ECG Case 057
Middle-aged patient presenting with chest pain and diaphoresis. Becomes unresponsive during recording of ECG. Interpret the ECG.
Describe and interpret this ECG
ECG ANSWER and INTERPRETATION
Main Abnormalities
This is a fascinating ECG with multiple abnormalities:
- The first half of the tracing shows a ventricular paced rhythm with positive Sgarbossa criteria indicating superimposed inferior STEMI.
- There is excessively discordant ST elevation (> 25% of Q/S wave depth) in II, III and aVF with reciprocal change in I and aVL.
- A ventricular ectopic (beat #8) occurs at a vulnerable time, resulting in a run of ventricular flutter (very rapid VT at rates > 200-300 bpm).
- This rapidly degenerates to ventricular fibrillation (seen in the rhythm strip, which is recorded after the other 12 leads).
- The artefact at the start of the rhythm strip may represent a precordial thump!
CLINICAL PEARLS
While most rhythm strips are recorded simultaneously with the 12-lead ECG, some older machines may record the rhythm strip after the other 12 leads.
Consider this as a possibility if your rhythm strip doesn’t seem to “line up” with the rest of the ECG.
References
Further Reading
- Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
- Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
- Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
- Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF
TOP 100 ECG Series
Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |
2 Comments
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I’m having a hard time diagnosing the ECG after beat 8. You state it goes into Vflutter for a while but the rest of the beats particularly those that appear in V2, V3, V4, V5 and V6 look like TdP. Could you elaborate on this. I understand the rhythm strip being Vfib, makes sense but the Vflutter before Vfib is kind of confusing. Thank you in advance for your attention this it is very much appreciated.
Cindy
Just to confirm (given some of us new physicians don’t see older ECG traces), I see this old ECG has 3 leads recorded simultaneously (e.g. I, II, III simultaneously) and each column is a simultaneous trace, and it sequentially progresses in time from left to right, finishing with the rhythm strip?
VW