Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


EKG Masterclass

Sean Fox, MD

  • Hyperkalemia
    • Peaked T-waves are narrow and symmetric.
    • Wide and irregular QRS morphology.
    • Strongly consider when QRS duration greater than 200 ms.
    • Give calcium early on in the management course.
  • Wellen's Sign
    • Classically, deep symmetric T wave in V1-4.
    • Less commonly, ST elevation with biphasic T wave in V2-3.
    • Highly specific for proximal LAD occlusion.

Board Review: Cardiology and EMS

Mike Runyon, MD

  • Level of personal protective equipment (PPE):
    • Level A: a self-contained breathing apparatus and a totally encapsulating chemical-protective suit.
    • Level B: a positive-pressure respirator and nonencapsulated chemical-resistant garments, gloves, and boots.
    • Level C: consists of an air-purifying respirator and nonencapsulated chemical-resistant clothing, gloves, and boots.
    • Level D: consists of standard work clothes without a respirator.
  • Vesicants, also known as blistering agents, initially cause erythema and itching. They quickly progress to blisters that appear similar to those of second-degree burns.
  • Accelerated idioventricular rhythm should not be treated with anti-arrthymics

Asymptomatic Hypertension in the ED: What’s the Urgency?

Phillip Levy, MD, MPH

Wayne State, Department of Emergency Medicine

  • Emergency department patients are more than twice as likely (16.3% vs. 6.8%) to have severely elevated BP than individuals seen in the primary care setting. Niska R. NCHS Data Brief. 2011;72.
  • Despite the relative frequency of severe BP elevations, there is no consensus on how to approach such patients absent overt evidence of target organ damage. Shayne and Pitts. Ann Emerg Med. 2003;41:513-29.
  • For patients with asymptomatic BP elevations, the focus of ED management should be on identification of true hypertension, referral to outpatient follow-up, disease-specific education, and, for some initiation of chronic antihypertensive therapy - achievement of BP "cosmesis" is unnecessary and potentially detrimental. Decker et al. Ann Emerg Med 2006;47:237-49
Filed under: Cardiac No Comments

Pericarditis / Myocarditis

  • Pediatric systolic blood pressure should be 70+ (age x 2)
    • Consider 90 + (age x 2) if you want to be more conservative
  • Change your initial fluid bolus to 10mL/kg if you are considering restrictive cardiac disease; watch carefully for signs of fluid overload!

Littmann’s EKG Course: Miscellaneous

  • S1Q3T3 is a pattern of acute right heart strain and is not specific to pulmonary embolism.  It may be seen with severe pneumonia, ARDS, tension pneumothorax, or pulmonary hemorrhage.
    • Watch for RSR' in V1, this is a very ominous finding!
      S1Q3T3 Pulmonary Embolism

      An excellent example of S1Q3T3 in a patient with massive PE. Note the ominous RSR' finding in V1.

      S1Q3T3 no PE

      A similar EKG in a patient with pneumonia, hypoxia, and ARDS... with no PE on CTA.

  • Always check the EKG in a syncopal episode.  Brugada pattern - coved ST segments in V1&V2 - is an indication for ICD placement.

    Brugada Pattern

    This young, healthy patient presented with syncope. He died after being sent home with this EKG. It should have been the indication for an implanted ICD.


Littmann’s EKG Course: T Waves

  • 1-3mm upsloping ST depressions in V1-V6 with tall, symmetric T-waves is highly concerning for hyperacute proximal LAD STEMI.

    New Wellens LAD

    This EKG was taken prior to cath of a patient with a 100% proximal LAD lesion. Note the upsloping ST segments.

    • N Engl J Med 2008;359:2071-3       Heart 2009;95:1701-6
  • The T-waves in hyperkalemia are often simply narrow-based rather than tall.  Because of this, the computer software often "double counts" the heart rate.


    This patient has a K+ of 7.2. Note that the computer "double-counts" the heart rate.


Littmann’s EKG Course: The ST Segment

  • When faced with a QRS with a terminal "notch" and hammock shaped ST's:
    • Consider pericarditis if tachycardic.
    • Consider benign early repolarization if normal rate.
    • Consider hypothermia if bradycardic.

      Tachycardia, PR depression in lead II, and PR elevation in aVR is concerning for pericarditis.

      Benign Early Repolarization

      In the setting of normal rate and a young healthy patient, this EKG is most consistent with benign early repolarization.


      Osborn waves with hypothermia look similar to the above two examples but are seen in bradycardia.

  • The "aVR sign." Chest pain, ST elevation in aVR and diffuse ST depressions is 80% sensitive for LAD main and high mortality.

    aVR sign

    Pay close attention to aVR in this EKG; this patient has a 100% occlusion to the LAD.

Tagged as: , , 29 Comments

Littmann’s EKG Course: The QRS Complex

  • LBBB makes most EKG's unreadable, except in those where the ST is concordant.  Watch for STEMI!


    Inferior STEMI seen in II, III, aVF in a patient with LBBB. ST segments should not be concordant!

  • Electrical alternans can be easy to miss but may indicate an underlying effusion.

    Electrical Alternans

    Electrical Alternans in an HIV patient with an effusion.

  • The finding of marked axis deviation, RBBB, and prolonged PR interval is concerning for trifascicular block.  In a patient with unexplained syncope this is a potentially lethal finding; admit for emergent pacemaker.
    Trifascicular block

    RBBB, left posterior fascicular block, and prolonged PR: trifascicular block in a patient with syncope. Emergent indication for pacemaker!




Littmann’s EKG Course: P waves

  • P-wave inversions in lead I are never normal.  Consider 3 common etiologies:
    1. Ectopic atrial rhythm - V1-V6 also reveal inverted P's from an abnormal depolarization site.
    2. Dextrocardia - V1-V6 show r-wave regression.
    3. Limb lead reversal - lead II shows a "flat line", repeat the EKG with a better tech.
  • Parkinsonian tremor and oscillators both can cause a 5hz artifact (300bpm) and are mistaken for aflutter.  Look for sinus rhythm in other leads.

    Parkinsonian tremor masquerading as artifact

    NSR seen in lead III with "flutter waves" in other leads. This patient has Parkinsons.

  • Always look for atrial flutter if the computerized interpretation on an EKG is any of these red flags; the computer routinely misinterprets flutter.
    1. "Sinus tachycardia with 1° AV block"
    2. "Sinus tachycardia with short PR"
    3. * cannot find p-wave axis
      Missed atrial flutter
      Look for the red flags!

Chest Pain Master Class

  • Cocaine Chest Pain - patients with cocaine chest pain typically do well. Patients with positive urine cocaine tests are NOT stressed at our institution. They can be safely ruled out with serial troponins.
  • Erlanger protocol doesn't just mean 2 EKGs, 2 sets of enzymes, 2 hours 'n go.  They require a true reevaluation prior to discharge, EKG comparison and followup the next day - and must be low-risk.
  • In the ED evaluation of the chest pain patient, classic risk factors like DM, HTN, and tobacco use are "nuisance" variables and do not affect your pretest probability. Clinician gestalt is overwhelmingly correct.
  • A Coronary Calcium CT score of zero is good for approximately 1 year (and possibly longer in those aged 35-45).