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Dr. Smith's ECG Blog

Instructive ECGs in Emergency Medicine Clinical Context
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1. Hyperkalemia, with near sinusoidal pattern. Note very wide QRS, bizarre deep T-waves in V1 and V2,
peaked T-waves in V4 and V5, long PR interval this case. Whenever you see a wide QRS, you must think of
hyperkalemia. The K was 8.7 mEq/L. It responded to therapy.
2. There are regular p-waves at a rate of about 90, but they do not conduct. Thus, there is 3rd Degree AV block with a probable Purkinje
escape at a rate of 36; the wide QRS and RBBB pattern (rSR' in V1, wide S-waves in lateral leads) tell us that the escape is from the left
bundle, creating an RBBB-like ECG. [Alternatively, there could be a nodal escape with RBBB]. There are also very wide, bizarre,
inverted T-waves. The QT is 680 ms, and QTc = 527 ms. There are no ST changes indicative of STEMI.
3. There is sinus rhythm with one PAC. The notable feature is a very long QT interval. The computer read this
as QT = 492 ms, with QTc = 518 ms. But when the QT gets very long, computers become inaccurate and you
must read it by hand.
4. This 80 yo woman had been increasingly lethargic for 2 days, and presented hypotensive (SBP =70), pale,
and tachycardic. She had not been complaining of chest pain. It was uncertain whether she had chronic
atrial fibrillation or not. She was afebrile. Here is the initial ECG. There is an irregularly irregularly rhythm (atrial
fibrillation) with a very fast ventricular response. There is an injury pattern, with ST elevation in II, III, aVF, reciprocal ST depression in I
and aVL, and ST depression of posterior injury in precordial leads
5. A 58 yo male with a h/o CABG developed on and off chest pain which became constant while playing golf.
There is sinus rhythm and clear posterolateral STEMI, with ST elevation in I and aVL and reciprocal ST depression in III and aVF. There
is ST depression in right precordial leads diagnostic of posterior STEMI.