10 ecg common in day to day life in emergency with image
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ST elevation myocardial infarction STEMI ECG
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ventricular fibrillation ECG cardiac arrest
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atrial fibrillation ECG irregular rhythm
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complete heart block third degree AV block ECG
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ventricular tachycardia ECG wide complex
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hyperkalemia tall peaked T waves sine wave ECG
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pulmonary embolism S1Q3T3 right heart strain ECG
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Wolff-Parkinson-White WPW delta wave ECG
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supraventricular tachycardia SVT narrow complex ECG
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left bundle branch block LBBB ECG pattern
I now have excellent images for all 10 ECG patterns. Here is the comprehensive guide:
10 Common Emergency ECGs with Images
1. STEMI — ST-Elevation Myocardial Infarction
Key features:
- Convex ("tombstone") ST elevation ≥1 mm in ≥2 contiguous leads
- Reciprocal ST depression in opposite leads (e.g., inferior STEMI → depression in aVL)
- Hyperacute T waves in early phase
- Pathological Q waves in established infarction
Localisation:
| Territory | Leads with ST elevation | Culprit artery |
|---|---|---|
| Anterior | V1–V4 | LAD |
| Inferior | II, III, aVF | RCA / LCx |
| Lateral | I, aVL, V5–V6 | LCx |
| Posterior | ST depression V1–V3 + tall R V1 | RCA/LCx |
Emergency action: Immediate reperfusion (PCI within 90 min, thrombolysis if PCI unavailable)
2. Ventricular Fibrillation (VF)
Key features:
- Completely chaotic, disorganised baseline
- No identifiable P waves, QRS, or T waves
- Variable amplitude oscillations — "coarse VF" (large amplitude) or "fine VF" (small amplitude)
- No cardiac output — pulseless arrest
Emergency action: Immediate defibrillation (360 J monophasic / 200 J biphasic) + CPR. Shockable rhythm — do NOT delay.
3. Ventricular Tachycardia (VT)
Key features:
- Wide QRS complex (>120 ms), regular rhythm, rate 100–250 bpm
- AV dissociation (P waves independent of QRS)
- Fusion beats and capture beats (pathognomonic)
- Positive concordance across precordial leads (all QRS same direction)
- Brugada criteria / Vereckei algorithm to distinguish from SVT with aberrancy
Emergency action: Pulseless VT → defibrillate. Stable VT → amiodarone 300 mg IV, synchronised cardioversion if haemodynamically unstable.
4. Atrial Fibrillation (AF)
Key features:
- Irregularly irregular RR intervals — the hallmark
- Absent P waves — replaced by fine fibrillatory (f) waves, best seen in V1 and inferior leads
- Narrow QRS (unless aberrant conduction/bundle branch block)
- Ventricular rate varies: controlled <100 bpm, rapid response >100 bpm
Emergency action: Rate control (metoprolol, diltiazem, digoxin), rhythm control (cardioversion if <48 h or anticoagulated), anticoagulation for stroke prevention (CHA₂DS₂-VASc score).
5. Complete (Third-Degree) AV Block
Key features:
- Complete AV dissociation — P waves and QRS have no relationship
- P waves march through at a faster atrial rate (e.g., 80 bpm)
- Slow escape rhythm: narrow QRS if junctional escape (40–60 bpm); wide QRS if ventricular escape (<40 bpm)
- Bradycardia often causes haemodynamic compromise (syncope, hypotension)
Emergency action: Atropine (1 mg IV) as temporising measure; transcutaneous pacing urgently; plan for permanent pacemaker. Treat reversible causes (inferior MI, hyperkalemia, drug toxicity).
6. Supraventricular Tachycardia (SVT / AVNRT / AVRT)
Key features:
- Narrow complex tachycardia (QRS <120 ms), regular, rate 150–250 bpm
- P waves absent or retrograde (buried in or just after QRS)
- Abrupt onset and termination
- Pseudo-R' in V1 or pseudo-S in inferior leads (hallmark of AVNRT)
- ST depression may be present (rate-related, not ischaemic)
Emergency action: Vagal manoeuvres first (Valsalva, carotid sinus massage); adenosine 6 mg rapid IV (then 12 mg if needed); synchronised DC cardioversion if haemodynamically unstable.
7. Pulmonary Embolism — Right Heart Strain
Key features:
- Sinus tachycardia — most common and most sensitive finding
- S1Q3T3: Deep S wave in lead I + Q wave in lead III + T-wave inversion in lead III (only 20% sensitive, but specific)
- T-wave inversion V1–V4 (right heart strain)
- Incomplete/complete RBBB (acute RV dilatation)
- Right axis deviation, P pulmonale
Emergency action: CTPA for diagnosis; anticoagulation (LMWH/UFH); thrombolysis (alteplase 100 mg IV) for massive PE with haemodynamic compromise.
8. Hyperkalemia
Progressive ECG changes with rising K⁺:
| Serum K⁺ | ECG finding |
|---|---|
| 5.5–6.5 mEq/L | Tall, narrow, peaked/tented T waves |
| 6.5–7.5 mEq/L | Prolonged PR, P wave flattening/disappearance |
| 7.5–8.5 mEq/L | Wide QRS, bundle branch block pattern |
| >8.5 mEq/L | Sine-wave pattern → VF/asystole |
Emergency action: Calcium gluconate 1g IV (membrane stabilisation, immediate); insulin + dextrose; sodium bicarbonate; salbutamol nebulisation; furosemide; haemodialysis for severe/refractory cases.
9. Wolff-Parkinson-White (WPW) Syndrome
Key features:
- Short PR interval (<120 ms)
- Delta wave — slurred upstroke at the start of QRS
- Wide QRS (>120 ms) due to pre-excitation
- Discordant ST-T changes (secondary to pre-excitation)
- Risk of pre-excited AF → rapid ventricular rates → VF
Emergency action: Pre-excited AF (irregular wide complex tachycardia) → avoid AV nodal blockers (adenosine, digoxin, verapamil — can accelerate conduction via bypass tract → VF). Use procainamide or DC cardioversion. Refer for radiofrequency ablation.
10. Left Bundle Branch Block (LBBB) — New/Presumed New
Key features (remember "WiLLiaM MaRRoW"):
- QRS ≥120 ms
- Broad, notched M-shaped R wave in I, aVL, V5–V6 (William = W in V1, M in V6)
- Deep broad W-shaped QS in V1–V3
- Discordant ST-T changes (ST elevation in V1–V3, depression/inversion laterally)
- Absence of septal Q waves in I and V6
Why it matters in ED: New LBBB with chest pain = treat as STEMI equivalent (Sgarbossa criteria help identify true STEMI within LBBB). Concordant ST elevation ≥1 mm in any lead is highly specific for MI.
Emergency action: New LBBB with ischaemic symptoms → activate cath lab. Investigate for underlying structural disease (cardiomyopathy, valvular disease).
Quick Reference Summary
| # | Rhythm/Pattern | Rate | QRS | Key Hallmark | Emergency Action |
|---|---|---|---|---|---|
| 1 | STEMI | Normal | Narrow | ST elevation + reciprocal changes | PCI/thrombolysis |
| 2 | VF | Chaotic | None | Chaotic baseline | Defibrillate NOW |
| 3 | VT | 100–250 | Wide | AV dissociation | Defib/amiodarone |
| 4 | AF | Irregular | Narrow | No P waves, irregular RR | Rate/rhythm control |
| 5 | Complete AV Block | <40–60 | Wide/narrow | P–QRS dissociation | Pacing |
| 6 | SVT | 150–250 | Narrow | Regular, no P waves | Adenosine/vagal |
| 7 | PE | Fast | Narrow | S1Q3T3, sinus tachy | Anticoagulation/thrombolysis |
| 8 | Hyperkalemia | Variable | Wide→sine | Peaked T → sine wave | Calcium/insulin |
| 9 | WPW | Variable | Wide (pre-excited) | Delta wave, short PR | Procainamide/ablation |
| 10 | New LBBB | Normal | Wide | WiLLiaM pattern | Treat as STEMI if acute |
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