Case #11
Night Time EKG Amalgam

Case Goals
  • Correctly identify each EKG finding

    • Goals

  • Correctly identify each EKG finding
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    You are the lone ED attending working a chaotic night shift at a small 6-bed critical access hospital. Disaster has struck: a mass casualty at the nearest Level 1 trauma center has led to every unstable patient being dumped on you. All six rolled in simultaneously, obtunded, unresponsive, or actively crashing. To make things worse: Your only nurse tonight is Florence, a 36-year veteran who's more sass than stethoscope, but sharp as a tack when it comes to patient care. You broke both legs last week trying to ride a hospital bed like a surfboard (don't ask). You're wheelchair-bound, can't get to the patients yourself and you don't have time to get a history on each patient. There's 50 patients in the waiting room. The only information you have? An EKG for each patient. Your job: interpret each EKG correctly, direct management, and then call the trauma center with your brilliant (or not) interpretations. Oh — and Florence has had seven espressos, so she's got plenty of commentary. Why don't you start by asking florence to hand you the EKG for room 1?

    Case Complete!

    High Yield points about this case:

    • Hyperkalemia on EKG: Peaked T waves, widened QRS, prolonged PR interval.
    • Digoxin toxicity on EKG: Frequent PVC's, Slow A-fib, AV Block. NOTE: Salvador Dali sign just means the patient is taking digoxin, not necessarily toxic.
    • AV Block on EKG: Look for the relationship between P waves and QRS complexes. Type I: progressive PR prolongation. Type II: dropped beats. Type III: complete dissociation.
    • Pericarditis on EKG: Diffuse, concave ST-segment elevations and PR depressions.
    • Dextrocardia on EKG: Right axis deviation, positive QRS in aVR, inverted P waves and QRS in lead I.
    • Pericardial Effusion on EKG: Low voltage QRS complexes and electrical alternans (beat-to-beat variation in QRS amplitude).
    • Management of Hyperkalemia: Calcium gluconate (stabilize membrane), insulin/glucose and albuterol (shift potassium), diuretics/dialysis (remove potassium).
    • Management of Digoxin Toxicity: IV fluids, supportive care, charcoal, Digifab, and/or dialysis for severe cases.
    • Management of AV Block: Atropine for symptomatic bradycardia, transcutaneous or transvenous pacing for unstable patients.
    • Management of Pericarditis: NSAIDs and colchicine are first-line treatments.
    • Management of Pericardial Effusion: Echocardiogram to assess for tamponade, pericardiocentesis if tamponade is present.