# 12 Lead EKG interpretations: let's do it!!!



## Dutch-EMT

A Dutch forum does this since a while, and it's actualy fun to do, but above all: It's always interesting to do and you can learn from eachother!!

I'll start with the post of an EKG. Everybody can interpretate on it here.
Who joins? 

Okay here it is. The first:










Well, what do we got here?


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## abuan

i'm still learning ecg interpretation, but it looks like

normal axis sinus rhythm with a possible 1st degree av block and possible left bundle branch block with no st changes or ectopy at 90?


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## emt_irl

ive seen that rythm before in lead II i posted up about it also. from reading its like a bundle branch block of some degree or previous m.i
coming from a basic point of view

btw keep this thread up its a great idea


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## rhan101277

emt_irl said:


> ive seen that rythm before in lead II i posted up about it also. from reading its like a bundle branch block of some degree or previous m.i
> coming from a basic point of view
> 
> btw keep this thread up its a great idea



I don't see any previous MI myself.  I see pathological left axis deviation, I don't really see a BBB, but a hemiblock is present.  Also there may be some electrolyte abnormalties. 

Lets remember that everyone can interpret these different.


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## BLSBoy

I see NSR with 1st Deg AV Blk.


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## DV_EMT

To me, there's no sign of an MI. There's no ST elevation or depression noted in any of the leads. Looks like a Sinus Rhythm w/ 1st degree av block. The QRS is to short for it to be a Bundle Branch Block. I eyeballed it, looked like 0.10 seconds


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## TomB

rhan101277 said:


> Lets remember that everyone can interpret these different.



That's true, but that doesn't mean they are all correct.

However, you are correct. This 12-lead ECG shows sinus rhythm with left anterior fascicular block.

Tom


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## Dutch-EMT

10 points for TomB!

Conclusion:
P tops followed by a QRS complex, so it's a sinusrythm.
PQ-time, well what can we say about it?
Frequenty about 85bpm
Axis: I = mainly positive, aVF = positive, so it's a left axis deviation.

QRS: it seems wide, but is it BBB? No, let's look to the QRS in V1-V6.
The R-top progression seems slow in V1-V6. The S is deeper than normal in V6.
A lower intraventricular conduction (is it correct english?),the R wich doesn't show up very well, in combination with a left axis deviation and a deep S in V6...

Answer: Left anterior hemiblock or left anterior fascicular block!

Okay, next one!!!






For a bigger screen, click HERE


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## MrBrown

Tooo easy mate! NSR (1500 method says 60bpm so technically is sinus brady) with anterior MI; I picked one of those up the other week.

How come Lead II in the first strip is negative instead of positive?


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## boingo

Don't believe this is a STEMI. Looks like NSR w/left posterior hemiblock.


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## Dutch-EMT

Okay, just a little information extra at this ECG:
male, 28 years, no history, no med's.


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## TomB

And no chief complaint?

At first glance it's acute anterior STEMI vs. benign early repolariation.

I would capture another ECG in 5 minutes and compare (assuming signs and symptoms of ACS).


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## TomB

The wandering baseline in leads I and aVL is unfortunate. It goes to show that even a minor problem with data quality can confound a nuanced interpretation. Looks like 1 mm ST-elevation may be present but I'd want a clean tracing.

The mean R-wave amplitude in leads V1-V4 is right at 5 mm, so Dr. Smith's decision rule is not decisive.

http://hqmeded-ecg.blogspot.com/2009/06/acute-anterior-stemi-from-lad-occlusion.html

Tom


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## Dutch-EMT

1mm ST-elevation mostly isn't significant... mostly...
I personally never make a MI out of this when it's the only sign i've got...


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## Dutch-EMT

At this EKG the R is very small in V1 and V2, and a deep S. But that's normal.
I have a standard procedure to look at EKG's, in hope to catch all information out of it.

1. Frequency
2. Rhytm: is it regullar or irregular
3. P's: yes/no, are they looking the same? P's followed correctly by a QRS?
4. PQ time (<0,2sec), QRS time, BBB? 
5. Heartaxis: Look at I and aVF
6. Hypertrophy? P in V1 (atrial hypertrophy) and S in V1 and R in V5 >3,5mV (LVH). R in V1 and S in V5 >1,05mV (RVH)
7. MI?  Q's, ST and T


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## Scubamedic

*Frequency*

1. Frequency
2. Rhytm: is it regullar or irregular
3. P's: yes/no, are they looking the same? P's followed correctly by a QRS?
4. PQ time (<0,2sec), QRS time, BBB? 
5. Heartaxis: Look at I and aVF
6. Hypertrophy? P in V1 (atrial hypertrophy) and S in V1 and R in V5 >3,5mV (LVH). R in V1 and S in V5 >1,05mV (RVH)
7. MI? Q's, ST and T 


I am a medic in the U.S and I understand your list except for the 1st word... frequency. 2-7 are simular to what I learned, but what do you mean by  Frequency?

Here is a great site for anyone that wants to work on their 12 lead's, I study here among other websites. 
http://library.med.utah.edu/kw/ecg/index.html


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## 8jimi8

i think he means heart rate


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## Scubamedic

*Lol.*

Thanks, that was my only guess. I got one to post I found. I had to get out my little als book and measure it, and I still got it wrong.


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## Dutch-EMT

The EKG I posted was a totally normal EKG.
It's made on myself by the cardiologist during a cardiologyclass.


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## Dutch-EMT

8jimi8 said:


> i think he means heart rate



Correct...
I guess i translated it a little wrong


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## TomB

It is not a totally normal ECG. It shows a repolarization abnormality, a downsloping ST-segment in lead III, and a flat ST-segment in lead aVF. If it was the ECG of a chest pain patient it would be suspicious, but inconclusive.

Tom


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## Dutch-EMT

Scubamedic said:


> Thanks, that was my only guess. I got one to post I found. I had to get out my little als book and measure it, and I still got it wrong.



1. Heartrate: about 75 bpm
2. Rhytm: regullar
3. P's are looking the same. negative in V1. P's followed by a QRS.
4. PQ time is normal, QRS time doubts me. Looks a little wide, BBB?... The R's don't show up very well...
5. Heartaxis: I = positive and aVF negative : left axis deviation.
6. Hypertrophy, no LVH, RVH or Atrial hypertrophy.
7. Q's and ST's normal. T's normal, flat T in V1.

So based on the information: low R in the precordial leads , left axis deviation... the wide looking QRS tells me there is a intraventricular conduction problem...
Left axis tells me it is possible anterior (also the S in III).
But with no signs of Q's, ST's and T's it isn't MI.
So, it is possible that it is Left anterior fascicular block.


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## DV_EMT

On the second one, looks like it could be an electrolyte imbalance causing a spiked T wave.


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## SeeNoMore

This is a great thread though as a new medic student I can not believe I will someday be able to interpret these. Who knows, with the fail rates in paramedic school maybe I wont:excl:


Thanks for posting it though


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## Dutch-EMT

*A new one...*

Okay, ECG number 3: A young male, 26years...
Any problems on this one?


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## Shishkabob

NSR with ST-elevation in V2-V4 leading to a possible septal infarct.

Can't quit tell so zoomed out, but there might be a mm of elevation in V1, which would then make it a possible anterio-septal infarct.


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## 8jimi8

Linuss said:


> NSR with ST-elevation in V2-V4 leading to a possible septal infarct.
> 
> Can't quit tell so zoomed out, but there might be a mm of elevation in V1, which would then make it a possible anterio-septal infarct.



I thought ST elevaton less than 1 mm was insignificant?


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## Shishkabob

Which is why I said there might be 1mm elevation but I wasnt too sure


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## 8jimi8

i meant to say less than 2 mm, but you seemed to imply that if it was there, it would increase the size of the infarct...

or am i reading your post incorrectly?

I was just looking for rationale as to why you felt that 1mm ste was significant...

(not that it absolutely cannot be... just curious as to what you are thinking)


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## Shishkabob

I was always taught 1mm / .5mm for elevation and depression respectively, was where a possible ischemic event was taking place.



EDIT: Hmph, reading in a couple of places say precordial leads need 2mm elevation... wheres my Dubin book when I need it?


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## 8jimi8

yah...

>2mm ste in the precordials is what I learned.  That is why I was curious, being that you just finished school, i didn't know if you were working with new infos.


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## Shishkabob

Could also be because I finished school I have a crap load of info and very little experience, so it all gets jumbled ^_^



Could have just been the limb leads I was thinking of... gah, now I have to find my cardiology notes.  Thanks, James, for ruining my lazy day!


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## Dutch-EMT

Linuss said:


> EDIT: Hmph, reading in a couple of places say precordial leads need 2mm elevation... wheres my Dubin book when I need it?



When the ST elevation / depression is the *only* sign pointing to a possible MI, that means no Q's, no typical complains (chestpain) or other signs/symptoms, then the elevation or depression must be 2mm or more...
0,5 or 1mm elevation/depression are mostly insignificant.
The patiënt monitors I use alarm for ST at 2mm elevation or depression...


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## Shishkabob

I found this interesting- 

http://www.slideshare.net/cksheng74/st-segment-elevations-in-ecg2

Look at slide page 9.









As per the 2007 AHA/ACC MI guidelines at http://content.onlinejacc.org/cgi/content/full/50/7/e1



> . The diagnosis of MI is confirmed with serial cardiac biomarkers in more than 90% of patients who present with ST-segment elevation of greater than or equal to 1 mm (0.1 mV) in at least 2 contiguous leads, and such patients should be considered candidates for acute reperfusion therapy.


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## 8jimi8

Linuss said:


> I found this interesting-
> 
> http://www.slideshare.net/cksheng74/st-segment-elevations-in-ecg2
> 
> Look at slide page 9.
> 
> 
> 
> 
> 
> 
> 
> 
> 
> As per the 2007 AHA/ACC MI guidelines at http://content.onlinejacc.org/cgi/content/full/50/7/e1




Good Info!  I am a fan of POC Biomarkers.

anecdotally... where I work, no MD would change any orders for a 1mm elevation other than ordering serial CEs every 6 hours.  

Unless the patient is symptomatic.


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## Dutch-EMT

Well, good information!!! Sheet 4 tells also something interesting:
"Of 123 adult chestpain patiënts with ST segment elevation equal or >1mm, 51% did not have myocardial infarctions. 21% LBBB and 33% LVH"...
Sheet 5 tells more reasons for ST elevation, for example Benign early repolarization. So that means it can be a harmless sign.

But, hey... let's go ontopic again with ECG nr 3 I posted. 
I agree that the ST in V2 and V3 is elevated. but anything more interesting to see?

for the sake of convenience: here it is (again)


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## MrBrown

Our guideline is >= 2mm

I'll try one ... this was a 19yof cc c/p ~ 7/24 maybe 2 or 3/10 other than that asymptomatic

I don't have the 12 lead ECG with me still so I found a comparable one online


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## Shishkabob

@Dutch-EMT

Seems sinus brady, or very close to it, not normal sinus like I said before.  I didn't count the boxes >_>


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## Dutch-EMT

Linuss said:


> @Dutch-EMT
> 
> Seems sinus brady, or very close to it, not normal sinus like I said before.  I didn't count the boxes >_>




It is a sinusrythm, about 60 bpm. 
The ST's in V2 and V3 in this case were'not significant for diagnose of any MI.
Heartaxis is normal and there is no significant Q in the ECG.

Again a normal ECG belonging to this specific (sportive, young) person.


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## Dutch-EMT

MrBrown said:


> Our guideline is >= 2mm
> 
> I'll try one ... this was a 19yof cc c/p ~ 7/24 maybe 2 or 3/10 other than that asymptomatic
> 
> I don't have the 12 lead ECG with me still so I found a comparable one online



Missing V4-V6... can you post thos missing leads?

1 Heartrate: 90bpm
2 Rythm: P followed by QRS, so sinusrythm
3 P looks very large in all leads... Different shapes in the various leads...
4 PQ is not larger than 0,2 sec so normal. QRS <0,12 sec. 
5 Axis: I more negative, aVF more positive... right axis deviation
6 Hypertrophy: P in V1 looks like right-atrialhypertrophy.
   Need V4 - V6 to review if this ECG shows ventricular hypertrophy.
7 Q in III, aVF, V1 V2 and V3. Q in II doubts me... 1mm wide or 1/3 of the QRS? ST depression in II (1,5 or 2mm), 1mm depression in aVF. Flat T in V1.

But i realy need the missing V4 - V6


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## MrBrown

Whoops I didn't even notice the missing leads!


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## Dutch-EMT

1 Heartrate: 90bpm
2 Rythm: P followed by QRS, so sinusrythm
3 P looks very large in all leads... Different shapes in the various leads...
4 PQ is not larger than 0,2 sec so normal. QRS <0,12 sec. 
5 Axis: I more negative, aVF more positive... right axis deviation
6 Hypertrophy: P in V1 looks like right-atrialhypertrophy. no ventricular hypertrophy.
7 Q in III, aVF, V1 V2, V3, V4 and V5. Q in II doubts me... 1mm wide or 1/3 of the QRS? ST depression in II (1,5 or 2mm), 1mm depression in aVF. Also light depression in V4 and V5. Flat T in V1.


Well... No ST elevation, but there is ischemia. also right axis deviation. Mi stage III anterior and posterior??? Difficult one...


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## Scubamedic

dutch-emt said:


> 1. Heartrate: About 75 bpm
> 2. Rhytm: Regullar
> 3. P's are looking the same. Negative in v1. P's followed by a qrs.
> 4. Pq time is normal, qrs time doubts me. Looks a little wide, bbb?... The r's don't show up very well...
> 5. Heartaxis: I = positive and avf negative : Left axis deviation.
> 6. Hypertrophy, no lvh, rvh or atrial hypertrophy.
> 7. Q's and st's normal. T's normal, flat t in v1.
> 
> So based on the information: Low r in the precordial leads , left axis deviation... The wide looking qrs tells me there is a intraventricular conduction problem...
> Left axis tells me it is possible anterior (also the s in iii).
> But with no signs of q's, st's and t's it isn't mi.
> So, it is possible that it is left anterior fascicular block.


____________________________________________________________



winner winner!!!!


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## MrBrown

My understanding is that it was right atrial enlargement.


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## Dutch-EMT

MrBrown said:


> My understanding is that it was right atrial enlargement.



Forgotten to write that in my conclusion...
Was that the only problem? What about the Q's?


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## Dutch-EMT

Because it's getting quiet here, should i post a new EKG?
Yeah! why not....
Here is a new one!!

Is there a problem, and what is the problem?


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## 8jimi8

MrBrown said:


> My understanding is that it was right atrial enlargement.



Right Atrial enlargement, that is all I saw, but I thought i was wrong until you said it.


P waves >= 3mv


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## MrBrown

Dutch-EMT said:


> Because it's getting quiet here, should i post a new EKG?
> Yeah! why not....
> Here is a new one!!
> 
> Is there a problem, and what is the problem?



Rate: 71 (1500 method)
Regularity: Regular
Rhythm:  Sinus rhythm
P:  Sinus P waves only
QRS: RS complex, ? Q waves in lead I only, ? something is seriously wrong with aVF looks like a block of some sort 
ST: The ST segments in the chest leads dont look normal 
PR Interval:  0.16 sec
QTc: Couldn't figure it out

There is something weird going on here.

This wasn't captured in Los Angeles was it?


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## TomB

Dutch-EMT said:


> Okay, ECG number 3: A young male, 26years...
> Any problems on this one?



This is a strange coincidence! 

I actually captured this 12-lead ECG. This is a great example of why it's important to interpret an ECG in light of the history and clinical presentation.

Normally the straight ST-segments in leads V2 and V3 with the slight terminal T-wave inversion in lead V2 would give me cause for concern.

But, since this was a totally asymptomatic firefighter lying on the kitchen counter in the fire station, I wasn't too concerned about it! 

Tom


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## MrBrown

Which one is TomB?


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## TomB

I wish I was Roy, but I have to admit being Johnny! LOL!


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## MrBrown

Johnny is better looking, and now, back to our regularly scheduled discussion


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## TomB

MrBrown said:


> Our guideline is >= 2mm
> 
> I'll try one ... this was a 19yof cc c/p ~ 7/24 maybe 2 or 3/10 other than that asymptomatic
> 
> I don't have the 12 lead ECG with me still so I found a comparable one online



Right atrial enlargement, right axis deviation, low voltage, terminal R-waves in leads V1 and V2, and Q-waves in the right precordial leads. I would say pulmonary disease pattern (at a minimum).

Tom


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## TomB

Dutch-EMT said:


> Because it's getting quiet here, should i post a new EKG?
> Yeah! why not....
> Here is a new one!!
> 
> Is there a problem, and what is the problem?



It's always a mistake to interpret an ECG like this without the history and clinical presentation, but assuming (for the sake of discussion) that this is a chest pain patient with a suggestive history, I always get nervous when I see ST-depression and/or T-wave inversion in leads III and aVF, particularly if there appears to be reciprocal activity between III and aVL.

Tom


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## FLEMTP

Dutch-EMT said:


> Well, good information!!! Sheet 4 tells also something interesting:
> "Of 123 adult chestpain patiënts with ST segment elevation equal or >1mm, 51% did not have myocardial infarctions. 21% LBBB and 33% LVH"...
> Sheet 5 tells more reasons for ST elevation, for example Benign early repolarization. So that means it can be a harmless sign.
> 
> But, hey... let's go ontopic again with ECG nr 3 I posted.
> I agree that the ST in V2 and V3 is elevated. but anything more interesting to see?
> 
> for the sake of convenience: here it is (again)





Did anyone else notice the indicators of ventricular hypertrophy on this 12 lead? does this particular patient have a history of hypertension? or is it possibly that he has undiagnosed hypertension?


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## TomB

FLEMTP said:


> Did anyone else notice the indicators of ventricular hypertrophy on this 12 lead? does this particular patient have a history of hypertension? or is it possibly that he has undiagnosed hypertension?



It wasn't even a patient. It was a firefighter in perfect health. What criteria are you using? 

Tom


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## Dutch-EMT

Hypertrophy??? I don't see it.
Hypertrophy is a pathology of the heart.
A sportive young person with a bigger heartmuscle doesn't have a pathology of the heart? 
When hypertrophy is suspected, a heartecho must be made to confirm a hypertrophy.


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## zmedic

Assuming it was a symptomatic patient, when the QRSs of the precordial leads touch that is a quick and dirty look for LVH. Or you can do that whole count boxes max V1 or V2 plus max V5 or V6 with a sum> I think 35.

Also that last one, the possible inferior wall, seems to have some slurring of the QRS, almost looks like a delta wave. Might have an abnormal pathway, concern for WPW if it were going faster.


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## boingo

TomB said:


> It's always a mistake to interpret an ECG like this without the history and clinical presentation, but assuming (for the sake of discussion) that this is a chest pain patient with a suggestive history, I always get nervous when I see ST-depression and/or T-wave inversion in leads III and aVF, particularly if there appears to be reciprocal activity between III and aVL.
> 
> Tom



Anyone else appreciate a delta wave?  Looks a bit WPW to me.


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## 8jimi8

now that you mention it... that hadn't even occurred to me


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## TomB

I don't think so. The PR-interval is borderline at 120 ms. The axis is normal at about 10 degrees. Normal septal Q-waves are present. Normal R-wave progression and transition. This all leans against pre-excitation.

Tom


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## FLEMTP

zmedic said:


> Assuming it was a symptomatic patient, when the QRSs of the precordial leads touch that is a quick and dirty look for LVH. Or you can do that whole count boxes max V1 or V2 plus max V5 or V6 with a sum> I think 35.



yeah that! I didnt get a chance to answer back quick enough.. its been a busy shift at work!


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## Dutch-EMT

Dutch-EMT said:


>



Should we go on with this one?
Anyone?


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## rhan101277

Dutch-EMT said:


> Should we go on with this one?
> Anyone?



Physiologic left axis.  

Looks like a normal ECG to me.


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## Dutch-EMT

1 Heartrate: ?
2 Rythm: ?
3 P ?
4 PQ ?. QRS ? 
5 Axis: I:? aVF:?
6 Hypertrophy: P in V1?. ventricular hypertrophy?
7 Q? ST? T?

conclusion based on this EKG?


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## rhan101277

Dutch-EMT said:


> 1 Heartrate: ?
> 2 Rythm: ?
> 3 P ?
> 4 PQ ?. QRS ?
> 5 Axis: I:? aVF:?
> 6 Hypertrophy: P in V1?. ventricular hypertrophy?
> 7 Q? ST? T?
> 
> conclusion based on this EKG?



2) Sinus Rhythm 90HR
3) P waves normal, upright etc.
4)PR interval and QRS normal
5) Physiologic left axis, no hypertrophy

There is some possible electrolyte abnormalties, but then again some people have inverted T waves normally in certain leads.  Maybe some minor damage in aVF but it is not full thickness.


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## Dutch-EMT

1 Heartrate: about 75 bpm
2 Rythm: P waves followed by QRS. regular rhytm... sinus rhytm.
3 P: Some P's look different in the 10sec. print. 
4 PQ is short. Delta-waves very good to see in II, V3-V6 
   QRS is <120msec. They look wider as usual. a very small spike after R in III, aVL, aVF.   Also the R doesn't show up very well in V4-V5...
5 Axis: I: very positive, aVF: negative. left axis deviation.
6 Hypertrophy: no signs of it.
7 No pathological Q's. ST's not significant elevated or depressed. T negative in III and V1, flat in aVF.

I would say WPW with pre-excitation.


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## FL_Medic

I concur with WPW


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## nmemtp01

This patient is a 36YO female who present at a rural clinic complaining of palpitations and dizziness.


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## clibb

nmemtp01 said:


> This patient is a 36YO female who present at a rural clinic complaining of palpitations and dizziness.



Any nicotine or caffeine intake prior to this? Lead one looks like SVT.
Lead two and looks like a V-Tach with a possible bundle branch block. 
I'm just a EKG-Basic. So I only know 4-leads


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## clibb

Dutch-EMT said:


> Because it's getting quiet here, should i post a new EKG?
> Yeah! why not....
> Here is a new one!!
> 
> Is there a problem, and what is the problem?



Is there some A-fib going on?


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## nmemtp01

The patient states that she has had these episodes for the last couple years, but her symptoms usually dissipate before she gets to an ER.  Therefore,  she doesn't have any diagnosed condition.  Usually the onset starts with exercise, however, today it was while cleaning her house.  The patient denies any other medical problems and allergies.  Vitals are as follows:

BP: 110/80
HR: 240
Resp:16
SPO2 98%
LS: clear to ausc.
Skin: P,W,D
BLG: 88


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## Dutch-EMT

1 Heartrate: +/- 250bpm
2 Rythm: Chaos! it is regular...
3 P top: In V1 it seems to me that there is an AV-block.
  There isn't any connection between the P and the complex following.
   It seems like the P top comes together with the QRS in the last complex of V1
4 PQ/QRS QRS seems wide... In V2 R-R1? Loss of R wave and Q wave formation.
5 Axis: I: + aVF: - That means leftaxis deviation
6 Hypertrophy: P in V1. ventricular hypertrophy
7 Q in II, III, AVF, V3, V4, V5 and V6 
   Negative T in aVL, V1 and V2

The Q's in II, III and aVF are pointing to an inferior MI
The Q's in V3-V6 are pointing to an Anterior Lateral MI
High T also in II, III, avF.
Q waveformation and loss off R tells me the infarct must be at least a couple of hours old.

I believe this is an Inferior MI and Anterior Lateral MI.
Possibly this patiënt has an infarct in the left main coronair artery.
This is blocking the ramus circumflexus and the left anterior descending artery. In 20% the ramus circumflexus provides the inferior heartmuscle with blood.  That's my guess...


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## TomB

FL_Medic said:


> I concur with WPW



If it was, the septal Q-waves in the high-lateral leads would be obliterated and the T-waves would be deflected opposite the delta waves.


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## TomB

nmemtp01 said:


> This patient is a 36YO female who present at a rural clinic complaining of palpitations and dizziness.



Slightly irregular and polymorphic wide complex tachycardia with a very fast rate. Shortest R-R interval is < 6 small blocks which indicates a high probability of an accessory pathway.

Differential diagnosis:

1.) WPW (either atrial fibrillation or 1:1 atrial flutter) 
2.) Ventricular tachycardia

Treatment:

Keep the drugs in the drug box! Unless, of course, you carry procainamide. The best course of action in the prehospital setting is supportive care and synchronized cardioversion if the patient becomes hemodynamically unstable.

Cool case!


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## Dutch-EMT

nmemtp01: What was the diagnosis?


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## nmemtp01

Although I do agree with Tom that monitoring and transport would be the idea treatment, that wasn't what was done.   The patient was given 6 mg of Adenosine and converted into a NSR.  As far as the diagnoses, I'm not 100% sure.  I'm guessing a WPW, LGL, or some other aberrancy pathway.  I'll try and get the official word from the cardiologist some time soon.


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## TomB

nmemtp01 said:


> Although I do agree with Tom that monitoring and transport would be the idea treatment, that wasn't what was done.   The patient was given 6 mg of Adenosine and converted into a NSR.  As far as the diagnoses, I'm not 100% sure.  I'm guessing a WPW, LGL, or some other aberrancy pathway.  I'll try and get the official word from the cardiologist some time soon.



Since the adenosine worked there's a good chance it was AV reentrant tachycardia (AVRT) which is a circus loop tachycardia with antegrade conduction down the accessory pathway and retrograde conduction up the AV node. It's probably not the treating paramedic's fault. Accessory pathway-mediated heart rhythms aren't generally covered in paramedic school. I'm glad it worked out! I commend the treating paramedic for capturing a 12-lead ECG prior to treating with an antiarrhythmic.

**Addendum**

Just looked at the post-conversion 12-lead ECG. Again, well done by the treating paramedic. The absence of a WPW pattern is interesting. If it's a concealed conduction pathway, it would suggest an orthodromic AVRT with aberrancy as opposed to an antidromic AVRT. But why knows? Patients like this probably end up in the EP lab. If you find out anything definitive, let us know! 

Really cool case! Thanks for sharing.


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## clibb

nmemtp01 said:


> Although I do agree with Tom that monitoring and transport would be the idea treatment, that wasn't what was done.   The patient was given 6 mg of Adenosine and converted into a NSR.  As far as the diagnoses, I'm not 100% sure.  I'm guessing a WPW, LGL, or some other aberrancy pathway.  I'll try and get the official word from the cardiologist some time soon.



Lead II, some 1st degree heart  block there?


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## nmemtp01

clibb,  I would agree that it looks like a first degree block, or possibly even a wenckebach(hard to tell without seeing a couple more seconds) after the patient converted.


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## clibb

nmemtp01 said:


> clibb,  I would agree that it looks like a first degree block, or possibly even a wenckebach(hard to tell without seeing a couple more seconds) after the patient converted.



If you look at lead II. 
It goes from V-Tach to Cuplet PVCs. Then the T waves aren't consistent at all. ST segment looks normal or I would think MI.
If you go to the fourth T-P waves after the V-tach on Lead II the T and P waves and how it the line declines is something I'd be worried about. 

And then it looks like it leads into the heart blocks.

On lead I and lead III, I would totally agree with the Wenckebach.


These are fun. I have like 100 strips from my EKG class if you guys want me to post them.


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## Dutch-EMT

Well post it, so we can shoot on it an learn from eachother! That's why I started this topic!


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## clibb

Here you go. Three different strips. Might be a little too basic, but still fun. 
Let me know if you need a more "zoomed in" picture.


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## FL_Medic

On Paramedicine 101, THIS CASE is presented in full.  

C/C Syncope.  No chest pain.


ECG 1








ECG 2


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## Dutch-EMT

I see a BBB  (clear in V4 and V5), so that makes it not possible to diagnose on MI based on ST. 
There are ST elevations in the precordial leads, but with a BBB not reliable for diagnose based on this ECG.


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## FL_Medic

Dutch-EMT said:


> I see a BBB  (clear in V4 and V5), so that makes it not possible to diagnose on MI based on ST.
> There are ST elevations in the precordial leads, but with a BBB not reliable for diagnose based on this ECG.



That is entirely incorrect, but I am not surprised to see a response like this.  Well, not entirely, they both present with BBB patterns, and there is ST-Elevation.  The assumption that you can not evaluate ECGs with BBBs for STEMI is incorrect.  

LBBB presents with negative QRS and T-wave discordance which can mimic a STEMI.  There are still ways to interpret LBBB ECGs for STEMI, search Sgarbossa's criteria.  I use a simple rule though.  If the STE is > 20% of the depth of the preceding S-wave, AMI is likely.  Also, convex STE is usually an ominous finding, even with LBBB.

RBBB presents with positively deflected QRS complexes and T-wave discordance which does not cause elevation of the J-point/ST-segment.  The problem some have with RBBB is that they are not evaluating the true width of the QRS complex due to funky looking morphology.  This is interpreter error however, and does not mean you can't interpret a RBBB ECG for STEMI.


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## Dutch-EMT

I agree with diagnose MI when there is RBBB. 
But when there is LBBB and you suspect a MI, will you start treatment with meds? An echo and/or lab (CK and troponine) will confirm MI.


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## FL_Medic

Dutch-EMT said:


> I agree with diagnose MI when there is RBBB.
> But when there is LBBB and you suspect a MI, will you start treatment with meds? An echo and/or lab (CK and troponine) will confirm MI.



Well think about the treatments we do for MI.  Transport to a PCI capable facility, ASA, & NTG.  A little morphine too.  Who will this hurt?  Some, but not most.  

So my answer is yes.

Concluding that you have changes indicative of a LBBB with STEMI should be no different when considering treatments, from any other STEMI.  

From our friend Tom B. <<-- go read,  you won't regret it.

Also, check out this link to better diagnose BBB/IVCD.  I believe looking at V4 & V5 for bunny ears is not beneficial.


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## Dutch-EMT

FL_Medic said:


> Well think about the treatments we do for MI.  Transport to a PCI capable facility, ASA, & NTG.  A little morphine too.  Who will this hurt?  Some, but not most.
> 
> So my answer is yes.
> 
> Concluding that you have changes indicative of a LBBB with STEMI should be no different when considering treatments, from any other STEMI.
> 
> From our friend Tom B. <<-- go read,  you won't regret it.
> 
> Also, check out this link to better diagnose BBB/IVCD.  I believe looking at V4 & V5 for bunny ears is not beneficial.



Interesting link!!!


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## Dutch-EMT

*Time for a new ECG?*

I copied this one yesterday.

The story behind this ECG:
A lady, 90 yrs old.
30-5-2010 she felt down and ended with a pertrochanter femurfracture.
She had surgery the same evening.

The 1st of june early morning her heartrate was goïng faster.
NIBP between 95/55 and 125/60, fluctuating the whole morning.
An ECG was made. Temp: 37,0. Also lab (hb/ht/KNUK/ery's/leuco's/CRP) was token.






For the large version click *HERE*


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## clibb

Dutch EMT,

When was her previous MI? Or is that the aftermath of the heart surgery I'm seeing with the declined ST segment? 
Obvious 1st degree heart block. I'd say her heart rate is between 180-220 so I'd say her rhythm is SVT.


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## truetiger

What's the general impression of this pt? Any CP's? SOB?


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## Dutch-EMT

Patiënts History:
-Only a bad spine caused by age and operated by a plastic surgeon (triggerfingers)
-no history at all, no MI in the past.

Patient looks a bit tired but is alert. No cheastpain or other complains...


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## Shishkabob

Here's one for ya---- 73yo female, no history of heart disease.

First image is a 3lead, second 2 images are the 12lead.


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## reaper

First degree with LBBB. 

Is it new or old?


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## rhan101277

reaper said:


> First degree with LBBB.
> 
> Is it new or old?



I concur.


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## TomB

Sinus bradycardia with 1AVB and nonspecific intraventricular conduction defect (LBBB morphology in lead V1 but S-wave present in lead I). QRS duration is at least 160 ms, approaching 200 ms. Consider hyperkalemia. What is the chief complaint, history, physical exam, etc.?

Tom


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## Dutch-EMT

Sinusbradycardia, about 50 bpm. 1st degree AV (>200msec)
Axis: I isoelectric, aCF positive, so heartaxis is normal, but about 90degree and heading to the right...

R-R1 in II (small), III, avF and a BBB pattern in V1 and V2.

I see a wide S in I and III in the 3 lead. Also wide QRS. Low R progression.

Can it be some kind of combination of BBB, 1st dgr AVblock and fascicular block.
QRS wider and low R fits hyperkalemia, but I don't see a Higher and sharper T.


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## Shishkabob

TomB said:


> Sinus bradycardia with 1AVB and nonspecific intraventricular conduction defect (LBBB morphology in lead V1 but S-wave present in lead I). QRS duration is at least 160 ms, approaching 200 ms. Consider hyperkalemia.


  Sweet... for my first true emergent 12-lead alone in the field, I was right!  I feel happy now 



> What is the chief complaint, history, physical exam, etc.?
> 
> Tom




CC was of a 70s yo female post fall in room, going from lethargic to completely unresponsive (GCS 3) and back again.


Pt had no prior cardiac history of arrhythmias, PAD, CAD or HTN.  No hx of CVA either.  Was hospitalized for pneumonia a while before but cleared up with Rifampin.  Pt type 2 DM.  

Physcal was unremarkable on everything but the diabetic sores she had on her legs.


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## Dutch-EMT

Anyone posting a new one?


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## tah06090




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## TomB

Bad, bad, bad.

Undetermined rhythm. Tachycardia. Low voltage. Possible long QT-interval. Q-waves in II, III, aVF, and V1-V3.

Impossible to interpret without context. In other words, in light of the history and clinical presentation.

Could be anything from a massive heart attack to a pericardial effusion or cardiac tamponade (although electrical alternans is not present).

If I were a betting man I'd say this patient is sick! 

Tom


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## tah06090

Elderly male chest pain Hx of inferior infarct and anterior infarct. dont know vitals all the info i know


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## tah06090

I work in a cardiology dept at a community hospital so i come across some pretty cool EKGs so i dont always know Hx or clinical presentation i have some more pretty interesting ones ill be posting soon.


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## clibb

tah06090 said:


>



Third degree heart block?


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## Shishkabob

I don't see any P-waves, and only one wide QRS


It seems junctional more than anything... junctional tachycardia?


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## tah06090

Doc called it sinus tach with extensive old injury which is altering qrs ie low voltage 

I can post another one maybe a little easier if you guys want


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## zmedic

Linuss said:


> I don't see any P-waves, and only one wide QRS
> 
> 
> It seems junctional more than anything... junctional tachycardia?



QRS isn't wide. Look at V5 and V6, narrow complexes. Don't get confused by those 3 PVCs.

Also since you have these huge, wide T waves it's quite possible that there are Ps buried in there.


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## tah06090

Elderly Female severe shortness of breath Hx of COPD, Diabetis any other things you wanna know ask


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## truetiger

How do her lungs sound? If clear, I would say she's having an MI. EKG shows an anterior hemiblock and her diabetes could be masking any chest pain.


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## Shishkabob

zmedic said:


> QRS isn't wide. Look at V5 and V6, narrow complexes. Don't get confused by those 3 PVCs.



Was that aimed at me or the guy who said it was a 3rd degree block?


If me, then no, because junctional tachycardia tends to be narrow, not wide, so I don't see why you mentioning that they are narrow is 'proving me wrong'?


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## Simusid

tah06090 said:


> Elderly Female severe shortness of breath Hx of COPD, Diabetis any other things you wanna know ask



As a basic, I should be barred from participating in 12 lead discussions   but as long as I'm here.... Do I see ventricular pacing spikes in V2-4?   And if so, does that even matter?   I think I see left axis deviation (lead I +, aVF -)  and possible BBB but I can't tell left from right (yet).


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## Shishkabob

No, no pacer spikes.


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## Simusid

Linuss said:


> No, no pacer spikes.



Argh, of course not.  If they were then the rate would be regular and it's clearly not.  You do see the spikes I'm talking about Linuss?   What are they?


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## TomB

Irregular and slightly polymorphic wide complex tachycardia with LBBB morphology. Probably AF. But do you trust that dx enough to give a CCB? I don't! Shortest R-R interval > 6 small blocks, so not so much worried about WPW but there are recorded cases of irregular VT. With no old ECG for comparison, I would leave it alone or give a drug like amiodarone that works on both supraventricular and ventricular arrhythmias. Very cool case and an excellent example of the real-world type of 12-lead ECG that can throw even experienced paramedics for a loop! 

Tom


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## tah06090

Pt admitted for COPD exacerbation interpretation according to cardiologist is rapid afib with LBBB fast rate was because of respiratory distress and pts old ECGs showed LBBB with afib ill post another one maybe tommorow or saturday


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## TomB

Thanks for making that point, tah06090. I didn't mean to imply this specific patient should receive _any_ antiarrhythmic. You always treat the underlying cause of a tachycardia (Hs and Ts) first.

Tom


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## tah06090

I understand what you meant its a hard 12 lead to fully interprt without looking at the pt right in front of you.


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## zmedic

Linuss said:


> Was that aimed at me or the guy who said it was a 3rd degree block?
> 
> 
> If me, then no, because junctional tachycardia tends to be narrow, not wide, so I don't see why you mentioning that they are narrow is 'proving me wrong'?



Must have read it too fast, thought you were saying the QRSs were wide. That's what I was commenting on. Not saying that junctional would be wide.


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## tah06090

This one might be to easy ill heres soomething for a time filler till i find a HARD one 57yr old male sudden onset CP and dyspnea no Hx no old ECG


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## reaper

I will call the funeral home for him!


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## Smash

tah06090 said:


> This one might be to easy ill heres soomething for a time filler till i find a HARD one 57yr old male sudden onset CP and dyspnea no Hx no old ECG



It's not often I agree with the computer interpretation!


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## jjesusfreak01

tah06090 said:


> this one might be to easy ill heres soomething for a time filler till i find a hard one 57yr old male sudden onset cp and dyspnea no hx no old ecg


rvi?


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## Shishkabob

jjesusfreak01 said:


> rvi?



No way to tell for sure without V4R... otherwise it's an Inferior MI.


Though, what, 40% of inferior MIs include a portion of the right ventrical?


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## Dutch-EMT

regular rhytm about 66bpm.
P: The 10sec print shows different shapes of P. So i guess on atrial rhytm.
P-Q: normal
QRS <120msec (looking at I, V4, V5).
Axis: normal axis (I positive and aVF positive).
Hypertrophy: P in V1 looks like left atrial hypertrophy (second wave looks bigger). No ventricular hypertrophy.
Infarct:
II, III, aVF shows ST-elevation. A pathologic Q in III.
Also V6 shows an elevation.
ST depressed in I, aVL, V1, V2 and V3.

Conclusion: Inferior MI.
(Inferior MI comes with elevations in II,III,avF and reciproke depressions in I, aVL, V1-V4.)


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## Medic50321

Oh yeah, too easy.......

Diagnostic for MI, with st elevations in II, III, AvF, with recipical (sp?) changes.

also seeing ST Depressions in V1-V3, and then ST Elevations in V4-V6, I wanna claim Extensive wall MI, but also the possibility of a Right Sided MI?


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## Dutch-EMT

A new one.

A 62yr old male.
ECG made before visit at cardiologist.
No chestpain or other problems at moment of making this ECG


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## tah06090

RBBB do we have a old EKG for comparison?


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## TomB

Bifascicular block (RBBB/LPFB-) with borderline 1AVB and left atrial enlargement. Appropriate T-wave discordance. Unusual downward convexity (scooping) of the ST-segment in leads II and aVF and slight ST-elevation in lead aVR. Since the patient has no complaints, this is probably an "old" ECG abnormality.


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## Dutch-EMT

TomB said:


> Bifascicular block (RBBB/LPFB-) with borderline 1AVB and left atrial enlargement. Appropriate T-wave discordance. Unusual downward convexity (scooping) of the ST-segment in leads II and aVF and slight ST-elevation in lead aVR. Since the patient has no complaints, this is probably an "old" ECG abnormality.




Sinusrhtymm 85bpm, right axis deviation. QRS in III 160msec.
RBBB with an LPFB. Depolirazation isn't normal, so the same could happen to the repolarization. The negative T's can't say much on this ECG. Maybe a heartecho can tell something more... Only this ECG isn't good enough to tell something about a small infarct.

Anyone a new ECG?


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## clibb

Post MI and a 1st degree heartblock.


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## tah06090

here ya go 57yr old male on cardiac floor for chest pain complaining of his chest ''feeling dizzy''


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## clibb

Depressed T wave. PAC. This person is on a pacemaker, correct? You could argue present MI with the ST segment. 
Bradycardia. After QRS 6 am I seeing Winkie Bach? 

My EKG is so rusty now. I really need to refresh myself with the books. Thanks for posting.


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## tah06090

No pacer


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## boingo

WAP, LAFB and poor R wave progression perhaps associated w/past anterior wall infarct.


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## Shishkabob

clibb said:


> After QRS 6 am I seeing Winkie Bach?



Do you mean Wenckebach?

And I'm not seeing it.


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## jjesusfreak01

Diagnosis Wenckebach


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## Dutch-EMT

1 Heartrate:about 50 bpm with PAC's
2 Rythm: sinusrhytm with PAC!
3 P top: P top shapes are the same (except the PAC's)
4 PQ/QRS: PQ time (looking at the 10 second print) is <0,2 sec. QRS widened (looking in V2 and V3 I see a small r1). QRS is 120msec so far i can see, so when i look at the deep S in II and III, i'll make it LAFB.
5 Axis: I: mainly positive  aVF: negative, left axis deviation
6 Hypertrophy: P in V1: second wave is bigger (got only one normal sinus-QRS to tell that...), left atrial hypertrophy. No left ventricular hypertrophy.
7 MI: No pathological Q's. ST:  I don't see something. 
  T: negative in III and V1, Very low in II and V2. Flat in aVF.

Based on this ECG i think the dizzy feeling can be caused by the bradycardia.
The low and negative T pointing at kind of ischemia i think. That explains the chestpain. I don't think it's AMI. 
Left axis deviation, deep S in II and III and complexes <120msec makes me guess there is a Left Anterior Fascikel Block. 

My conclusion: Sinusbradycardia with PAC, right ventricular ischemia and LAFB suspicion.


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## BuQuE

any new ecg's this is good stuff


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## clibb

Linuss said:


> Do you mean Wenckebach?
> 
> And I'm not seeing it.



Yes, haha. I saw it between QRS 6 and 7 on lead I


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## Dutch-EMT

tah06090: Do you have the diagnosis? I'm curious


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## Dutch-EMT

Well, A brand new one:

Female: 85yrs, Found unconscious and not breathing.
RR 100/40, SpO2 60%.

Aspirated a lot of food. Airway opened with suction unit and 100% oxygen was given. After 5 minutes SpO2 was 93% and this ECG was made.

History: only known with SVT, Total Hip and AUE.
No meds.

For large immage of ECG click HERE


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## R.O.P.

1st deg block, LBBB, LVH, ischemia.


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## Hockey

Here's a real brain stumper 
Click to enlarge


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## Dutch-EMT

Looking at the P waves, they look multiform. Also the baseline is very freakish.
The P waves are followed by a QRS complex.
Also P-Q is >0,2 sec. 
QRS shows in one lead a R-R1. But the complex isn't wider than 0,12msec.

But i'm missing the 12 leads.


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## squrt29batt12

Dutch-EMT said:


> Well, A brand new one:
> 
> Female: 85yrs, Found unconscious and not breathing.
> RR 100/40, SpO2 60%.
> 
> Aspirated a lot of food. Airway opened with suction unit and 100% oxygen was given. After 5 minutes SpO2 was 93% and this ECG was made.
> 
> History: only known with SVT, Total Hip and AUE.
> No meds.
> 
> For large immage of ECG click HERE



sinus rhythm, LBBB, septal injury pattern, anterolateral ischemia


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## Hockey

Dutch-EMT said:


> Looking at the P waves, they look multiform. Also the baseline is very freakish.
> The P waves are followed by a QRS complex.
> Also P-Q is >0,2 sec.
> QRS shows in one lead a R-R1. But the complex isn't wider than 0,12msec.
> 
> But i'm missing the 12 leads.



Mine?


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## Dutch-EMT

Hockey said:


> Mine?



Yup... Got only 3 lead?


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## Hockey

Dutch-EMT said:


> Yup... Got only 3 lead?




Nah just an old one.  Here's a 12 lead.  Maybe not 100% perfect but had to improvise


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## Hockey

Admin, please delete above post.



Dutch-EMT said:


> Yup... Got only 3 lead?




Nah just an old one. Here's a 12 lead. Maybe not 100% perfect but had to improvise 




[Click to enlarge]


----------

