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VAQ 6. Don Liew December 2013. Stem (It’s Very Important!). A 71yo man presents after a collapse at home . He is currently asymptomatic with a GCS of 15 and BP of 160/90 mmHg. Describe and interpret his ECG (100%). Answer the Question!. “Describe”

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vaq 6


Don Liew

December 2013

stem it s very important
Stem(It’s Very Important!)

A 71yo man presents after a collapse at home. He is currently asymptomatic with a GCS of 15 and BP of 160/90 mmHg.

Describe and interpret his ECG (100%).

answer the question
Answer the Question!


a. Findings, including b. Relevant Negatives


c. Conclusion(s), including d. Differentials

Therefore, to pass, you had to include all 4 elements. Know the exam Glossary of Terms.

pass criteria
Pass Criteria
  • Bradycardia (had to declare a HR, preferably 42 bpm, but anything between 35 and 50 accepted.
  • AV dissociation, or something to that effect (ie, no clear, constant relationship between Ps and QRS
  • QRS complexes regular, or nearly so
  • Complete heart block (CHB), at least as a differential Dx
pass criteria1
Pass Criteria
  • QRS not completely normal. Slightly widened, with a RBBB pattern. Even a LBBB pattern was accepted, provided there was justification for this declaration.
  • T wave inversion, at least in aVL, V5 and V6
  • ST depression, at least in V4 to V6
pass criteria2
Pass Criteria
  • An interpretation in the CLINICAL context, acknowledging his age, current GCS of 15 and BP of 160/90.
  • Include a short but very important list of differential causes for the condition in THIS patient:
    • Acute coronary syndrome
    • Medications: Beta blocker, CCB, Digoxin
    • Electrolyte abN, esphyperkalaemia
pass criteria3
Pass Criteria
  • Conclude not only the probable Dx of CHB, but that he is at high risk of recurrent syncope, and needs admission. This is the key clinical implication.

Clinical interpretation distinguishes a clinician from a non-clinician (or even non-human) ECG reader. This is precisely why the information in clinical stem is provided. Always use the clinical info!

bonus marks
Bonus Marks
  • Identifying the first QRS as a probable ventricular ectopic. Look at the top strip. There are 3 different QRS morphologies. 2 belong to leads I and aVR; the remaining one must be an ectopic. In this ECG, the ectopic is likely the first QRS complex.
  • Using the second QRS to determine axis, which is likely leftward. But candidates who declared Right Axis Deviation because they used the first complex did not fail for this reason alone.
bonus marks1
Bonus Marks
  • Consider that he has RBBB, LAD and CHB. He actually has features of a COMPLETE tri-fascicular block, probably with an escape rhythm from the left posterior fascicle.
  • Candidates declaring a junctional or ventricular escape rhythm were not penalised, as these were reasonable.
  • Given the rate and presence of VE (1st complex), the rhythm is probably a supraventricular (junctional or fascicular), rather than a ventricular escape rhythm.
bonus marks2
Bonus Marks
  • Biphasic T waves in leads V4 to V6.
  • Stating possible digoxin effects in lateral leads.
  • Prolonged QTm, but probably normal QTc, given QT is less than half of RR interval.
bonus marks3
Bonus Marks
  • Stating he will likely need a PPM.
  • Using the info that he comes from home, suggesting a reasonable premorbid QOL and suitable candidature for advanced Rx such as monitoring, PPM, cardiac catheterisation if indicated.
what to avoid
What to Avoid
  • Prose. Wastes your time, makes it difficult for me to read.
  • Giving this patient adrenaline now, without at least some explanation. With his GCS, BP and possible acute coronary syndrome, such Rx is risky.
  • Calling this (incomplete) tri-fascicular block, without justification.
    • LAD (or RAD) and RBBB present, but he does NOT have 1st degree heart block.
    • LAD/RBBB/2nddeg block is more reasonable in this ECG, but this is a rarer version. You had to justify your position if declaring this.
what to avoid1
What to Avoid
  • Calling this Mobitz 1 second degree heart block (the ECG teases us with features of this), without at least offering CHB as a differential.
  • Stating TCA toxicity as a differential. The stem and prop do NOT suggest this, so it’s unlikely to be point of silly.
tips for point scoring
Tips for Point Scoring
  • Read the bloody question,and answer it in total. Without doing this, you will struggle to pass.
  • Commit the exam Glossary of Terms to your brainstem. Then, answer every Q as it is asked.
  • Every bit of the clinical stem is provided for a reason. Use it all. Always. No buts. This is an exam for clinicians - not pathologists, radiologists, lab technicians, automated ECG machines, algorithm analysers. Sometimes, a pass criterion lies in the stem.
tips for point scoring1
Tips for Point Scoring
  • Spread out your answer. Use lots of space, and clear, logical subheadings. Makes marking your paper (out of 80 or so) a less tedious task.
  • Be precise in your terminology. Q waves are NORMAL, being the first downward deflection in any QRS. By declaring abN Q waves, you should state “DEEP Q WAVES” or “PATHOLOGICAL Q WAVES”.
tips for point scoring2
Tips for Point Scoring
  • Be precise in your terminology. Understand the difference between QTm, and QTc. Don’t just write “QT normal”, without some explanation.
  • Lastly, as an extension of conclusion(s) for this scenario, state what the implication(s) for THIS patient is / are. It may be for further assessment, Mx, prognosis or combinations of these. A short phrase will suffice.