We return with a new series of EKG’s! Welcome to our new interns.
A big focus on this blog is to have a system. If you skip around then you miss things, and there’s a lot of different things going on with this EKG.
We start with rate. It’s an irregular rhythm (more later) which makes it harder to quickly eyeball the rate. There are 11 complexes on the 10 second EKG though, so 6×11 = 66, the rate is averaging in the mid 60’s.
Rate. Whenever we see irregularity we first think of A fib, but this is irregular because of a bunch of PVC’s, that are in a bigeminy pattern in much of the EKG. Each of the narrow complex beats has a P wave preceding it so this is a sinus rhythm with frequent bigeminy.
Looking at the axis, the QRS is up in I. In aVF we first see a PVC (don’t look at it), and then a narrow complex beat which is also upward. The axis therefore is normal.
PR interval looks fairly normal. The QRS alternates between narrow and wide complexes. The bigeminous beats are wide complex and have a polarity opposite of the narrow complex beats; they are ventricular in origin.
There are some points to be made on the ST waves. We have narrow complex beats to evaluate in each lead and those are the ones we’ll focus on. There’s T wave inversion in III; T wave flattening in the lateral I, aVL, and V6. Let’s zoom in on the central chest leads.
The J point is elevated in each of these leads. It’s only a millimeter, it coves up, and we don’t see reciprocal depression anywhere so it’s probably not indicative of a current STEMI (though it’s still possible). An old EKG would be very helpful here to determine the significance of those J points. Did you see anything else abnormal in the repolarization?
The T wave in biphasic, this can be indicative of Wellen’s syndrome, evidence of a critical LAD lesion.
What did we do with the patient? His troponins were negative as was an abdominal CT. Given the non-specific T wave changes and possible Wellen’s repolarization we put him in the chest pain unit where cardiology … was unimpressed. The first take-home from this EKG though is that look carefully at the T waves even when there’s a lot of distracting PVC’s as T wave flattening is a non-specific abnormality. The other take-home is to remember Wellen’s T waves, this patient was felt not to require intervention, but the next one may.