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ECG examples and quiz

Question 1

A 35 year old man presents with palpitations. He has been drinking heavily with friends over the weekend. This is his ECG. Present your
findings and give a diagnosis.
Presentation:
Rate 100 – 150

Rhythm Irregularly irregular

Axis Normal

PR/P-wave No p-wave seen. Fibrillating base line

QRS Narrow

ST/T-wave Normal

QTc/other Normal

Diagnosis:
This ECG shows atrial fibrillation (AF) with a fast ventricular response. With this history the underlying diagnosis would fit with a ‘holiday
heart’ syndrome.
Question 2

A 45 year old business man presents with a feeling that his heart is racing. He also has some shortness of breath. This is his ECG. Present
your findings and give a diagnosis.
Presentation:
Rate 150

Rhythm Regular

Axis Normal

PR/P-wave No p-waves. Seesaw baseline

QRS Narrow

QTc/other Normal

Diagnosis:
This is atrial flutter. The atria contract at 300 beats per minute causing a ‘seesaw’ baseline. Beats are transmitted with a 2:1, 3:1 or 4:1
block, leading to ventricular rates of 150, 100 and 75 BPM respectively.
Question 3

A 75 year old man with a history of COPD presents with fever and increased sputum production. An ECG is taken in the emergency
department. What does it show?
Presentation:
Rate 100 – 150

Rhythm Irregularly irregular

Axis Normal

PR/P wave Polymorphic p-waves (see arrows)

QRS Narrow

ST/T wave Normal

QTc/other Normal

Diagnosis:
This is polymorphic atrial tachycardia. It occurs in respiratory disease and reflects an aberrant foci of atrial excitation. The morphology of
the p-waves is therefore variable but all p-waves are transmitted via the bundle of His and therefore the QRS complexes are all the same.
Question 4

A 65 year old man is found unresponsive. He has no central pulse and is making no respiratory effort. Surprisingly someone has done an
ECG. What would you do?
ANSWER:
We will not go through the ECG as the most important information is in the clinical history.

This is pulseless electrical activity (PEA). It is the most extreme example of why you should
look at the patient in conjunction with the ECG! There are no specific ECG changes in PEA
– the most important thing is to recognize that this patient is in cardiac arrest and to start
chest compressions and Advanced Life Support (ALS) immediately.

However, the ECG may help you ascertain the underlying pathology. In this case there are
low voltage QRS complexes which may simply due to large body habitus or could
indicate pathology ‘interrupting’ the signal between the heart and the electrode. This can
include pericardial fluid or pneumothorax. This is worth thinking about as tamponade and
tension pneumothorax are both reversible causes of PEA.
Question 5

A fit and well 31 year old man presents for a routine insurance medical. This is his ECG. Present your findings and give the diagnosis.
Presentation:
Rate 85

Rhythm Regular

Axis Normal

PR/P-wave Normal

QRS Narrow

ST/T-wave Normal

QTc/other Normal

Diagnosis:
This is a normal ECG. There are many variants of normal and it is worth looking at as many ECGs as possible to get exposed to the
common variants. It is crucial to remember that a very sick patient can have a normal ECG so always use all the information available to
you and don’t rely on the ECG alone.
Question 6

A 65 year old man with a history of ischaemic heart disease is found unresponsive. He has no central pulse and is making no respiratory
effort. This is his ECG. What is the diagnosis and what will you do?
Presentation:
Rate 150

Rhythm Regular

Axis Left axis deviation

PR/P wave Not visible

QRS Wide

ST/T wave Unable to assess

QTc/other Unable to assess

Diagnosis:
This is ventricular tachycardia (VT) and in this case the patient is in cardiac arrest as they have no central pulse. He should be treated as
per ALS guidelines with chest compressions beginning immediately. This is a shockable rhythm and should be treated using the ALS
algorithm with DC cardioversion and adrenaline.

If the patient was conscious the ALS algorithm would not be necessary and management depends on symptoms. If acutely symptomatic
urgent DC cardioversion is indicated. If there were no symptoms of decompensation (e.g. shortness of breath, chest pain, shock, confusion,
syncope) he could be managed pharmaceutically in the first instance.
Question 7

A 40 year old lady comes to the emergency department from her husband’s funeral with a sensation of ‘fluttering’ in her chest. She is
feeling very anxious. An ECG is performed. What is the diagnosis?
Presentation:
Rate 160

Rhythm Regular

Axis Normal

PR/P wave Not visible

QRS Narrow

ST/T wave Slight lateral ST depression

QTc/other Normal

Diagnosis:
The history makes a sinus tachycardia secondary to anxiety seem likely. However, sinus rhythm rarely goes above 120 BPM and in this
case there are no p-waves visible. This is therefore a junctional supraventricular tachycardia (SVT): a narrow-complex tachycardia
originating from the AV node. Treatment includes vagal manoeuvres followed by adenosine.

Atrial flutter would be a reasonable differential as the rate is regular and close to 150. However, there is no variation in the baseline and not
a hint of sawtooth appearance so this is less likely than SVT.
Question 8

A 58 year old man who attends the emergency department with chest pain loses consciousness whilst he is having his initial ECG. He has
no central pulse and is taking occasional deep breaths. What is going on?
Presentation:
Rate Initially 100, then 300

Rhythm Initially regular, then irregular

PR/P wave Initially present, then unable to visualise

QRS Initially narrow, then wide

Initially massive ST elevation in II III and aVF with reciprocal depression in I and
ST/T wave
aVL. Then unable to visualise

QTc/other Unable to assess

Diagnosis:
This is ECG initially shows an inferior STEMI, which then deteriorates into ventricular fibrillation (VF).
The breaths described are agonal breaths – this does not represent normal respiratory effort and
resuscitation for cardiac arrest with CPR should be started immediately.

Remember: in collapse with abnormal breathing and no central pulse always start CPR.
Question 9

A 72 year old lady presents with collapse. This is her ECG. Present your findings. How would you proceed?
Presentation:
Rate 50 bpm

Rhythm Regular

Axis Normal

PR/P wave Normal

QRS Narrow

ST/T wave Normal

QTc/other Normal

Diagnosis:
This is sinus bradycardia. In a young fit person this rate may be normal. However, in the
context of a more elderly person and presenting with collapse it should be further
investigated. A medication review, blood tests including thyroid function, repeat ECGs,
chest x-ray, echocardiogram and 24-hour tape would be reasonable first-line investigations.
Question 10

A 60 year old man presents with tight central chest pain radiating to his left shoulder. This is his initial ECG. Present your findings and give
a diagnosis.
Presentation:
Rate 90

Rhythm Regular

Axis Normal

PR/P wave Normal

QRS Narrow

ST/T wave Grossly elevated in V2, V3, V4, V5 and V6. Reciprocal depression in II, III and aVF.

QTc/other Normal

Diagnosis:
This patient has ST elevation in the anterior and lateral leads. This is therefore an anterolateral ST elevation MI (STEMI). This dramatic ST
elevation is also referred to as ‘tombstone’ ST elevation, both for its resemblance to a tombstone and as a reflection on the poor prognosis
without rapid intervention.

What would you do? This patient should be assessed and treated urgently for a STEMI, ideally with primary angioplasty (primary coronary
intervention: PCI). Immediate management also includes aspirin, clopidogrel, heparin, nitrites, morphine and controlled oxygen.
Question 11

A 55 year old renal dialysis patient presents to the emergency department having missed his last session of dialysis due to feeling dizzy
and unwell. This is his ECG. Present your findings and give a diagnosis.
Presentation:
Rate 100 – 150

Rhythm Irregular

Axis Unable to establish

PR/P wave Not visible

QRS Widened

ST/T wave Merged with QRS

QTc/other Unable to assess


Diagnosis:

This is the classic sine wave ECG pattern of severe hyperkalaemia. It can quickly deteriorate into
ventricular fibrillation (VF). There are three main ECG changes in hyperkalaemia:

1. In the early stages of you may only see tenting or peaking of the t-waves.

2. Later changes involve a decrease in height of the p-wave and increase in length of the PR interval as
conduction is slowed through the atrial myocardium.

3. This is later accompanied by widening of the QRS and merging of the QRS complex and the t-wave.
This pattern eventually deteriorates to the sine wave pattern seen above.

What would you do? This is a medical emergency. Treatment is with 10ml 10% calcium gluconate for
cardioprotection, followed by 10 units of fast acting insulin (with 50ml 50% dextrose) to drive potassium
into the intracellular space. Inhaled salbutamol has a similar effect if there is no IV access. Bicarbonate
50ml IV can also be given. Ultimately total body potassium needs to be decreased – in this case urgent
dialysis or haemofiltration is indicated.
Question 12

A 65 year old woman presents with chest pain radiating to her jaw and down her left arm. It feels like her ‘normal’ angina but on this
occasion it has not eased with GTN spray. This is her ECG. Present your findings and give the diagnosis.
Presentation:
Rate 60

Rhythm Normal

Axis Normal

PR/P wave Normal

QRS Normal

ST/T wave T wave inverted in II III and aVF , V4 – V5. ST elevation in aVR>1mm

QTc/other Normal

Diagnosis:
On initial inspection this looks like an inferolateral NSTEMI. There is (we assume new) t-wave inversion
in consecutive leads which fit with an anatomical territory (inferolateral) and most importantly there is
ongoing ischaemic sounding chest pain not eased by GTN. However, note the ST elevation in aVR. As
such, this is more suggestive of critical left main stem occlusion. This ECG should therefore be
discussed with cardiology with a view to urgent PCI.
Question 13

A 25 year old man presents with a collapse which occurred as he was playing in a football match. He has suffered episodes of fainting in
the past. This is his ECG. What is the diagnosis?
Presentation:
Rate 60

Rhythm Regular

Axis Normal

PR/P wave Shortened PR interval

QRS ‘Slurred’ upstroke on QRS

ST/T wave Normal

QTc/other Normal
Diagnosis:

This picture of shortened PR interval and slurred QRS upstroke – also know as a ‘delta
wave’ – are typical of Wolff-Parkinson White (WPW) syndrome. These changes represent
transmission through an accessory pathway. The history of collapse in this case is
concerning as these episodes could be due to re-entrant tachycardias which can be fatal.
Other features not seen here which may be present in WPW include a dominant R wave in
V1 and T wave inversion in the anterior chest leads.

A further example to illustrate the delta wave is shown below:


Question 14

An 18 year old man signs up to join the army. He is fit and well. This is his ECG taken at his medical examination. Is it normal?
Presentation:
Rate 60

Rhythm Regular

Axis Normal

PR/P wave Prolonged PR interval

QRS Wide in the inferior lateral leads

ST/T wave Abnormal in V1, V2 and V3 with unusually-shaped ‘coved’ ST elevation

QTc/other Normal

Diagnosis:
No it is certainly not normal. This ECG is characteristic of Brugada Syndrome (Type 1). In leads V1 – V3
there is >2mm ST elevation, the T waves are inverted and the ST segment has a characteristic ‘coved’
shape. This condition has a high risk of sudden death from ventricular fibrillation (VF). Treatment is with
an implantable cardioverter-defibillator (ICD).
Question 15

A 58 year old smoker presents with tight epigastric pain. He looks sweaty and unwell. One of the nurses shows you his routine ECG. What
is the diagnosis?
Presentation:
Rate 45

Rhythm Regular

Axis Normal

QRS Narrow

ST/T wave Dramatic ST depression in V1 – V3

Diagnosis:
This is acute posterior MI. What we see in the anterior leads is the equivalent of ‘upside
down’ ST elevation. Imagine flipping the ECG paper over and looking at it from behind or
looking at the ECG in a mirror held along the inferior border. You would see ST elevation
(the deep ST depression reversed), t-wave inversion (upright t-waves seen upside down)
and this represents what is going on in the posterior region of the heart. Another clue is the
bradycardia seen in this case: the vessels supplying the posterior of the heart also supply
the ‘pacemaker’ region of the SA node.
Question 16

A 29 year old presents with central chest pain. She has a history of recent flu-like illness but no significant past medical history. This is her
ECG. What is the diagnosis?
Presentation:
Rate 60

Rhythm Regular

Axis Normal

PR/P wave PR segment depression

QRS Narrow

ST/T wave Widespread ST elevation (saddle shaped)

QTc/other Normal

Diagnosis:
The diagnosis is pericarditis. Pericarditis often presents in young people after a history of
viral illness. He you can see the characteristic widespread saddle-shaped ST elevation and
PR depression.
Question 17

A 70 year old woman presents with sudden onset of chest pain. The pain is crushing in nature and radiates up to her jaw. This is her ECG.
Present your findings and give the diagnosis.
Presentation:
Rate 100

Rhythm Regular

Axis Normal

PR/P wave Every p-wave followed by a QRS

QRS Narrow

ST/T wave ST elevation in II III and aVF

QTc/other Normal

Diagnosis:
This ECG shows ST elevation in the inferior region of the heart. This patient should be
assessed and treated urgently for a STEMI, ideally with primary angioplasty. Immediate
management also includes aspirin, clopidogrel, heparin, nitrites, morphine and controlled
oxygen.
Question 18

A 45 woman has just stepped off a flight from Japan when she develops severe pleuritic chest pain and shortness of breath. On
examination her chest is clear. Present your findings. What is the most likely diagnosis?
Presentation:
Rate 100

Rhythm Regular

Axis Right axis deviation

PR/P wave Normal

QRS Wide – right bundle branch block (RBBB)

ST/T wave T wave inversion in lead III

QTc/other Normal

Diagnosis:
Given the history, examination and ECG findings, pulmonary embolism (PE) is the most likely diagnosis. In PE the
constellation of ECG findings of ‘S1Q3T3’ is classically described. It refers to a deep S wave in lead I, pathological Q
wave in lead III and inverted T in V3 (and other anterior leads). However, though it may be classical it is extremely rare in
clinical practice! The most commonly observed ECG abnormality in PE is a sinus tachycardia. There may also be RBBB
or a RV strain pattern with T wave inversion in V1 to V4.
Question 19

It is early January and a middle-aged man is found lying in a park. He is surrounded by bottles of Buckfast and has a GCS of 9. An ECG is
performed in the ambulance. What is going on?
Presentation:
Rate 50

Rhythm Regular

Axis Normal

PR/P wave Normal

QRS Narrow

ST/T wave Normal

QTc/other J wave visible after the QRS

Diagnosis:
This patient is hypothermic. The positive deflection after the QRS but before the t-wave is an Osbourne
J-wave; these can also be seen in subarachnoid haemorrhage (SAH) and hypercalcaemia. Classically a
hypothermic patient is bradycardic and their ECG will show J-waves. Treatment in this case would be
with gentle rewarming provided there was no immediate risk to life from an arrhythmia.
Question 20

A 61 year old woman presents to the emergency department with diarrhoea and vomiting. She has recently been started on furosemide by
her GP for hypertension. What has happened?
Presentation:
Rate 85

Rhythm Regular

Axis Left axis (may be normal)

PR/P wave Normal

QRS Narrow

ST/T wave Normal

QTc/other Prolonged QTc

Diagnosis:
This ECG shows changes consistent with hypokalaemia. This has likely be precipitated by the new loop diuretic. Note
also that furosemide is not a first-line treatment for hypertension.

Classically hypokalaemia causes t-wave flattening with ST depression. In severe cases you may see a U-wave. This is a
positive deflection following the t-wave but preceding the p-wave. These are found in hypokalaemia but also in
hypercalcaemia and thyrotoxicosis.
Question 21

An 18 year old lady is found collapsed at home. When you see her she has a GCS of 10 and you notice that her pupils are dilated. This is
her ECG. Present your findings and give the diagnosis.
Presentation:
Rate 85

Rhythm Regular

PR/P wave Unable to assess

QRS Wide

ST/T wave Wide

QTc/other Prolonged
Diagnosis:
The diagnosis is tricyclic antidepressant overdose. This causes widening of the QRS complex and
lengthening of the QT interval due to blockade of sodium channels.

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[toggle_item title=”What would you do?” active=”false”]

o A,B,C,D,E (ventilation may be required)


o Bloods including paracetamol level; ABG (likely metabolic acidosis)
o Activated charcoal if within 8hrs of ingestion
o Sodium bicarbonate (50ml of 8.4%)
o Give if any arrhythmia or QRS>110
o Further options:
o If ventricular tachycardia: lignocaine (avoid beta blockers, amiodarone and calcium blockers)
o If seizures: benzodiazepines
Question 22

A 45 year old man is found collapsed at home. There is no history available. This is his ECG. What is the diagnosis?
Presentation:
Rate Highly variable – up to 300 bpm

Rhythm Irregular

Axis Unable to assess

PR/P wave Absent during episodes of extreme tachycardia

QRS Wide

ST/T wave Unable to assess

QTc/other Unable to assess

Diagnosis:
This is a difficult case and shows runs of polymorphic VT or Torsades de pointes (literally translated as twisting of the
points). It has a number of causes including medications (especially psychotropics) and electrolyte imbalance. Essentially
any cause of long QT can precipitate polymorphic VT.

Management in the first instance is magnesium 2g IV, independent of serum magnesium concentration before treating
any other cause of long QT.
Presentation:
Rate 60

Rhythm Regular

Axis Normal

PR/P wave Normal

QRS Narrow

ST/T wave Normal

QTc/other Prolonged QT interval

Diagnosis:
This patient has a prolonged QT interval and a cause for this should be sought. Medications are the likely culprits in this
case: both clarithromycin and the antihistamine diphenhydramine can cause prolonged QT interval.

The normal length of the QT varies with heart rate and there is a formula that is applied to correct for this. ECG machines
automatically provide you with this ‘corrected QT’ (QTc). Normal QTc is generally under 480ms. As a rule of thumb, if the
end of the QT interval is over over half way to the next QRS then consider long QT.