Andrew Schmidt DO MPH
Assistant Professor Emergency Med Deputy Medical Director
ECGs amp STEMIs
RA
RV
LA
LV
IVC RA
RV
LA
LV
To Lungs
From Lungs
Aorta
Basics of EKG
RA
RV
LA
LV
P T
QTSTPR
QRS
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ECGs amp STEMIs
RA
RV
LA
LV
IVC RA
RV
LA
LV
To Lungs
From Lungs
Aorta
Basics of EKG
RA
RV
LA
LV
P T
QTSTPR
QRS
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RA
RV
LA
LV
IVC RA
RV
LA
LV
To Lungs
From Lungs
Aorta
Basics of EKG
RA
RV
LA
LV
P T
QTSTPR
QRS
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
IVC RA
RV
LA
LV
To Lungs
From Lungs
Aorta
Basics of EKG
RA
RV
LA
LV
P T
QTSTPR
QRS
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Basics of EKG
RA
RV
LA
LV
P T
QTSTPR
QRS
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Contraction = P WAVESA node AV Node
Causes atrial contraction
P WAVE
SA
AV
P
QRS
T
PR QT
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
PR Interval
RA
RV
LA
LV
P T
PR QT
At the AV Node
Allows delay before Ventricular contraction
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular contraction = QRS
RA
RV
LA
LV
P
QRS
T
QTPR
Electricity passes down LV and RV
Depolarizes Ventricle
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ST segment
RA
RV
LA
LV
P T
STPR
QRS
During ventricular contraction
(depolarization)
before relaxation (repolarization)
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Relaxation = T wave
Ventricles repolarize in same direction as
depolarizedRA
RV
LA
LV
P T
QT
STPR
QRS
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RA LA
RL LL
V1 V2 V3
V4 V5V6
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RA LA
RL LL
V1 V2 V3
V4 V5V6
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
aVF
IIIII
I
aVLaVR
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ECG InterpretationRate
RhythmIntervals
Morphology
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rate
300
150
100
75
60
50 300 big boxes
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Tachycardia vs Bradycardia
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RhythmRegular or irregular
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RhythmIs the rhythm ldquosinusrdquo
Are P waves presentIs there a P for every QRS
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Intervals
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Intervals
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
PR Interval120-200 ms
Normal
gt200 msAV Block
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
AV Blocks
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
RA
RV
LA
LV
TPR
Partial or complete block of impulse
transmission from atria to ventricles
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
1st degree AV Block1st degree prolonged PR gt 200 ms
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
2nd degree type 1Progressively increasing PR interval until
non-conducting p wave
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
2nd degree type 1
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
2nd degree type 2Intermittent non-conducting p waves without
progressive prolongation of PR interval
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
3rd degreeComplete dissociation between P and QRS
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
2nd Degree Type IIamp
3rd Degree AV Blocks
May Require Pacing
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
QRS Complexlt 100 msNarrow
gt120 msWide
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
QRS
Narrow
Wide
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
QRS
Narrow
SUPRAVENTRICULARSinus Rhythms (SA)Atrial RhythmsJunctional Rhythms (AV)
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
QRS
Wide Ventricular RhythmsBundle Branch Blocks
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
SupraventricularArrhythmias
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Supraventricular(above the ventricles)
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Fibrillation
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Fibrillation
>
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Fibrillation
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Fibrillation
Irregularly irregular
No discernable P waves
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Fibrillation
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
A fib with RVR
Rapid Ventricular Rate
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial Flutter
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial flutter
>
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial flutter
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial flutter
Regular
ldquoSaw-toothrdquo waves
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Atrial flutter
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ldquoSVTrdquoActually ldquoAV Nodal Reentry Tachycardiardquo
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
AV Nodal Re-entry Tachycardia
>
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
AV Nodal Re-entry Tachycardia
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
AV Nodal Re-entry Tachycardia
RegularNo P waves
Rate typically ~ 150
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
AV Nodal Re-entry Tachycardia
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
VentricularArrhythmias
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
VentricularTachycardia
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Tachycardia
>
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Tachycardia
Regular (usually)
Wide Complex
No P waves
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
VentricularFibrillation
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Fibrillation
>
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Fibrillation
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ventricular Fibrillation
Rapid chaotic Irregular
No obvious P QRS
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Letrsquos do some ECGs
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Normal Sinus
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Tachycardia
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
AVNRT (ldquoSVTrdquo)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Junctional Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Fibrillation (RVR)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
2nd Deg (Type 1) AV Block
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg
P wave
(lots)
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Atrial Flutter
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
V Tach (Torsades)
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Paced Rhythm
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Sinus Bradycardia
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
MorphologyBut first a break
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
QRSMorphology
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Bundle Branch Blocks
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Bundle Branch Blocks
>
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Left Bundle Branch Block
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Right Bundle Branch Block
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
T waveMorphology
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Ischemia
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Hyperkalemia
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ST SegmentMorphology
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMIs
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Coronary artery occlusion
Infarction(tissue death)
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ST Elevation gt 2mm in 2 contiguous leads
+CP SOB Nausea Syncope
OR
ECG reads ldquoAcute MIrdquo
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Reciprocal ST Depressions
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI Alert
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI ALERT ndash ECCKings Bay ndash ETA 20
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI Treatment
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Which of the following are proven to improve survival from STEMI
bull Lights and Sirensbull Aspirinbull Morphinebull Oxygenbull Cardiac Catheterizationbull ALS unitbull Helicopter transportbull Nitroglycerin
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Aspirin+
Cath
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Cardiac Catheterization
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
>
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI Geography
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
INFERIOR LATERAL
LATERAL
LATERAL
ANTERIOR
SEPTAL
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI ECGs
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Anterior MI
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Anterolateral MI
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
From Kings Bay
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
From Kings Bay
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
InferiorSTE II III aVFSTD aVL
SeptalSTE V1-V2
AnteriorSTE V3 V4
LateralSTE V5 V6 aVL
PosteriorSTE V7-V9STD V1-V2
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
From Kings Bay
Inferior MI
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
What is special about Inferior MI
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Right VentriclePreload
Dependent
High risk of hypotension
with Nitro
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
How do we determine right
side involvement
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Right Sided ECGSwitch V4 to right side
V4R
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Pre-hospital ECG
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
ED ECG
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Right Side ECG
V4R
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
If ST Elevation in V4R hold Nitro
Remember Nitro doesnrsquot save lives
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
What ELSE is special about Inferior MI
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
SA and AV Nodes
Sinus Bradycardia
AV Blocks
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Pre-hospital ECG
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Rhythm
Reg Irreg P wave
No P Wave
Rate
Brady Normal Tachy
Intervals
PR normal
AV Block
Narrow QRS
Wide QRS
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
3rd Degree AV BlockComplete A-V Dissociation
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Morphology
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Morphology
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Inferior MI+
3rd Degree AV BlockComplete A-V Dissociation
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
EC ECG
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Right Side ECG
V4R
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
STEMI Mimics
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
+
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
A
C
B
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
LBBB + MI
ECG wwwemeduorg
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
LBBB + MI
A Concordant STE gt 1mm V5-V6C Discordant STE gt 5mm V3
ECG wwwemeduorg
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Pericarditis
30 yo male healthy recent URI
ECG wwwlifeinthefastlanecom
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
PericarditisWidespread concave STE
Widespread PR depression(often late not specific)
ECG wwwlifeinthefastlanecom
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Pericarditis STEMI
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Benign Early Repolarization
18 yo female healthy co dizziness
ECG wwwlifeinthefastlanecom
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Benign Early Repolarization
Widespread concave STEMost prominent V2-V5
STE usually lt 2mm
Notching at J-pointUsually prominent in V4
httplifeinthefastlanecom
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Benign Early Repol STEMI
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Brugada
20 yo male presents with sudden cardiac arrest
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Brugada
ldquoSudden Unexplained Nocturnal Death Syndrome (SUNDS)rdquo
ldquoBangungutrdquo (Phil)(ldquoto rise and moan in sleeprdquo)
ldquoPokkurIrdquo (Japan)(ldquosudden and unexplained
ceased phenomenardquo) ECG wwwecgpediaorg
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Brugada
Mutation of cardiac sodium channel gene
60 mutations described
May be familial
ECG wwwecgpediaorg
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
wwwJaxEMScomField toolsVideo LecturesCase Feedback
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Brugada Type I
STE gt 2mm in gt1 of V1-V3Followed by negative T
wwwlifeinthefastlanecom
Questions amp Comments
www JaxEMS com
Questions amp Comments
www JaxEMS com
