Tag Archives | ECG

New STEMI Diagnostic Criteria from the ACCF/AHA

Here’s a snippet from the December 2012 release of the new 2013 AHA STEMI Management Guidelines, which has a couple of subtle changes to the diagnostic ECG criteria for STEMI, which may come up in the exam.  You can access the full guideline here:

“STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis. Diagnostic ST elevation in the absence of left ventricular (LV) hypertrophy or left bundle-branch block (LBBB) is defined by the European Society of Cardiology/ACCF/AHA/World Heart Federation Task Force for the Universal Definition of Myocardial Infarction as new ST elevation at the J point in at least 2 contiguous leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads (7). The majority of patients will evolve ECG evidence of Q-wave infarction. New or presumably new LBBB has been considered a STEMI equivalent. Most cases of LBBB at time of presentation, however, are “not known to be old” because of prior electrocardiogram (ECG) is not available for comparison. New or presumably new LBBB at presentation occurs infrequently, may interfere with ST-elevation analysis, and should not be considered diagnostic of acute myocardial infarction (MI) in isolation (8). Criteria for ECG diagnosis of acute STEMI in the setting of LBBB have been proposed (see Online Data Supplement 1). Baseline ECG abnormalities other than LBBB (e.g., paced rhythm, LV hypertrophy, Brugada syndrome) may obscure interpretation. In addition, ST depression in ≥2 precordial leads (V1–V4) may indicate transmural posterior injury; multilead ST depression with coexistent ST elevation in lead aVR has been described in patients with left main or proximal left anterior descending artery occlusion (9). Rarely, hyperacute T-wave changes may be observed in the very early phase of STEMI, before the development of ST elevation. Transthoracic echocardiography may provide evidence of focal wall motion abnormalities and facilitate triage in patients with ECG findings that are difficult to interpret. If doubt persists, immediate referral for invasive angiography may be necessary to guide therapy in the appropriate clinical context ((10),11). Cardiac troponin is the preferred biomarker for diagnosis of MI”.


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VAQ 8 Answer

Here’s the answer to VAQ 8.  It’s a bit of tricky one, and there’s bound to be some controversy over what the actual rhythm is, and what sequence one should do things in the management.  NB I didn’t mention DCR as part of the management, as the rhythm is unclear.  I don’t think you’d fail if you DCR’d this guy for a possible SVT, but given that you’d be giving sedatives to do it, you’d probably want to do it afer you’d thrombolysed, started inotropes and intubated him.  Anyway hope you find this useful, and feel free to leave a comment!


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This was a real case I had last week, which threw up some real challenges.  Given my lack of ECG VAQ’s I thought I’d put this one up as it was a real doozy.  Good luck!

Here’s the link to VAQ 8.


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Don't Miss These ECG's

My ECG content has been a bit lacking on the site, mainly because so many other sites do it so well, but alas you will get ECG’s in the exam, I got two in the VAQ and one in the SCE, and none of them were easy, so I’ve decided to beef up the ECG quota and get teaching.

As the ED Consultant you are the last bastion of ECG diagnosis in the ED, and if you don’t have a list of “if I miss it, no-one else will pick it & the patient may die” ECG’s then fear not, in this 2-part video whiteboard session I run through 6 of the most serious and subtle ECG’s that you can’t afford to miss, in the exam, or in real-life!  Of course there’s ischemic ECG’s, electrolyte abnormalities and toxicologocal ECG’s, and I’d hope by now you can pick those, but here is a collection of rare but important ECG’s that frequently get missed (one of these cropped up in my written exam, and the pass rate was around 30% – go back to the 2009.1 writtens to see which one it was), so don’t be slack, watch & learn, & you may just save someone’s life one day with this knowledge! 

Every time I see a patient with syncope, unexplained collapse or altered conscious state – I run through this list, it applies to children and adults.

Don’t Miss These ECG’s – Part 1


Don’t Miss These ECG’s – Part 2


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EM Educational Videos at Rahul's EM Blog

My WPW & AF whiteboard session has gone around the globe, and I was contacted by a Canadian Emergency Physician, Rahul, who saw the video and very nicely gave me a link to his site, and it appears he’s been making similar videos for a while! They’re great summaries, with the same “tutorial feel” to them, with Rahul talking and drawing on a digital whiteboard simultaneously.  I reckon they’re pretty good, and worth a look, so check them out at Rahul’ EM Blog.


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Amal Mattu: ECG's for the Emergency Physician – book review

This is a quick review of Amal Mattu’s (one of the Godfathers of Emergency Medicine Education!) excellent book: ECG’s for the Emergency Physician 1 ( ECG’s for the Emergency Physician 1
). It is essentially a question and answer format book of ECG’s, with 50-odd ECG’s in the front half, each with a short question stem, and the back half of the book is where you’ll find the answers.  It starts out with fairly straightforward ECG’s, and they get more tricky as you progress.  The answers are succinct, but expand on electrophysiologic and clinical concepts as required.  I used this book when preparing for the Fellowship exam as it almost exactly mimics the style of questions you will get in the exam (mainly the VAQ’s and SCE’s), with a short question stem, and an ECG to describe & interpret. 

I photocopied the book (sorry Amal and your copyright lawyers), and cut the ECG’s out, and did the same with the answers, and pasted the answers on the back of the corresponding cards, so I could use them as flashcards (rather than having to flick through the whole book looking for the answer to each ECG).  Although blatantly illegal, I just found it more efficient to do it this way, and it was a great way to add some variety to my study time. (ie I’d do an hour or two of textbook slog, then break it up by doing some ECG flashcards).

ECG Intepretation is an “Expert” level topic in the Fellowship exam, and this is one way to really hone your ECG skills.  Great book and highly recommended.

There’s a second volume you can also get if you really want to go nuts ( ECGs for the Emergency Physician 2
), but volume 1 will probably suffice for most people.

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Inaugural EDExam Whiteboard Session: WPW & AF

I found that I was explaining this concept (AF & WPW) to Registrars quite frequently, and drawing the diagrams of the heart/accessory pathways on scraps of paper that I’d then throw in the bin, and recently thought “I should just record this on video and put it on youtube so I don’t have to keep drawing this out every time!” Around the same time I stumbled across the Khan Academy, started by Salman Khan who was using these types of videos to teach his nephews in a different city maths.  So Ive come up with the EDExam Whiteboard sessions, as a way to provide tutotials for people who may not get on the floor teaching, or need tricky concepts in Emergency Medicine visually and verbally explained. 

Check out our first EDExam whiteboard session over on our youtube channel.  It took me a while to get the technology sussed, but I think it works pretty well (for a first go).  Any comments/suggestions/feedback welcome, and hopefully I’ll get some more of these up soon.



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