EMU 365: Killer ECGs

This EMU365 video features EM cardiology guru Dr. Amal Mattu on killer ECGs associated with pericardial effusions. He eloquently explains the utility of electrical alternans, specific lead and voltage criteria required to make the diagnosis of low voltage and more. 

Pericardial effusion (PCE) ECG 

  • Classic teaching: Electrical alternans (“classic” but occurs in <30%), tachycardia (may be blunted in patients on beta blockers), low voltage, cardiomegaly on CXR (sensitive but not specific)
  • PEARL: Tachycardia + low voltage = PCE until proven otherwise
  • Low voltage: QRS amplitude in I+ II +III <15 or V1+ V2 +V3 <30mm
  • Think PCE when patients present with SOB!
  • Low voltage ddx: 
    • conduction blockage: fluid (PCE, pleural), air (COPD), tissue (obesity)
    • Low power: myxedema, cardiomyopathy, infiltrative disease
  • Avoid anticoagulation or antiplatelets until PCE is ruled out

Author Biography
Dr. Amal Mattu is currently a tenured professor of Emergency Medicine at the University of Maryland School of Medicine in Baltimore, Maryland. Dr. Mattu’s areas of academic focus are emergency cardiology, geriatric emergency medicine, faculty development, and risk management. For more than 20 years, he has had a passion for learning about and teaching electrocardiography. He has lectured and run workshops on advanced ECG interpretation at numerous national and international conferences and has written two case books on advanced electrocardiogram interpretation.

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