HyperK at its finest.
After some Calcium, Bicarb, & Insulin… this EKG tightened up to near-normal in appearance.
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
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.
60 year old female comes to your ED after tripping and breaking her fall with her right hand. Now she complains of wrist pain, and you decide to order some imaging. You notice something suspicious.