Name that ECG: 66 year old female

Welcome to another installment of Name that ECG! Remember, this is a cold read and your job is to interpret the ECG to its fullest.

66 year old female, resolved chest pain.

Name that ECG: 66 year old female

 

Rhythm:

  • Rate?
  • Regularity?
  • P-waves?
  • PR interval? Associated?
  • QRS width?

Bonus points:

  • Axis?
  • QTc?
  • ST/T-wave changes?

What are your differentials?

Posts which include any permutation of the phrase "treat the patient not the monitor" will be deleted and their author beaten with a LifePak 5.

7 Comments

  • Robert says:

    Interpretation: Sinus Brady @ 50-60 (based on upright P waves in I, II, III, avf and negative p wave in avr and hr < 60 w/ regular rhythm), Left Axis Deviation, LAFB(LAD, qr in I/AVL, rS in II, III, Avf), Biphasic T waves in V2, V3, V4 highly suggestive of Wellens Syndrome. Inverted T wave in AVL.
    Cheers!

  • Todd says:

    Wellen's Syndrome with some left axis deviation?

  • alex says:

     
    •Rate?
    About 60
     
    •Regularity?
    Regular
     
    •P-waves?
    Yes
     
    •PR interval? Associated?
    Borderline for 1st degree AVB. 1:1 association
     
    •QRS width?
    Normal at 0.08s
     
    •Axis?
    Left (positive QRS in I, negative QRS is aVF)
     
    •QTc?
    Less than half the RR interval so probably ok
     
    •ST/T-wave changes?
    Wellens waves in V2-V5
    TWI in I and aVL
     
    Which all points to partial LAD occlusion but isn't enough to activate a cath lab?

  • RyanTee says:

    Rate is about 60 bpm, regular rhythm P waves are these, PRI is good, QRS is wide with LBBB, LAD is seen..QTc is normal, Biphasic T waves seen with negative terminal – first stage of Wellens syndrome…urgent but not immediate cath…R waves are there meaning the artery is not yet infarcted…there is spontaneous reperfusion..
     

  • Ben W says:

    I definitely say it’s textbook wellen’s syndrome. Inversion in AvL and hyper acute-ish looking T waves inferiorly kinda makes me think Type III wraparound LAD occlusion due to possible inferior injury with the more obvious anterior injury. Happy holidays kids!

  • @Ryan Tee – I'm not seeing any evidence of left bundle-branch block (LBBB).  In fact, if LBBB was actually present, then it would probably mask the ST-T changes of "Wellens' warning".  The duration of the QRS interval is normally narrow at 0.08s and there are triphasic "qRs" complexes in both lead I and V6. 

  • Andrew Przepioski says:

     
    Rhythm: Sinus bradycardia
     
    Rate? 56
    Regularity? Yes.
    P-waves? Yes.
    PR interval? Associated? 0.16s. Yes.
    QRS width? 0.08s.
    Bonus points:
     
    Axis? QRS -30 degree. Z +40.
    QTc? 425 ms.
    ST/T-wave changes? Biphasic T-waves V1-V5. Retrograde in aVL.
    What are your differentials? LAD occulsion. I have nothing else to add to my DDx.
     
    =====================================================
     
    56, sinus bradycardia, LAFB, LAE, anteroseptal ischemia.
     
    Rate: 56
     
    Rhythm: Regular, p-waves present, P:QRS 1:1, PRi about 0.16s, QRS narrow 0.08s. Sinus bradycardia.
     
    Axis: QRS – I +, avF -, II -, -30 degree, LAD, LAFB (qR in I, rS in III too).
    Z V4 +40m, V1-V3 looks like the leads were placed 1 ICS too high (V3 r-wave >3 mm).
     
    Enlargement/Hypertrophy: Left atrial enlargement (2nd 1/2 of P-wave in V1 >0.04s, 1mm deep)
     
    ST/T, Q: insignificant q-waves in I and aVL. Significant Q in II and aVF. III has a small r-wave. No significant STE, but V1-V5 has retrograde T-waves. V2-V3, are those Wellen's T-waves? aVL also has a retrograde T-wave.
     
    QT 440 ms.
    QTc 425 ms.
     
    I'd be concerned about LAD occulusion cause of the T-waves in the anteroseptal leads.

Leave a Reply

Your email address will not be published. Required fields are marked *

EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation

JEMS Talk: Google Hangout

Comments
Stephen Smith
Conclusion: “And then I gave her a NTG…”
There is also no data I'm aware of that shows that, in the reperfusion era, nitroglycerine helps patients with STEMI who do not have elevated BP or pulmonary edema. Data is lacking in all regards.
2014-10-24 16:14:36
Kevin
44 year old male CC: Palpitations
Why on earth would you risk VF, by giving Adenosine to rule out rhythms.. This is dangerous, and foolish. There might be a slight chance that this is WPW.. You might as well just give him Cardizem, they are both AV nodal blockers... I don't know why the AHA even added this stupid idea..
2014-10-22 13:31:06
Vince DiGiulio
The 360 Degree Heart – Part II
It is standard practice in electrocardiography to label the first 90 degrees counter-clockwise from "zero" that way. When you see a patient with "left axis deviation" you'll see that their measured QRS axis is somewhere between -30 and -90 degrees. Imagine if you saw someone with a mean QRS axis at 5 degrees. Now imagine…
2014-10-21 14:00:37
Bryan
The 360 Degree Heart – Part II
I don't understand why (-)III and aVL are be labeled -60 and -30 degrees instead of 300 and 330 degrees?
2014-10-21 13:43:29
The 360 Degree Heart – Part II | EMS 12 Lead
The 360 Degree Heart – Part I
[…] first post in our “360 Degree Heart” series attempted to visualize how the different frontal plane […]
2014-10-21 12:50:56

STEMI Expert?

  • Click here to find out!
  • 12-Lead ECG Challenge Smartphone App

    Photobucket

    12-Lead ECG Challenge Smartphone App - $5.99

  • Apple iOS
  • Android
  • Amazon
  • Web Based

  • FRN-TV video review
  • iMedicalApps.com review
  • Interested in resuscitation?

    FireEMS Blogs eNewsletter

    Sign-up to receive our free monthly eNewsletter

    Visitor Map / Stats

    Locations of visitors to this page


    LATEST EMS NEWS

    HOT FORUM DISCUSSIONS