Pearls From Cases

Question 1

What must you consider in a pt with sob, Dyspnea and syncope? What additionally?

Answer 1

PE Pericardial effusion

Question 2

What defines low voltage? Low voltage (especially if new) + tachycardia think what?

Answer 2

QRS complexes < 15mm in leads I, II, III combined Or QRS amplitudes in V1+V2+V3 < 30mm Pericardial effusion

Question 3

AHA circulation 2004 chemo drugs and SEs, author is Yeh (cardiovascular complications) What drug causes cardiac vasospasm?

Answer 3

5-FU

Question 4

What are the 5 things that can cause diffuse STE?

Answer 4

Large acute MI —> Reciprocal depression Pericarditis Vasospasm Ventricular aneurysm —> Q waves from old MI Early Repol —> dx of exclusion, look for fishhooks (looks like J wave)

Question 5

Pt that has AFib that presents with bradycardia and appears regular, what must you think of?

Answer 5

Digoxin toxicity —> look for Salvador Dali sloping ST segment

Question 6

How does Digoxin make the rhythm regular in AFib?

Answer 6

Blocks AV node, it becomes a Junctional escape rhythm (40-60)

Question 7

What is Contraindicated in Digoxin toxicity with hyperkalemia? What is this called?

Answer 7

Calcium —> Stone Heart

Question 8

LBBB what is present in leads V1-V3? What about in lead I, V5, V6?

Answer 8

Deep wide S, absent R wave No Q wave

Question 9

What is appropriate discordance in LBBB (Also in pacemakers)? Where QRS goes down what should you see?

Answer 9

QRS goes up should see ST depression ST elevation

Question 10

What is excessive discordant ST elevation in LBBB for MI?

Answer 10

Discordance ST elevation >/= 5mm I.e. if QRS goes down and you have > 5mm of ST elevation This is Sgarbossa criteria C —> Not validated

Question 11

What is Sgarbossa Criteria A? B?

Answer 11

Concordant ST elevation >/= 1mm in any lead Concordant ST depression >/= 1mm in V1, V2, V3 ONLY

Question 12

What is the Revised Sgarbossa C?

Answer 12

ST elevation > 25% than the S wave in their discordance

Question 13

What is the 1st marker on EKG in someone with active Chest Pain that could be having acute inferior wall STEMI? Then what?

Answer 13

Inverted T wave in aVL ST depression

Question 14

T wave height greater than ENTIRE height of QRS could mean what? Do what?

Answer 14

Early cardiac ischemia Get a REPEAT EKG This is a called a type 2 hyperacute T wave

Question 15

DDx long QTc (> 500ms)?

Answer 15

HypoK HypoMg HypoCa Hypothermia Na blocking drugs Elevated ICP

Question 16

What are the only 2 etiologies that prolong the QT d/t via prolonged ST?

Answer 16

Hypothermia HypoCalcemia

Question 17

What is intermittent WPW?

Answer 17

Sinus rhythm with a normal beat then a WPW beat (short PR with delta Wave and subsequent long QRS) Can cause flipped T waves in general

Question 18

How to diagnose Right axis Deviation? What are the main ddx for RAD + STE?

Answer 18

Large S wave in lead I PE, HyperK and Na channel blocking drugs

Question 19

PE can produce STE in what leads?

Answer 19

Rightward leads —> aVR, V1, V2, III

Question 20

Signs of right heart strain?

Answer 20

Tall RV1 RAD T wave inversions (anteroseptal and inferior leads) ST changes in V1, V2, aVR, III

Question 21

Patient with NEW weakness think about what? Can cause what?

Answer 21

HyperK and Rhabdo —> get a CK STE

Question 22

STE + RAD think about what?

Answer 22

1 —> HyperK Na Channel blocking drugs Acute Pulm HTN (PE)

Question 23

STE in lead V1, V2, aVR with a RAD think immediately of what?

Answer 23

HyperK

Question 24

What is the treatment for symptomatic PVCs?

Answer 24

Beta-Blockers (IV metoprolol)

Question 25

What factors strongly suggest STEMI over Pericarditis?

Answer 25

STD in any leads except V1 or aVR STE in III \> II Horizontal or convex upwards of STE

Question 26

What is Spodick’s Sign? Indicates what?

Answer 26

Downsloping of the TP segment Pericarditis

Question 27

Sgarbossa Criteria?

Answer 27

Question 28

How to tell STEMI vs Pericarditis?

Answer 28

Question 30

Pt that has lead V1, V2 concerning for Brugada but not 100% clear picture, what can you do to confirm?

Answer 30

Move leads 1-2 interspaces higher

Question 31

What are signs of early cardiac ischemia?

Answer 31

T wave inversion in aVL Hyperacute T waves - T wave height \> qrs height or straightening of T wave

Question 32

When deciding if a pt has AFib, where to check P waves first? why?

Answer 32

Lead V1 Sitting right over the RA

Question 33

What is most commonly misdiagnosed as AFib?

Answer 33

Mobitz Type 1

Question 34

Whenever you have grouped or clumped beats (regularly irregular) in the rhythm strip it is indicating what?

Answer 34

Mobitz type 1 or PAC

Question 35

T wave alternas with long QT can lead to what? QTc \> what level?

Answer 35

Torsades or sudden cardiac arrest \> 500

Question 36

Patient with deep T Wave inversions and prolonged QT interval has what?

Answer 36

Inc ICP

Question 37

Patient with RBBB, what should you NEVER see? where to look?

Answer 37

STE, you should see ST depression V1, V2

Question 38

What rate is VTach is usually seen? If it is kinda slow what can kill the pt?

Answer 38

Needs to be GREATER than 130 (maybe 120) Na channel blocker like amio, procainamide, lidocaine if the underlying problem is hyperK

Question 39

What can you do to helpdiagnose if you suspect HyperK mimicking VTach on EKG?

Answer 39

give 1 amp NaHCO and the rhythm will change

Question 40

what is the DDx for STE in V1, V2, aVR?

Answer 40

STEMI But also: HyperK and PE

Question 41

How to tell if a pt with a Pacemaker is having a STEMI?

Answer 41

Sgarbossa A - Concordant STE in ANY lead B - Concordant STD in V1-V3 C - Discordant STE \> 5mm in ANY lead

Question 42

How to Dx LBBB on ekg?

Answer 42

look at V1, usually no Q wave, Very small r wave, then deep S wave that is negatively deflected QRS \> 120 lead V5-V6 has RsR' and no Q wave

Question 43

What is BRASH syndrome?

Answer 43

Bradycardia Renal Failure AV nodal blockers (BB or CCB) Shock HyperKalemia (mild)

Question 44

how to treat BRASH?

Answer 44

treat the hyperKalemia with 2g Calcium gluconate even if K is mild (5-6.5)

Question 45

RAD (or big S wave in lead I) with STE in leads aVR, V1, V2 what must you strongly consider?

Answer 45

PE

Question 46

TCA overdose EKG findings?

Answer 46

tachycardia tall R wave in aVR RAD long QT Wide QRS

Question 47

DDx long QT?

Answer 47

Question 48

DDx wide QRS?

Answer 48

Question 49

DDx Right Axis Deviation? What degrees is RAD?

Answer 49

90-180

Question 50

EKS and ACS chart indicating when to go to CATH lab

Answer 50

Question 51

What are the only 2 things that cause a prolonged QT because of a prolonged ST segment?

Answer 51

Hypocalcium Hypothermia

Question 52

What must you check before you call an EKG a STEMI? when does this commonly occur?

Answer 52

Check the QRS length, it may just be part of QRS and not STEMI RBBB patterns

Question 53

Narrow complex regular tachycardia, what are the possibilities?

Answer 53

Sinus tachy SVT Atrial flutter 2:1 (rate of 150 +/- 20)

Question 54

What is the Bix Rule?

Answer 54

T wave that is poky/sharp (P wave buried in T wave) exactly bw 2 QRS complexes means you probably have atrial flutter

Question 55

What leads to look for in Benign Early Repol? What is a characteristic pattern? what makes you think it is more likely a STEMI?

Answer 55

V1 - V4 Only Fishhook Shark takeoff from J point

Question 56

What does LV aneurysm look like?

Answer 56

STE lead V1, V2 Q waves leads V1-V4 NO recipricol changes

Question 57

How do you determine if it is a junctional rhythm?

Answer 57

rate is around 40 with narrow QRS No P waves OR short PR

Question 58

How to tell if it is Mobitz I, Mobitz II, or 3rd degree heart block?

Answer 58

If PR interval is changing then it is 3rd degree

Question 59

Large T wave inversions (MC in anterolateral leads) + QT prolongation think what? what else may they have?

Answer 59

ICH STE

Question 60

Pt with atypical chest pain/ongoing chest pain with most unremarkable EKG, what lead may show T Wave changes that are concerning?

Answer 60

New upright T wave V1

Question 61

Describe VTach rate If not VTach bc of rate, what is it? due to what?

Answer 61

\> 120 AIVR Usually reperfusion

Question 62

What are the Lewis leads for? Place where?

Answer 62

Question 63

Give the DDx of RAD

Answer 63

Question 64

Pt with wide complex tachycardia with a rate below 120, what is it? Means what? Treat how?

Answer 64

Accelerated Idioventricular rhythm Reperfusion rhythm (usually after giving lytics) Observe!

Question 65

How to treat stable pt with nonsustained VTach?

Answer 65

Treat underlying cause Beta Blockers Amiodarone

Question 66

How to calculate ventricular rate if the machine is not giving it to you?

Answer 66

count up all the QRS complexes and multiply by 6 each ekg is 10 seconds (10x6 is 60 seconds so 1 minute)

Question 67

What leads mimic STEMI in massive PE?

Answer 67

V1, V2 then aVR then finally lead III

Question 68

Treatment of sustained VTach that is stable?

Answer 68

Class I recomendation: Shock Cardioversion 250 or 360J Class IIa - Procainamide Class IIb - Amio

Question 69

Difference bw "generic" Polymorphic VTach vs Torsades?

Answer 69

Generic has Normal QT

Question 70

where to look for STD in inferior MI?

Answer 70

aVL

Question 71

Inverted U wave in lateral leads (V4-V6) indicates what?

Answer 71

LAD occlusion - ischemic heart disease 93% specific

Question 72

What is required to Dx BER? If it does not, called what?

Answer 72

S wave or J wave in BOTH leads V2 and V3 Terminal QRS distortion - means STEMI