EKG Practice

By Ray Fowler, MD
Professor of EM / EMS
UTSW / Parkland

Edited by Alex Koyfman, MD

 
45 male with intense epigastric pain radiating to his left arm with associated NV and diaphoresis.

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55 female with crushing anterior chest pain and diaphoresis.

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A sinus tachycardia is present in this 54 year old man with severe chest pain radiating to the left arm.

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This is a narrow complex tachycardia in a 31 year-old female that is perfectly clock regular. There is no obvious atrial activity seen. The QRS is narrow.
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This 65 year-old woman presents with lightheadedness and worsening dyspnea on exertion.
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This 81 year old man had a syncopal episode. He presents a little confused, GCS 14 (lies with his eyes closed), and is “not right” per his wife. His BP is 110/76, and he has the cardiogram below.
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This is an odd 12 lead ECG to have done in this 54 year old man. The rate is profoundly slow, in the 20’s or so. The rhythm is regular. There is no evident atrial activity. The QRS is very widened.
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4 thoughts on “EKG Practice”

  1. Case 3 looks to be an acquired Brugada pattern due to hyperkalemia (sodium channel dysfunction) rather than true Brugada syndrome [1]. Along that route, the channelopathy present in BrS causes SCA due to triggered VF/VT rather than bradyarrhythmias.

    The clinical picture in this case should dictate whether these changes are considered acquired or evidence of BrS. Sudden syncopal episode, palpitations, cardiac arrest, or aborted cardiac arrest? BrS. Otherwise we should rule out the other causes and work from an acquired BrS pattern.

    The BrS patterns are important to recognize, but also the situations in which the three types can be mimicked:
    – Hyperkalemia [2]
    – Hyponatraemia [3]
    – Improperly high placement of V1/V2 [4]
    – Incorrect high-pass filter settings [5]

    [1] Littman L, et al. The hyperkalemic Brugada sign. J Electrocardiol. 2007; 40:53-59.
    [2] Kovacic JC, Kuchar DL. Brugada pattern electrocardiographic changes associated with profound electrolyte disturbance. Pacing Clin Electrophysiol. 2004; 27:1020-1023.
    [3] Tamene A, et al. Brugada-like electrocardiography pattern induced by severe hyponatraemia. Europace. 2010; doi:10.1093/europace/euq034
    [4] Garcia-Niebla J, Baranchuk A, Bayes de Luna A. True Brugada pattern or only high V1-V2 electrode placement. 2014; doi:10.1016/j.jelectrocard.2014.04.020
    [5] Garcia-Niebla J, Serra-Autonell G, Bayes de Luna A. Brugada Syndrome Electrocardiographic Pattern as a Result of Improper Application of a High Pass Filter. Am J Cardiol. 2012; 110:318-320.

  2. Case 3 looks to be an acquired Brugada pattern due to hyperkalemia (sodium channel dysfunction) rather than true Brugada syndrome [1]. Along that route, the channelopathy present in BrS causes SCA due to triggered VF/VT rather than bradyarrhythmias.

    The clinical picture in this case should dictate whether these changes are considered acquired or evidence of BrS. Sudden syncopal episode, palpitations, cardiac arrest, or aborted cardiac arrest? BrS. Otherwise we should rule out the other causes and work from an acquired BrS pattern.

    The BrS patterns are important to recognize, but also the situations in which the three types can be mimicked:
    – Hyperkalemia [2]
    – Hyponatraemia [3]
    – Improperly high placement of V1/V2 [4]
    – Incorrect high-pass filter settings [5]

    [1] Littman L, et al. The hyperkalemic Brugada sign. J Electrocardiol. 2007; 40:53-59.
    [2] Kovacic JC, Kuchar DL. Brugada pattern electrocardiographic changes associated with profound electrolyte disturbance. Pacing Clin Electrophysiol. 2004; 27:1020-1023.
    [3] Tamene A, et al. Brugada-like electrocardiography pattern induced by severe hyponatraemia. Europace. 2010; doi:10.1093/europace/euq034
    [4] Garcia-Niebla J, Baranchuk A, Bayes de Luna A. True Brugada pattern or only high V1-V2 electrode placement. 2014; doi:10.1016/j.jelectrocard.2014.04.020
    [5] Garcia-Niebla J, Serra-Autonell G, Bayes de Luna A. Brugada Syndrome Electrocardiographic Pattern as a Result of Improper Application of a High Pass Filter. Am J Cardiol. 2012; 110:318-320.

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