High Risk ECGs

Amal Mattu, MD
Professor and Vice Chair
Department of Emergency Medicine
University of Maryland School of Medicine
Baltimore, Maryland
amalmattu@comcast.net

A Few Points To Start

Workshop
Questions? amalmattu@comcast.net

Writing
Handout/PDF
Gold standard Marriott, Chou
www.ekg.umem.org EKG cases of
the week
Advanced video course on emedhome,
books ACEP bookstore

Why is this important?

ACS is high-risk but high payoff!
Very good outcome vs. very bad outcome

#1: 38 yo man with sharp

chest pain and dyspnea

STEMI or Acute Pericarditis?

ECGs and Pericarditis

1. Factors that rule-in STEMI
STD except in V1 or aVR

(STD in V1 or aVR is allowed in AP)

STE in III > II

Horizontal or convex upwards STE
Q-waves that you know are new

2. Factors that suggest AP

Friction rub
PR depression in multiple leads
(Only reliably seen in viral AP, transient)

ECGs and Pericarditis

When in doubt, get

serial ECGs!

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

STEMI or AP?

Causes of STE

When in doubt, get

serial ECGs!

STEMI or AP?

STEMI or AP?

STEMI or Acute Pericarditis?

STEMI

STEMI or AP?

Acute pericarditis?

Acute pericarditis?

Acute pericarditis?

Diffuse ischemia

#2: 55 yo woman with

SOB, chest heaviness

55 yo woman with SOB,

chest heaviness

55 yo woman with SOB,

chest heaviness

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Large Pericardial Effusion

(LV + tachy)

Pericardial Effusions
Low voltage + tachycardia = pericardial
effusion until proven otherwise
When in doubt about the ECG baseline,
use the T-P segment!

#3: 48 yo man with chest

pain and dyspnea

Pulmonary Embolism
New T-wave inversions are very
common in cases of large PEs
Especially common in anteroseptal leads
Marriott and other others:
Simultaneous TWIs in anteroseptal +
inferior leads is HIGHLY specific for acute
pulmonary hypertension (= PE)

Pulmonary Embolism

PE Simulating ACS Case 2

Baseline ECG

PE Simulating ACS Case 3

Baseline ECG

PE Simulating ACS Case 4

Baseline ECG

PE Simulating ACS Case 5

PE Simulating ACS Case 5

#4: 62 yo woman presents

unconscious

#4: Intracranial
Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

Previous ECG

Intracranial Hemorrhage

Intracranial Hemorrhage

Intracranial Hemorrhage

#5: 49 yo man with vomiting

and diarrhea for 3 days

#5: Severe Hypokalemia

Severe Hypokalemia

Severe Hypokalemia

Severe hypokalemia

Digoxin Toxicity With

Hypokalemia

Remember
Just because electrocardiography is
a basic skill in EM doesn t mean
that our skills should be basic.
YOU must be the experts in
electrocardiography!