- 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!
- Always check the EKG in a syncopal episode. Brugada pattern - coved ST segments in V1&V2 - is an indication for ICD placement.
- 1-3mm upsloping ST depressions in V1-V6 with tall, symmetric T-waves is highly concerning for hyperacute proximal LAD STEMI.
- 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.
- LBBB makes most EKG's unreadable, except in those where the ST is concordant. Watch for STEMI!
- Electrical alternans can be easy to miss but may indicate an underlying 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.
- P-wave inversions in lead I are never normal. Consider 3 common etiologies:
- Ectopic atrial rhythm - V1-V6 also reveal inverted P's from an abnormal depolarization site.
- Dextrocardia - V1-V6 show r-wave regression.
- Limb lead reversal - lead II shows a "flat line", repeat the EKG with a better tech.
- "Sinus tachycardia with 1° AV block"
- "Sinus tachycardia with short PR"
- * cannot find p-wave axis
- 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).