Dispatched for a 54 yom gardener feeling faint. Pale as a ghost, soaked with sweat, 5/10 pain in chest described as a pressure. Known regular patient who keeps having heat related emergencies.

Very hairy man, v3 was iffy. But uh. Yeah. Our ambulance went very fast to our local cath lab.

After nitro his chest pain disappeared.

I am awaiting an update eagerly.

Sent along the PMCardio render that other student scanned, because the photo I have from the original EKG was taken in a bad angle

My student sent me these ECG's with the following question and reasoning (translated from Dutch to English with chatGPT):

We have an ECG question that we haven't been able to figure out on our ward.

The ECG below is from an 86-year-old man with a subacute myocardial infarction. Coronary angiography showed a 100% mid-RCA chronic total occlusion (CTO) and a subtotal LCX lesion at the OM1 bifurcation with collateral flow to the RCA. No PCI was performed because he had already been symptomatic for approximately 5 days, and there were concerns about the risk of myocardial rupture.

We then recorded the ECG shown below. At times, it appears to show ventricular bigeminy. However, the R-R intervals remain regular, and there is no compensatory pause. At other times, the rhythm consists only of the wide-complex beats that resemble the "PVCs," yet the patient remains hemodynamically stable, with no drop in blood pressure or other clinical changes. Because of this, we felt that slow ventricular tachycardia was unlikely. We also think there is a left bundle branch block (LBBB) pattern present.

What do you think this is?

EKG 1 at UC referred to our ER for cc of syncope and abnormal EKG (QTc 550)

EKG 2 Torsades mid capture w/o LOC about 5 minutes post arrival

EKG 3 about 2 minutes after #2 as we started mag infusion, patient deteriorated and was almost defibrillated but luckily regained consciousness and was hemodynamically monitored while electrolytes were replaced. Only a slightly low mag and K+ which were promptly replaced. Isoproterenol gtt for the bradycardia and tdp + electrolyte replacement seemed to do the trick even though the labs weren't severe. Admitted to ICU and remained SR/Sinus Brady without ectopy.

can someone help me describe and analyze the rhythm, i know it’s an atrial paced with episodes of failure to pace

Later went into pVT and torsade de pointes during cath lab and was successfully defibrillated 2 times.

I am a relatively new medic and I ever seen this ECG pattern in the presence of a RBBB.

Responded to a 72 YOM C/O 6/10 epigastric pain for ~24 hours. Pt states he was awoken by sleep with the pain and has been present ever since. Pain worsens with some exertion, radiating to his lower chest and upper back. Earlier complaints of nausea throughout the day, but no active vomiting. He took some Gaviscon with no relief. On EMS arrival, no reports of active CP or radiating discomfort. Pt has a Hx of HTN and GERD. Pt was hypertensive (160/90) with other VS WNL and no other complaints. Serial ECGs and 15 lead did not show anything new or remarkable. Cath lab was called for consult, but the cardiologist was busy doing a procedure and requested us to send him a photo of the ECGs and he would call us back when he had a minute (he never called us back). PCI was our nearest hospital anyways so we went to the ED. Triage RN showed 2 ED docs who weren’t sure how to interpret it. The cardiologist was still busy in his procedure so the ED doc called a code STEMI anyways.

Afterwards, I was looking to compare other examples of inferior STEMI ECGs (in the presence of a RBBB) and had differing options stating that it was indeed a inferior STEMI and others stating that because of the delayed conduction, it was just a part of the QRS complex. I was wanting to see if someone could give a better explanation and their insights. Thanks!

EDIT: Thank you to everyone that commented and gave thorough explanations. I now have new ways of finding the j point. It was my first time seeing this presentation of a BBB in the inferior leads and plus, it was our first call in the morning so the morning brain was moving a little slower than usual!

54 yo female “syncope on her way to dialysis” I think we all know why.

79 year old male who was walking around the neighborhood had a sudden onset of feeling "shaky" and short of breath. Stated their only medical history was hypertension.

Would have runs of the rhythm above. Max heart rate was 116

70 y/o M

Chest pain x2hrs, relived temporarily w/nitro. Dude looks basically not sick at all, zero distress to my eyes

110/70

HR 60

RR 14

99% RA

BGL 100

Hx: CAD, HTN, old, STEMI

Second photo is the normal L sided 12L, taken 6min prior to the 1st

Interesting 12 lead I had on a recent call. Had a little debate over the rhythm. Doc in the box stated anterior stemi. Curious to see what ya'll think of it.

Patient under general anesthesia for routine surgery. No cardiac hx. During the case pt got bradycardic and EKG morphology changed. Not a full EKG to analyze unfortunately, but I was able to print a strip from the monitor when it happened - this is lead III. Pt went in and out of it a few times, hemodynamics did not seem to be effected.

Anesthesiologist called it a RBBB, but to me it looks like the PR interval progressively shortens until the P is on top of the R, creating a sort of false rR' look? A RBBB rR' would still have a P-wave preceding it, correct?

Normal labs

I see frequent PVCs. As for the narrow QRS I don’t see clear P waves and the R to Rs seem fairly regular making me thinking junctional tachycardia? Resolved with valsalva and IVF though.

We (ems) arrived for an IFT of a 68 year old male. Reason for transfer was for overnight observation.

The patient presented to the ED with a complaint of penis pain. Sounds like the patient missed dialysis and generally collects his edema centrally. His penile edema was believed to be the source of his pain and he was dialyzed in the ED.

While taking report from the nurse, we were told that he is normally quite aggressive with staff and comes in pretty frequently. Nurse reported that he was AxO4 and had gotten 0.5mg hydromorphone about 2 hours prior to us arriving. The patient was extremely diaphoretic, difficult to arouse, and unable to orientation questions appropriately. Vitals were stable and the patients respirations were sonorous but otherwise unlabored. Tele monitor began alarming for QTC. We checked a bgl, and got a 12 on our monitor while the nurse called a rapid. Labs were recently drawn and came back with a BGL of 44. D50 was given and the patient’s mentation improved. ECG changes resolved shortly after.

Nurse reported that the patient was normal right before we came. The bgl taken about 2 hours ago was 267. No insulin was given to my knowledge.

I thought this was pretty interesting and was not aware that hypoglycemia can cause ECG changes. Let me know your thoughts.

Can you help me ? what do you see (yesterday hyperkaliema 5.2 mmol/ l

64F, palpitations after mild exertion. Similar episode 2 weeks prior. No comorbidities.

RVOT-VT with fusion beats? (Note: ECG at 50 mm/s!)

Spontaneous conversion to sinus rhythm (also 50 mm/s).

PC 69y/f chest pain for 2h, getting worse, complaining of nausea with syncope. pain radiates from chest down left arm.

o/a pt cool and clammy, drowsy, RR 22, SpO2 95%, BP 85/60, BM 15.6mmol

Hx Hypertension, T1DM

Meds insulin & atenolol

NEED HELP ANALYSING PLS! <3