso-spacerun: yes;">    </span></span><span style="font-family: 'Arial',sans-serif; mso-fareast-font-family: 'Times New Roman'; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">4 week old female infant with past medical history of meconium aspiration at birth with APGAR scores of 2,4,6. Intubated and given nitric oxide for pulmonary hypertension. Weaned in NICU over 10 days. Echocardiogram during that time showed stiff pulmonic valve. This ECG was obtained at follow up appointment. Infant is eating well, no cyanotic spells. Four- week echo continues to show pulmonic valve stenosis. We do not know chamber measurements. Patient scheduled for a balloon valvuloplasty. </span><span style="color: #222222; font-family: Arial, sans-serif; font-size: 8pt;"> </span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="color: #222222; font-family: Arial, sans-serif;">Babies are born with relatively symmetrical hearts.</span><span style="mso-spacerun: yes;">  </span><span style="color: #222222; font-family: Arial, sans-serif;">Unlike adult hearts, the right ventricle comparatively large due to the work it has to do to pump against the high pulmonary pressure before birth.</span><span style="mso-spacerun: yes;">  </span><span style="color: #222222; font-family: Arial, sans-serif;">Because newborns’ hearts are more to the right side, we often do right-sided chest leads in addition to the standard 12-lead ECG.</span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="font-family: 'Arial',sans-serif; mso-fareast-font-family: 'Times New Roman'; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;"> </span><strong><span style="font-family: 'Arial',sans-serif; mso-fareast-font-family: 'Times New Roman'; color: #00b050; mso-font-kerning: 0pt; mso-ligatures: none;">The ECG:</span></strong><span style="font-family: 'Arial',sans-serif; mso-fareast-font-family: 'Times New Roman'; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;"><span>   </span>In spite of the pulmonary valve stenosis, this ECG is within normal limits for this 4-week old.</span><span style="color: #222222; font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; color: #222222;">Some of the ECG findings here that would be abnormal for an adult ECG, but are normal for this 4-week-old baby are:</span><span style="color: #222222; font-family: Arial, sans-serif; font-size: 8pt;"> </span></p></div></div></div> Wed, 27 Sep 2023 21:12:01 +0000 Dawn 872 at https://www.ecgguru.com Inferior Posterior Wall M.I. In Cabrera Format https://www.ecgguru.com/ecg/inferior-posterior-wall-mi-cabrera-format <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-posterior-wall-mi-cabrera-format"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/112022%20IWMI%20Cabrera%20%20Format%20%233%20%20Edit%20for%20Guru.jpg" width="2400" height="438" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left">Does something about this ECG look "different" to you?    This ECG shows a “classic” presentation of inferior-posterior M.I. when it is caused by a lesion in the <strong>right coronary artery (RCA).</strong> There are ST elevations in leads II, III, and aVF.<span style="mso-spacerun: yes;">  </span>Reciprocal ST depression is seen in Leads I and aVL.<span style="mso-spacerun: yes;">  </span>There is also reciprocal ST depression in Leads V1 – V3.<span style="mso-spacerun: yes;">  </span>These more rightward anterior leads are reciprocal to the posterior (or posterior-lateral) wall, so the ST <em>elevation</em> is actually posterior.<span style="mso-spacerun: yes;">  </span>Another sign that this is an RCA lesion is that the ST elevation in Lead III looks <em>worse</em> than the STE in Lead II.<span style="mso-spacerun: yes;">  </span>It would be helpful to check the right precordial leads, or at least V4 Right, as elevation there would indicate right ventricular M.I. </p><p class="MsoNormal" style="text-align: left;" align="left">Depending on how experienced you are at evaluating ECGs, you might have immediately noticed something “different” about this tracing.<span style="mso-spacerun: yes;">  </span>It is printed in Cabrera format, which groups the leads (viewpoints) more geographically than a traditional ECG does.<span style="mso-spacerun: yes;">  In addition to grouping the leads more geographically, instead of aVR, the machine records - aVR.  That reverses the negative and positive poles of aVR, putting the positive ("seeking") electrode at 30 degrees - halfway between Leads I and II.  </span><span style="mso-spacerun: yes;"> </span>Those of us who have been looking at ECGs for decades often feel a bit disconcerted by this format, because we have developed almost an intuitive way of seeing the ECG as a “map”, and this rearrangement thwarts our brains’ approach to the ECG.<span style="mso-spacerun: yes;">  </span>I would imagine, however, that this might make interpretation a bit easier for someone who is not prejudiced by the standard way of printing.<span style="mso-spacerun: yes;">  </span>This method is especially helpful when looking for inferior wall M.I., as we see here, because the lateral leads are together in a row, and the inferior leads are grouped together. </p></div></div></div> Sat, 26 Aug 2023 22:53:09 +0000 Dawn 866 at https://www.ecgguru.com Severe Triple Vessel Disease https://www.ecgguru.com/ecg/severe-triple-vessel-disease <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/severe-triple-vessel-disease"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/072923%20Triple%20Vessel%20Disease%20Ed.jpg" width="1800" height="1117" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The Patient:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: black; mso-color-alt: windowtext;"><span style="mso-spacerun: yes;">   </span>This ECG is from a 63-year-old man who complained of epigastric pain for three hours. The pain was sudden in onset, burning in nature, and accompanied by nausea and palpitations.<span style="mso-spacerun: yes;">  </span></span><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">The patient is a heavy smoker, diabetic and hypertensive with a long history of non-compliance to his medications.</span><span style="font-size: 8pt;"> </span></p><p class="MsoNormal" style="text-align: left; line-height: normal; background: white;" align="left"><span style="mso-fareast-font-family: 'Times New Roman'; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; mso-font-kerning: 0pt; mso-ligatures: none;">He was given crushed aspirin, loaded with clopidogrel and heparin, given high-intensity statins, and rushed to the cath lab.</span><span style="font-size: 8pt;"> </span></p><p class="MsoNormal" style="text-align: left;" align="left"><strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #00b050;">The ECG:</span></strong><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-spacerun: yes;">  </span>The rhythm is normal sinus, a bit fast at 90 bpm.<span style="mso-spacerun: yes;">  </span>The intervals, frontal plane axis, and R wave progression are normal.  </span>This ECG shows a very dreaded pattern:  ST segment elevation in aVR and V1 with widespread ST depression, seen here in all other leads.  This is an ECG sign of GLOBAL ISCHEMIA.  There are several possible causes, all bad.  The most common causes of this pattern are:</p><p class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -.25in; mso-list: l0 level1 lfo1;" align="left"><!--[if !supportLists]--><span style="font-family: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt 'Times New Roman';">        </span></span></span><!--[endif]--><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">Severe triple vessel disease, with significantly decreased flow in the left anterior descending, right, and circumflex arteries.</span></p></div></div></div> Sun, 30 Jul 2023 23:01:07 +0000 Dawn 855 at https://www.ecgguru.com Inferior Posterior M.I. https://www.ecgguru.com/ecg/inferior-posterior-mi-1 <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/inferior-posterior-mi-1"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/111222%20IWMI%20Ed%20ON%20GURU.jpg" width="1291" height="620" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p>This is a "classic" ECG of very good quality for you to use in a classroom setting.</p><p><strong>The Patient:</strong>&nbsp; A 57-year-old man who complains of a sudden onset of "sharp" chest pain while on a long bike ride.&nbsp; The pain does not radiate, and nothing makes it worse or better.&nbsp; He is pale, cool, and diaphoretic.&nbsp; His medical history is unknown.</p><p><strong>The ECG:</strong>&nbsp; This ECG could be considered "classic" for an inferior wall ST elevation M.I. caused by occlusion of the right coronary artery.&nbsp; ECG findings include:</p><p>*&nbsp; &nbsp;Normal sinus rhythm</p><p>*&nbsp; &nbsp;Marked ST elevation in Leads II, III, and aVF.&nbsp; The elevation is higher in Lead III than in Lead II, a reliable sign of RCA occlusion.</p><p>*&nbsp; &nbsp;Reciprocal depression in Leads aVL and I.&nbsp; ST depression in the setting of acute transmural ischemia (STEMI) is almost ALWAYS due to&nbsp; reciprocal change. The fact that this STD is localized to leads that are reciprocal to the inferior wall is proof of the nature of the STD.</p><p>*&nbsp; &nbsp;Reciprocal depression in V1 - V3.&nbsp; More localized depression.&nbsp; What wall is reciprocal to the anterior-septal wall?&nbsp; The posterior (postero-lateral).&nbsp; Since the inferior wall is really the lower part of the posterior wall, inferior wall M.I. is often accompanied by posterior wall M.I.</p><p>An additional lead, V4R, is helpful in this situation, since the right ventricle is often affected in RCA occlusions.&nbsp; The EMS crew reports that V4R was negative for ST elevation, but we do not have a copy.</p><p>Small q waves have formed in Lead III, and we would watch for progression of this sign, as it can indicate necrosis.</p><p><strong>Outcome:</strong>&nbsp; The patient went to the cath lab, but we have no further followup.</p><p>&nbsp;</p><p>Our thanks to Ashley Terrana for donating this tracing.</p><p>&nbsp;</p><p>&nbsp;</p></div></div></div> Mon, 24 Jul 2023 20:41:39 +0000 Dawn 850 at https://www.ecgguru.com Atrial Fibrillation With Aberrant Conduction in Adolescent Patient https://www.ecgguru.com/ecg/atrial-fibrillation-aberrant-conduction-adolescent-patient <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/atrial-fibrillation-aberrant-conduction-adolescent-patient"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/081014%20Peds%20A%20Fib%20w%20Aberrant%20Cond%20Ryan%20Cihowiak%20%20at%20BRFR%20edited%20on%20EKG%20Club%20%26%20Guru.jpg" width="1800" height="1333" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><strong>The Patient:</strong>  This ECG was taken from a 14-year-old girl with a complaint of palpitations.  Her medical history is not known.</p><p><strong>The ECG:</strong>  The rate is about 160 bpm, with an irregularly-irregular rhythm.  There are no P waves.  This is atrial fibrillation.  There are several different morphologies noted in the QRS complexes.  First, a narrow QRS with normal axis, as demonstrated in beats #5 and #7.  There are distinctly wide QRS complexes with a right bundle branch block pattern.  See beats #2, #3, and #19.  This represents aberrant conduction.  Atrial fib often displays aberrant conduction, especially when a beat follows closely after a long R-R cycle followed by a short R-R cycle. The refractory period is set by the preceding cycle.  So a lont R-R causes a longer refractory period.  The short R-R that follows finds itself in a relative refractory period - not refractory enough to prevent conduction altogether, but in this case, the right bundle branch has not yet recovered, so the impulse continues down the left bundle, bypassing the right bundle branch.  The right ventricle depolarizes late, causing a widening of the QRS.</p><p>There is a sliight variation seen in the aberrant beats, notably in #1 and #2.  This may represent varying amounts of aberrancy, where the pathways change slightly from beat to beat.  Atrial fibrillation is rare in children and adolescents, but can be caused by many factors, including stress, caffeine, endocrine disorders, obesity, and heart infections.  </p><p>This ECG was published by me on Facebook nearly a decade ago, and received some excellent comments from Dave Richley and Dr. Ken Grauer (two of our favorite Gurus).  I will reproduce them here to spare them re-writing their comments.</p></div></div></div> Tue, 23 May 2023 21:59:22 +0000 Dawn 839 at https://www.ecgguru.com ECG Basics: Ventricular Fibrillation Seen In Twelve Leads https://www.ecgguru.com/ecg/ecg-basics-ventricular-fibrillation-seen-twelve-leads <div class="field field-name-field-ecg field-type-image field-label-hidden"><div class="field-items"><div class="field-item even"><a href="/ecg/ecg-basics-ventricular-fibrillation-seen-twelve-leads"><img typeof="foaf:Image" src="https://www.ecgguru.com/sites/default/files/051323%20v%20fib%2012-Lead%20donated%20by%20Dr.%20Andreas%20Roschl%20Cardioplegic%20VF%20bypass%20for%20surgeryEdit.jpg" width="2305" height="1401" alt="" /></a></div></div></div><div class="field field-name-field-ecg-interpretation field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p class="MsoNormal" style="text-align: left;" align="left"><span style="font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: black; background: white;">This is an image of ventricular fibrillation as seen in all twelve standard leads simultaneously.&nbsp; This is cardioplegic ventricular fibrillation, occurring as the heart is stopped during cardiopulmonary bypass for open heart surgery.&nbsp; Each channel (horizontal strip) is run during the same ten-second period.&nbsp; Our thanks to Dr. Andreas&nbsp;</span><span style="font-size: 12.0pt; line-height: 107%; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: #222222; border: none windowtext 1.0pt; mso-border-alt: none windowtext 0in; padding: 0in; background: white;"><span style="font-variant-ligatures: normal; font-variant-caps: normal; orphans: 2; text-align: start; widows: 2; -webkit-text-stroke-width: 0px; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; word-spacing: 0px;">Röschl</span> from Germany for contributing this image.</span></p></div></div></div> Fri, 19 May 2023 21:07:26 +0000 Dawn 838 at https://www.ecgguru.com