EKG Quiz

Barry Bertolet, MD

Use your Audience Response Device

EKG #1

1. What is the rhythm?

a. V-Tach

b. A-Fib

c. A-flutter

d. normal

EKG #1

1. What is the rhythm?

a. V-Tach

b. A-Fib

c. A-flutter

d. normal

Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex

Regular ST

SVT

Atrial flutter

ST w/ BBB

SVT w/ BBB

VT

Irregular A-fib

A-flutter w/ variable conduction

MAT

A-fib w/ BBB

A-fib w/ WPW

VT

4

EKG #2

1. What does this EKG represent?

a. pericarditis

b. myocarditis

c. digitalis effect

d. infero postero lateral wall ST-elevation MI

EKG #2

1. What does this EKG represent?

a. pericarditis

b. myocarditis

c. digitalis effect

d. infero postero lateral wall ST-elevation MI

Cardiac Location of Event

7

EKG #3

1. What is the rhythm?

a. V-Tach

b. A-Fib

c. A-flutter

d. normal

EKG #3

1. What is the rhythm?

a. V-Tach

b. A-Fib

c. A-flutter

d. normal

Ventricular Tachycardia

Rate 110 -250 bpm

Wide complex (>0.12 – 3 small blocks)

Regular

AV dissociation

Extreme Right Axis Deviation + Upright MCL-1

I III II III

MCL-1

EKG #4

1. What does this EKG represent?

a. sinus bradycardia

b. sinus tachycardia

c. 2nd degree AV block

d. complete heart block

EKG #4

1. What does this EKG represent?

a. sinus bradycardia

b. sinus tachycardia

c. 2nd degree AV block

d. complete heart block

Blocks

AV blocks

First degree block • PR interval fixed and > 0.2 sec

Second degree block, Mobitz type 1 • PR gradually lengthened, then drop QRS

Second degree block, Mobitz type 2 • PR fixed, but drop QRS randomly

Type 3 block • PR and QRS dissociated

13

EKG #5

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

EKG #5

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

EKG #6

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

EKG #6

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

Bundle Branch Blocks

Turn Signal Theory

1 2 3

LBBB

RBBB

EKG #7

1. What does this EKG represent?

a. V-fib

b. A-fib

c. Supraventricular tachycardia

d. normal

EKG #7

1. What does this EKG represent?

a. V-fib

b. A-fib

c. Supraventricular tachycardia

d. normal

Differential Diagnosis of Tachycardia

Tachycardia Narrow Complex Wide Complex

Regular ST (HR < 150)

SVT (HR > 150)

Atrial flutter (HR = 150)

ST w/ BBB

SVT w/ BBB

VT

Irregular A-fib

A-flutter w/ variable conduction

MAT

A-fib w/ BBB

A-fib w/ WPW

VT

21

EKG #8

1. What would you do next based on this EKG?

a. Reassure and discharge

b. Refer for electrophysiology study

c. Begin a beta-blocker

19 year old

male with

complaints

of

palpitations

EKG #8

1. What would you do next based on this EKG?

a. Reassure and discharge

b. Refer for electrophysiology study

c. Begin a beta-blocker

19 year old

male with

complaints

of dizziness

and

palpitations

EKG #9

1. The therapy of choice is:

a. Thrombolytics

b. Cath and PCI

c. NSAIDs and Colchicine

EKG #9

1. The therapy of choice is:

a. Thrombolytics

b. Cath and PCI

c. NSAIDs and Colchicine

Pericarditis

PR segment depression, usually in lead II

27

EKG #10

This patient is a 50 year old man who presented to the ED with chest tightness and is noted to be markedly hypotensive on exam. What is your therapy for BP restoration? A. Dopamine B. IVF bolus C. Balloon pump

EKG #10

This patient is a 50 year old man who presented to the ED with chest tightness and is noted to be markedly hypotensive on exam. What is your therapy for BP restoration? A. Dopamine B. IVF bolus C. Balloon pump

What about the right side?

RV infarcts

Move V4 to the

right side same

location

5th intercostal

space anterior

axillary

Occur in conjunction with inferior MIs

30

Acute MI with RV involvement

31

Acute MI with RV involvement

IVF to increase filling pressures

Inotropes to follow IVF loading

RV - VAD

32

EKG #11

This patient is 40 year old woman with pleuritic chest pain and breathlessness. What is the diagnostic test of choice?

a. Echo b. CTA c. CXR

EKG #11

This patient is 40 year old woman with pleuritic chest pain and breathlessness. What is the diagnostic test of choice?

a. Echo b. CTA c. CXR

S1Q3T3 pattern is only second to D-dimer

EKG #12

1. What does this EKG represent?

a. V-fib

b. A-fib

c. A-flutter

d. V- tach

EKG #12

1. What does this EKG represent?

a. V-fib

b. A-fib

c. A-flutter

d. V- tach

EKG #13

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

EKG #13

1. What does this EKG represent?

a. V-fib

b. left bundle branch block

c. right bundle branch block

d. normal

EKG #14

1. What does this EKG represent?

a. Pericarditis

b. Myocardial infarction

c. Early Repolarization

EKG #14

1. What does this EKG represent?

a. Pericarditis

b. Myocardial infarction

c. Early Repolarization

Classic findings

1. J-point “notching”

2. Concave-up ST segment (smiley face)

3. ST segment elevation from baseline in V2-V5, typically <3mm

4. Large, symmetrically concordant T-waves in leads with STE

43

Classic findings

1. J-point “notching”

2. Concave-up ST segment (smiley face)

3. ST segment elevation from baseline in V2-V5, typically <3mm

4. Large, symmetrically concordant T-waves in leads with STE

44

Can we tease it out?

The degree of ST segment elevation is thought to be

indirectly proportional to the degree of sympathetic tone

In other words, the more relaxed the patient, the more

pronounced the ST segment elevation (and vice versa)

If you truly want to test your patient, get their heart rate up

and look at the ST segment

45

HR 64 HR 83

The ST segment is NOT fixed in pts w/ BER and changes from EKG to EKG and with the degree of sympathetic strain On the right, note the complete resolution of the ST elevation but maintenance of the J-point notching in V4 46