A 64 year old man is being evaluated in your emergency department after an episode of chest pain which has now resolved.
a. Describe and interpret his ECG (100%)
FACEM VAQ Exam 2010.1 – Question 6
- The overall pass rate for this question was 57/70 (81.4%)
- ECG demonstrates irregular rhythm with 2nd degree heart block.
- Pass criteria Part A:
- Rate: Variation in actual rate acceptable as irregular – around 30 to 70 acceptable.
- Rhythm: Need to say irregular & 2nd degree heart block – expected most likely Type 1/Wenckebach, but acceptable to say could be Type 2 as dropped QRS not occurring regularly so would need longer rhythm strip to be sure.
- Intervals: PR: Need to recognise that prolonged PR and variable length QRS: Need to recognise narrow complex QT:Looks normal – not pass/fail if rest OK, but fail if say prolonged QT and that is basis for other findings.
- ST segments: Should be some comment on these in view of history given – to pass, need recognition that ST not completely normal ie small amount of ST elevation in anterior leads, but could be repolarisation and would warrant serial ECGs.
- Interpretation: Recognise 2nd degree heart block, most likely Type 1, and ischemia-related most likely in patient described.
- Other ECG features: Extra marks if mention axis normal and how measured intervals and T waves and more detail in general.
- Pass criteria Part B:
- Ischaemia: Better answers included ideas re where in conducting system affected or coronary circulation or region of heart.
- Drugs: Should mention at least 2 relevant drugs eg beta blockers, CCBs, digoxin. Better answers mentioned digoxin and/or more drugs with indication re most common, and mention therapeutic or overdose could be possible.
- Other causes: Higher level answers also considered infection eg myocarditis, or structural causes eg cardiomyopathy/valvular problems. If electrolyte disturbance top of the list then concern re lack of perspective.