High Risk ECGs

Amal Mattu, MD Professor and Vice Chair

Department of Emergency Medicine University of Maryland School of Medicine

Baltimore, Maryland amalmattu@comcast.net

A Few Points To Start…

•  Workshop – Questions? à amalmattu@comcast.net

•  Writing •  Handout/PDF •  “Gold standard” à Marriott, Chou •  www.ekg.umem.org à EKG cases of

the week •  Advanced video course on emedhome,

books à ACEP bookstore

Why is this important?

•  ACS is high-risk but high payoff! – Very good outcome vs. very bad outcome

#1: 38 yo man with sharp chest pain and dyspnea

STEMI or Acute Pericarditis?

ECGs and Pericarditis

1.  Factors that rule-in STEMI – STD except in V1 or aVR

•  (STD in V1 or aVR is allowed in AP) – STE in III > II – Horizontal or convex upwards STE – Q-waves that you know are new

2.  Factors that suggest AP – Friction rub – PR depression in multiple leads

•  (Only reliably seen in viral AP, transient)

ECGs and Pericarditis

When in doubt, get serial ECGs!

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

Causes of STE…

When in doubt, get serial ECGs!

STEMI or AP?

STEMI or AP?

STEMI or Acute Pericarditis?

STEMI

STEMI or AP?

Acute pericarditis…?

Acute pericarditis…?

Acute pericarditis…?

Diffuse ischemia

#2: 55 yo woman with SOB, chest heaviness

55 yo woman with SOB, chest heaviness

55 yo woman with SOB, chest heaviness

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Large Pericardial Effusion (LV + tachy)

Pericardial Effusions

•  Low voltage + tachycardia = pericardial effusion until proven otherwise

•  When in doubt about the ECG baseline, use the T-P segment!

#3: 48 yo man with chest pain and dyspnea

Pulmonary Embolism

•  New T-wave inversions are very common in cases of large PEs

•  Especially common in anteroseptal leads •  Marriott and other others:

– Simultaneous TWIs in anteroseptal + inferior leads is HIGHLY specific for acute pulmonary hypertension (= PE)

Pulmonary Embolism

PE Simulating ACS — Case 2

Baseline ECG

PE Simulating ACS — Case 3

Baseline ECG

PE Simulating ACS — Case 4

Baseline ECG

PE Simulating ACS — Case 5

PE Simulating ACS — Case 5

#4: 62 yo woman presents unconscious

#4: Intracranial Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

Previous ECG

Intracranial Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

#5: 49 yo man with vomiting and diarrhea for 3 days

#5: Severe Hypokalemia

Severe Hypokalemia

Severe Hypokalemia

Severe hypokalemia

Digoxin Toxicity With Hypokalemia

Remember…

•  Just because electrocardiography is a basic skill in EM doesn’t mean that our skills should be basic.

• YOU must be the experts in electrocardiography!