Posted by: medicblog999 | September 13, 2009

ECG Geek 5 – Is this too Easy?

heart-angiogram-sd3453-gaIve been looking through my rather extensive collection of ECG traces that I have collected over the last couple of years (some may find that a bit sad but hey, what can I say)and I am picking some out to share with you over the coming months. However, I am trying to find the right difficulty to work on. I know that we are all at different levels of knowledge on interpretation but I want to post ones which most of you will find interesting rather than just think, ‘well thats obvious, its…….’

So here is a quick one for you. Have a go at the interpretation and let me have your thoughts, but more importantly, if you find it easy please tell me in the comments.

The history for this one is a 47 year old man who is short of breath on exertion. No previous cardiac problems, no angina, no MI etc, although he did have a bout of ‘indegsestion’ 3 days ago which lasted “alot longer than it usually does”

He is a good colour, all observations are within normal limits, other than being tachycardic (at times upto 170 bpm). He has no chest pain at the moment, and is just mildly dyspnoeic (short of breath).

What do you think?

(If someone has commented already with the correct answer, then please still let me know if you found it easy or not)

ECG Geek 5 Crop

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Responses

  1. Looks a bit like an incomplete LBBB?

  2. I’m going to let others have a crack at it before I offer my opinion, but I think this an interesting ECG. By no means too easy! A lot going on here. Just out of curiosity, do you keep any of the computerized interpretations?

    Tom

  3. Mark,

    Is there a site that caters for real newbies to the art of ECG interpretation?

    As a CFR I’ve never been trained in them (as there’s no need). However, I’m interested and would like to be able to do more than grunt when a paramedic or tech shows me a strip. It’s rare that they have both the time and inclination to give me any instruction.

  4. Well now, what do we have here? It interesting, but I’m glad it’s not MY EKG.

    It’s fast, it’s irregularly irregular, other than maybe in V1 I don’t see P waves. I’m going to say it’s Atrial Fibrillation. I think the ventricular block is from his three day old infarct.

    The bottom line here is that he’s still symptomatic. I’d not spend too much time pondering the EKG, because he needs to be in an ED pretty fast. At least I think so.

  5. I agree with the first comment. Without the benefit of other clinical correlation, it looks like a LBBB. Question is…is it a new LBBB or a pre-existing LBBB. If it is a new LBBB, one must be a little bit suspicious of an undiagnosed infarct. Now I was always instructed that further analysis is not possible with a LBBB, but a recent post has convinced me otherwise…refer prehospital 12 lead blog. To be honest I have not got my head around it yet…hence the jury is out for me. Bottom line though…if “he looks crook, he is crook until proven otherwise” Good post. Thanks Scotty

  6. First glance – LBBB. With some ectopic beats.
    First time LBBB can present with some s/s of cardiac issues.
    With our system in our service if there is any question of LBBB we go straight to the ER and not bypass to the cath lab. There are other diagnostic markers but if it isnt’ STEMI positive, we just go straight ER and treat the patient s/s
    there are some ectopic beats and the a-fib idea i can’t tell because the 12 lead is too little to get the full picture.
    Thanks for the challenge. I look forward to any further discussion!

  7. Interesting….

    – Seems irregularly irregular so an underlying AFib. seems feasible.
    – Seems to be a LBBB (lead I and the ST elevation in V1-V3 point to this)
    – Leads II, III and AvF look iffy for ST elevation.

    Definitely a candidate for a Cardiac Tertiary center, keep him out of a community ED!

  8. Knowing very little about ECGs other than what they are (I don’t technically *need* to know as my medical knowledge only goes as far as advanced first aid really) I have no idea beyond:

    – it’s definitely not regular
    – it definitely looks wrong
    – therefore he should be in hospital
    – given history, his “indigestion” was probably an MI of some description.

  9. EmilyT deserves a prize. Without being a medic she recognized the essential significance of the EKG.

  10. Based on the appearance of the isoelectric line in the inferior leads (lead III in particular), I suspect the underlying rhythm is atrial flutter, although atrial fibrillation is also a possibility.

    The QRS is wide, with LBBB morphology in leads V1 and lead I. That’s usually enough for me to call something a LBBB. However, a unique feature of this ECG is the negative concordance in the precordial leads, a finding usually suggestive of a ventricular origin, including some paced rhythms.

    To me, once a baseline abnormality like LBBB (or IVCD with LBBB-like morphology) is identified, the next step is to check for appropriate T-wave discordance, and this ECG is an excellent example for several reasons.

    In the first place, the T-waves are deflected opposite the main deflection of the QRS complex in every lead, which is normal for LBBB.

    Second, if you check the ECG for the QRS complexes with the smallest amplitude, you find them in lead aVR. Not coincidentally, the ST/T abnormality is also very small in this lead.

    The next smallest QRS is lead II, and in this lead the ST/T abnormality is slightly more pronounced.

    Moving along you see the same pattern in leads V6, V5, aVF and V1, I and V4, and so on. So the extent of the discordant ST segment elevation or depression and the size of the T waves are proportional to the height of the R-wave or the depth of the S-wave, which is normal for LBBB.

    Could this patient be having an AMI? Certainly. But I don’t think it’s a STEMI. Having said that, I could be convinced by changes on serially obtained ECGs.

    Interesting case! Thanks for sharing.

    Tom

  11. Absolutely agree, TOTWTYTR!

    Tom

  12. That's odd! What happened to the comments? I have a case I'm getting ready post that's semi-related to this ECG (shows a similar morphology but is paced as opposed to atypical LBBB). Also noticed that you can't expand the ECG anymore. Just the low-res tracing. Any theories, Mark?Tom

  13. That's odd! What happened to the comments? I have a case I'm getting ready post that's semi-related to this ECG (shows a similar morphology but is paced as opposed to atypical LBBB). Also noticed that you can't expand the ECG anymore. Just the low-res tracing. Any theories, Mark?Tom

  14. That's odd! What happened to the comments? I have a case I'm getting ready post that's semi-related to this ECG (shows a similar morphology but is paced as opposed to atypical LBBB). Also noticed that you can't expand the ECG anymore. Just the low-res tracing. Any theories, Mark?Tom

  15. That's odd! What happened to the comments? I have a case I'm getting ready post that's semi-related to this ECG (shows a similar morphology but is paced as opposed to atypical LBBB). Also noticed that you can't expand the ECG anymore. Just the low-res tracing. Any theories, Mark?Tom


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