Crash Course in Advanced EKG

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Dr. Amal Mattu gave a fantastic lecture on advanced EKG interpretation at the AAEM Conference in NYC today. For those who were unable to attend, here are some highlights:

1.) Sgarbossa Criteria helps diagnose an acute MI in the setting of an LBBB. Concordance bad. Discordance good (but TOO much discordance is bad too).
Elegantly shown from EMS12lead.com – http://tinyurl.com/ndw285

2.) Wellens Syndrome describes T wave changes indicating a proximal LAD lesions.
Type 1 are deep, symmetric TWI which hit you square in the face and Type 2 are subtle, biphasic changes.
Nicely displayed here: http://pages.mrotte.com/wellens/five.png

3.) Posterior MIs present as ST depressions in V1-V3 with tall R waves (N.B., the R waves are actually evolving Q Waves)
Get a posterior lead EKG to look for ST Elevations (Leads V7-V9: http://lifeinthefastlane.com/wp-content/uploads/2011/09/posterior-leads.gif)

4.) aVR: unloved, forgotten. Elevations here can be indicative of LMCA, proximal LAD occlusions. Bad, bad, bad.

5.) STEMI vs Pericarditis? Keep this in mind:
a.) ST Elevations with reciprocal ST Depressions anywhere (except aVr or V1) = STEMI
b.) ST Elevation greater in III than II = STEMI
c.) Morphology of ST Segment is either convex or flat = STEMI

6.) BER

7.) aVL changes can present as early reciprocal changes of impending doom. A TWI in this lead alone might evolve into an inferior wall STEMI.

8.) Hyperacute T Wave – not just tall, pointy, and would hurt to sit on… but also can present subtlety… of normal height… with a straight initial up-sloping of a T wave.

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