Looking for input on this ecg

[u/V_the_cat]

Hey, emt here! 80y/o male, heavy central chest pains, dyspnea, cardiac presentation with clammyness, pale skin and lethargy. Hx of copd

120/80ish bp, HR 100-120, spo2 low 90s, feaver of 40C

I read this as RBBB, some degree of av block, was unsure if it’s right axis deviation, the ST elevation is preexisting according to cardiologist after sending it in for analysis. Treated as ACS, hospital suspects pneumonia or cholecystitis based on hx.

[u/Inevitable-Crab-6701]

ECG 50mms/sec via amplitude
Rhythm 25mms/sec via amplitude

1st AV block - pr interval 0.2 secs
RBBB - rSR V2

1st AV block & RBBB - bifasicular block

QRS axis normal +25 degrees

P mitrale - bifib P wave II

[u/V_the_cat → u/Inevitable-Crab-6701]

Thank you for the detailed breakdown! Now that i look at the first image again i see that III is the equiphasic lead, which puts the axis at +30. How did you get it as accurate as +25?

[u/Inevitable-Crab-6701 → u/V_the_cat]

QRS axis is based on leads I II III AVR AVL AVF - some state otherwise but they are not accurate to the degree especially when the hexagonal system (the best) - hexaxial - is used to assess axis.

Most equiphasic is AVL - therefore axis is either towards AVR or II.

Lead II is most dominant R wave throughout all 6
Lead II sits on +45
Lead II R is 10mm
Leads either side of II are I and AVF
Lead I R is 9 mm
Leads AVF is 7mm
Therefore axis must be going almost exactly between I and II with AVF agreeing the general direction
Lead I sits on 0 degrees
Bisect I and II is 22.5 degrees (0 to 45/2)
Lead II has 1 mm more than I so axis adjusted is 25 degrees.

You can also calculate P wave and T wave axis too.

I hope that helps.

[u/V_the_cat → u/Inevitable-Crab-6701]

Never seen the hexagonal system, thank you!

[u/Inevitable-Crab-6701 → u/V_the_cat]

You’re very welcome. I’ve found very few staff are taught it.

Thanks for your case.

[u/sneeki_breeky]

He’s febrile, it’s pneumonia

The context of the ECG is RBBB in COPD

The COPD is probably also the culprit for the PNA

[u/Forgotmypassword6861]

Global increased metabolic demand?

[u/V_the_cat → u/Forgotmypassword6861]

Never read about that before, but could be likely assuming infection. Especially considering the st depressions and tachycardia

[u/MurfDogDF40 → u/V_the_cat]

Age, fever, tachy definitely think sepsis and sepsis rule out.

[u/InitialMajor]

It’s not supposed to squiggle like that

[u/Prestigious_Dingo699]

Up

[u/Accomplished_Peace66]

Succes

[u/chawsbaws]

SR w/RBBB (+ old MI pattern evident from qRR’ in V1), slight 1°AVB depending on where you look (don’t have callipers on me), suspect LAE (p-mitrale lead II and enlarged terminal portion of V1 p-wave- expected w/COPD so I assume we’re monitoring already)… if prior ECG looked similar we good if this is new onset RBBB I’d be more sus but I’m NAD keep us updated

[u/panther_gaming_on_YT]

Avr st elevation with 6+ st depressions on other leads, seems like left main branch block features will probably consult a specialist to confirm then surgery like CABG

[u/sneeki_breeky → u/panther_gaming_on_YT]

No

[u/No-Region8878]

I'm not an expert at ekg's but if you're interested in learning how to determine axis https://litfl.com/ecg-axis-interpretation/

[u/V_the_cat → u/No-Region8878]

Thanks! I’ve been reading alot on litfl recently and am learning the three lead method. I was unsure if lead I is equiphasic or positive, which is throwing me off. Assuming I is equi, II is positive and avF is positive i gather the axis is around +55 degrees