1. ECG Practice Cases: Part 3—Special Cases
Megan Chan, PGY-1
UHCMC 2015
Torsades picture:

2. 84 y/o female with syncope
DIAGNOSIS?
#39
Sinus bradycardia, HR 40. Tx: pacemaker placed
Possible LAE
Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle)
Incomplete RBBB

3. What Causes Low Voltage QRS?
#39
Sinus bradycardia, HR 40. Tx: pacemaker placed
Possible LAE
Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle)
Incomplete RBBB
Sinus Bradycardia (HR 40) with Low Voltage QRS
Incomplete RBBB
(RSR’ in V1 but no deep S in V6)

4. Low Voltage QRS Amplitude of QRS is < 5mm in limb leads &
< 10mm in precordial leads
Etiology
Pericardial effusion
Hyperinflation of lungs (e.g. COPD, pneumothorax)
Pericarditis (2/2 less activated muscle)
Obesity
Generalized edema
Severe ischemic disease
Infiltrative diseases (e.g. amyloidosis)
Thyroid disease
Pleural effusion
Post-open heart surgery

5. What Treatment Would You Recommend?
#39
Sinus bradycardia, HR 40. Tx: pacemaker placed
Possible LAE
Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle)
Incomplete RBBB
Sinus Bradycardia (HR 40) with Low Voltage QRS
Incomplete RBBB
(RSR’ in V1 but no deep S in V6)

6. What Treatment Would You Recommend?
#39
Sinus bradycardia, HR 40. Tx: pacemaker placed
Possible LAE
Low voltage QRS (consider pulm disease, pericardial effusion, obesity, myocarditis 2/2 less activated muscle)
Incomplete RBBB
Pacemaker Placement

7. Indications for Cardiac Pacemakers
Sinus node dysfunction
Mobitz Type II heart block
Complete heart block
Symptomatic bradyarrhythmias
Tachyarrhythmias (e.g. recurrent/sustained SVT)
Hypersensitive carotid sinus syndrome
Sinus node dysfunction = most common indication
Indications for ICD Therapy
Class I
1. Cardiac arrest due to VF or VT not due to a transient or reversible cause. (Level of evidence: A)
2. Spontaneous sustained VT. (Level of evidence: B)
3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study when drug therapy is ineffective, not tolerated, or not preferred. (Level of evidence: B)
4. Nonsustained VT with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at electrophysiological study that is not suppressible by a Class I antiarrhythmic drug. (Level of evidence: B)

8. 65 y/o male at a follow up visit
DIAGNOSIS?
#44
Sinus rhythm with occasional PVC, HR 75
Ventricular pacing (usually LBBB pattern unless biventricular pacing then can be RBBB pattern)
*If p waves are present, this means atrial tracking and ventricular pacing is occurring.

9. Ventricular pacing with PVC (P waves indicate atrial tracking,
Pacer spikes
#44
Sinus rhythm with occasional PVC, HR 75
Ventricular pacing (usually LBBB pattern unless biventricular pacing then can be RBBB pattern)
*If p waves are present, this means atrial tracking and ventricular pacing is occurring.
Ventricular pacing with PVC
(P waves indicate atrial tracking,
LBBB pattern typical unless biventricular pacing)

10. Compared to… Atrial pacing

11. Atrial Pacing Normal QRS interval Atrial pacing

12. 59 y/o female with SOB DIAGNOSIS? #42 NSR, HR 65
Left posterior fascicular block
S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE

13. NSR with R axis deviation (Left posterior hemiblock)
#42
NSR, HR 65
Left posterior fascicular block
S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE
S1Q3T3
NSR with R axis deviation (Left posterior hemiblock)

15. What is Your Clinical Diagnosis?
#42
NSR, HR 65
Left posterior fascicular block
S1Q3T3 = right heart strain 2/2 pulmonary HTN and not PE
S1Q3T3
NSR with R axis deviation (Left posterior hemiblock)

16. S1Q3T3 ECG finding that indicates right heart strain
Thus differential diagnosis should include PE and Pulmonary HTN (which this pt had)

17. 65 y/o male on a new medication
DIAGNOSIS?
Digitalis Effect: Scooping t waves, U waves
Digitalis toxicity: arrhythmias from PVCs to V fib, conduction abnormalities from first degree to third degree heart block

18. DIGITALIS EFFECT Scooping T waves U waves
Digitalis toxicity: arrhythmias from PVCs to V fib, conduction abnormalities from first degree to third degree heart block
Scooping T waves
U waves

19. 68 y/o female who collapses
DIAGNOSIS?
Monomorphic VT
Sustained run = > 30 seconds

20. >30 second run = Sustained VT
Monomorphic VT
Monomorphic VT
Sustained run = > 30 seconds
>30 second run = Sustained VT

21. 75 y/o male with COPD DIAGNOSIS? Multifocal atrial tachy
-Originates from ectopic atrial foci, characterized by varying p-wave morphology and PR interval, irregular
-Clinical correlations: COPD, advanced age, CHF, diabetes, theophylline use
Tx: manage underlying disease, antiarrhythmics are ineffective

22. Multifocal Atrial Tachycardia
-Originates from ectopic atrial foci, characterized by varying p-wave morphology and PR interval, irregular
-Clinical correlations: COPD, advanced age, CHF, diabetes, theophylline use
Tx: manage underlying disease, antiarrhythmics are ineffective
Irregular rhythm with varying P wave morphology
& PR intervals

23. 60 y/o uremic patient DIAGNOSIS?
Pericarditis: Diffuse ST elevations (concave upward), diffuse PR depressions, diffuse T wave inversions
Causes: Uremia, viral/bacterial/fungal, Dressler syndrome, collagen vascular diseases, cancer, idiopathic
1. Diffuse concave up ST segment elevation.
2. T waves are concordant with ST segment.
3. ST segment depression in aVR and v1.
4. PR segment depression.
5. Absence of reciprocal ST segment depression.

24. Diffuse concave ST elevations Diffuse PR depressions
Pericarditis
Pericarditis: Diffuse ST elevations (concave upward), diffuse PR depressions, diffuse T wave inversions
Causes: Uremia, viral/bacterial/fungal, Dressler syndrome, collagen vascular diseases, cancer, idiopathic
1. Diffuse concave up ST segment elevation.
2. T waves are concordant with ST segment.
3. ST segment depression in aVR and v1.
4. PR segment depression.
5. Absence of reciprocal ST segment depression.
Diffuse concave ST elevations
Diffuse PR depressions

25. 53 y/o male with SOB and intermittent CP
DIAGNOSIS?
Electrical alternans—beat-to-beat alternation that’s relatively specific of pericardial effusion usually with cardiac tamponade, occurs because of the swinging motion of the heart within the effusion.

26. Electrical Alternans
Electrical alternans—beat-to-beat alternation that’s relatively specific of pericardial effusion usually with cardiac tamponade, occurs because of the swinging motion of the heart within the effusion.
Beat-to-beat alternation is relatively specific of pericardial effusion usually with cardiac tamponade.

27. 55 y/o male with dizziness
DIAGNOSIS?
WPW: short PR, delta wave = delay in initial deflection of QRS
-Occurs as preexcitation syndrome due to conduction from SA node to ventricle through accessory pathway that bypasses the AV node.

28. Wolff-Parkinson-White Delta wave, Short PR interval
WPW: short PR, delta wave = delay in initial deflection of QRS
-Occurs as preexcitation syndrome due to conduction from SA node to ventricle through accessory pathway that bypasses the AV node.
Delta wave, Short PR interval
Preexcitation syndrome through accessary pathway that bypasses AV node.

29. 65 y/o dialysis patient
DIAGNOSIS?

30. Mild hyperkalemia: narrow, diffuse peaked T waves
Severe hyperkalemia: PR prolongation, P wave flattens/disappears (junctional rhythm), QRS widens. *Complication: can progress to “sine wave” then asystole or V fib!

31. 30 y/o female on Furosemide
Diagnosis?
Hypokalemia: ST depression with U waves
-Prominent U waves = marker for increased susceptibility to Torsades

32. Hypokalemia U waves (increased susceptibility for Torsades)
Hypokalemia: ST depression with U waves
-Prominent U waves = marker for increased susceptibility to Torsades
U waves
(increased susceptibility for Torsades)
ST depressions also associated (not seen here)

33. 50 y/o male with Nephrolithiasis
Diagnosis?

34. Hypercalcemia: Shortened QT Hypocalcemia: Prolonged QT
Hypercalcemia: Short QT
Hypocalcemia: Prolonged QT
Hypercalcemia: Shortened QT
Hypocalcemia: Prolonged QT

35. Hypothermia: “Osborn wave” (arrow) Amiodarone: prolonged QT
1) Hypothermia—”Osborn wave” (arrow) = convex hump at J point, due to altered ventricular action potential
2) Amiodarone—prolonged QT
3) TCA overdose—QRS/TQ prolongation with sinus tach
4) Intracranial bleed, esp SAH: “CVA T-wave pattern” = deep, wide T-wave inversions, also prolonged QT
Hypothermia: “Osborn wave” (arrow)
Amiodarone: prolonged QT
TCA: QRS/QT prolongation with sinus tach
Intracranial bleed: “CVA T-wave pattern” =
deep, wide T wave inversions

36. REFERNCES
Agabegi SS, Agabegi ED. Step up to Medicine, 3rd ed Lippincott Williams & Wilkins. Philadelphia, PA.
Gomella LG, Haist SA. Basic EKG reading. In: Clinician’s Pocket Reference. McGraw-Hill; Accessed Nov 18, 2014.
Longo DL, Fauci AS, Kasper DL, et al. Electrocardiography. In: Harrison’s Principles of Internal Medicine, 18th ed McGraw Hill. New York, NY.
University of Illinois at Chicago. Online ICU Guidebook ver_442934/Image/1.1/residentguides/final/icuguidebo ok.pdf. Accessed December 1, 2014.