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MODULE 6: The ECG and the ABG
Here it is: the week featuring the two most asked and feared investigations in the fellowship exam: the ECG and the ABG.
A cautionary note - this week will not teach you everything about the ECG and the ABG. A lot of the content for each question will depend on the nature of the underlying disease process that is being asked about. However, understanding the ECG and the ABG and having a system to work through them is vital to succeeding in the fellowship written.
This week should act as a reference page for you as you look at ECGs and ABGs throughout the course. Mostly these crop up in the context of other topics (each investigation has an underlying diagnosis after all.) So make sure you use this page as a reference throughout the course as you need it.
A cautionary note - this week will not teach you everything about the ECG and the ABG. A lot of the content for each question will depend on the nature of the underlying disease process that is being asked about. However, understanding the ECG and the ABG and having a system to work through them is vital to succeeding in the fellowship written.
This week should act as a reference page for you as you look at ECGs and ABGs throughout the course. Mostly these crop up in the context of other topics (each investigation has an underlying diagnosis after all.) So make sure you use this page as a reference throughout the course as you need it.
watch.
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THE ECG IN THE FELLOWSHIP EXAM
In Emergency Medicine and as it follows in the Fellowship Exam, we are expected to be experts in the reading of the ECG. ECG's are asked commonly in the exam. In the last exam they made up 10% ie., 3/30 of the SAQ's. However, you need not stress about this, as there are a limited number of ECG's they tend to ask over and over. In this video I will go over the ECG's asked in the past, as well as the ECG in 20 Seconds Method. This is good revision from the ECG in the FACE to FACE. WATCH: UNDERSTANDING ACID-BASE BALANCEThis video deals with some of the major concepts in interpreting acid-base chemistry.
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THE 'ECG in 20 Seconds' Approach
This technique for reading the ECG, was developed by A/Prof Kas. The aim of it is to focus on specific findings when looking at each part of the ECG. These are your high yield findings.
You can practice the method by completing the 'modules' on www.resus.com.au. You can then practice by doing ECG's from the ECG library. What is special about these ECG's is that they have been taken from the college data base of ECGs, i.e.., these are the ECGs used in previous exams. You can click on the buttons below or go to the 'ecg' section of www.resus.com.au.
One other thing you should get used to doing is going to the 'ECG of the Week' on www.resus.com.au, by going to the same section, alternatively sign up for the resus newsletter on the site and get it delivered to your inbox.
You can practice the method by completing the 'modules' on www.resus.com.au. You can then practice by doing ECG's from the ECG library. What is special about these ECG's is that they have been taken from the college data base of ECGs, i.e.., these are the ECGs used in previous exams. You can click on the buttons below or go to the 'ecg' section of www.resus.com.au.
One other thing you should get used to doing is going to the 'ECG of the Week' on www.resus.com.au, by going to the same section, alternatively sign up for the resus newsletter on the site and get it delivered to your inbox.
READ: the ECG.
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De Winter's T waves - traditionally newer ECG patterns have been a favourite subject for examiners. Don't be fooled by De Winter's T waves.
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Separating out different abnormal repolarisation patterns is critical. Have a look at the blog below.
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Can't remember what different electrolytes do what? Step back and take a heuristic approach to the ECG.
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Quite an interesting case. The article (opens in a new window) gives a very good description of the ECG features of Wellen's syndrome. Note though that the presence of Wellen's syndrome is an indication for urgent PCI (not a stress test, which this patient unsurprisingly failed!).
READ: The ABG
Below is an excerpt from OWN the ABG explaining the basic principles of the 4 step method to interpreting an ABG. It builds on the video about acid base balance presented above. Below is Peter Kas' ABG method, with all the equations needed to solve an arterial blood gas. As usual files are below for iPad users.
| facetoface_abg_notes.pdf |
| approach_to_the_abg.pdf |
solve.
One of the most important things candidates forget about ABGs is context. To illustrate the point have a look at the exercises below.
EXERCISE 1.
Write down the major abnormalities you would expect to find in an ABG for the following clinical scenarios.
a. A 28 year old insulin dependent diabetic presents to the emergency department with an altered level of consciousness. His vital signs are:
b. A 65 year old lady with a history of diverticular disease presents to the emergency department with a history of abdominal pain, bloody diarrhoea, fevers and lassitude. Her vital signs are:
EXERCISE 2.
Write down the major abnormalities and the unifying diagnosis for the ABG below....
FiO2 21%
pH 7.10
pO2 105 mmHg
pCO2 20 mmHg
HCO3- 8 mmol/L
BE -14
Na+ 140 mmol/L
Cl- 104 mmol/L
EXERCISE 1.
Write down the major abnormalities you would expect to find in an ABG for the following clinical scenarios.
a. A 28 year old insulin dependent diabetic presents to the emergency department with an altered level of consciousness. His vital signs are:
- HR 128 /min
- BP 105/66 mmHg
- RR 35 /min
- sats 98% RA
- T 37.6 degrees celcius
b. A 65 year old lady with a history of diverticular disease presents to the emergency department with a history of abdominal pain, bloody diarrhoea, fevers and lassitude. Her vital signs are:
- HR 128 /min
- BP 105/66 mmHg
- RR 35 /min
- sats 98% RA
- T 38.6 degrees celcius
EXERCISE 2.
Write down the major abnormalities and the unifying diagnosis for the ABG below....
FiO2 21%
pH 7.10
pO2 105 mmHg
pCO2 20 mmHg
HCO3- 8 mmol/L
BE -14
Na+ 140 mmol/L
Cl- 104 mmol/L
write.
Below are a series of questions that I would like you to answer and then place the answers in the dropbox, for everyone to look at. I will not be supplying answers to these, as I want you to learn from each other. We can talk about them on the virtual study group. Remember, one of the aims of the course is to have you write as scientifically as possible. Write more with less, don't give us a 1500 word essay!
EXERCISE 1.
a. What are 5 causes of wide complex tachycardia?
b. How do you diagnose Ventricular tachycardia?
c. What drugs cause wide complex tachycardia?
EXERCISE 2.
A 32 year old Italian man has an episode of syncope whilst playing football with his friends. He had a brief episode of tachycardia. His ECG is shown below.
a. What does the ECG show and what is the diagnosis?
b. List 4 other ECG patterns you might see in syncope.
c. What investigations would you perform in this patient?
EXERCISE 1.
a. What are 5 causes of wide complex tachycardia?
b. How do you diagnose Ventricular tachycardia?
c. What drugs cause wide complex tachycardia?
EXERCISE 2.
A 32 year old Italian man has an episode of syncope whilst playing football with his friends. He had a brief episode of tachycardia. His ECG is shown below.
a. What does the ECG show and what is the diagnosis?
b. List 4 other ECG patterns you might see in syncope.
c. What investigations would you perform in this patient?
