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![What is next ?
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• Start CPR - ACLS](https://image.slidesharecdn.com/ecgqiuzfinal-180316131334/75/Ecg-quiz-SEMICON-1018-62-2048.jpg)
Uploaded byDr.Venugopalan Poovathum Parambil
Ecg quiz @ SEMICON 1018
The document contains a detailed analysis of various case scenarios related to electrocardiograms (ECGs) and their interpretations in emergency medicine. It discusses multiple patient cases with specific symptoms and presents ECG findings along with potential diagnoses, management strategies, and critical considerations. The document serves as a comprehensive guide for emergency physicians in recognizing and responding to different cardiac conditions based on ECG readings.
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Ecg quiz @ SEMICON 1018
- 1. ECG for Emergency physician Dr.VenugopalanP P DA,DNB,MNAMS,MEM-GW Director & Lead Consultant -Emergency Medicine(Aster DM Health care ) PG Teacher -NBE
- 2. Contents • Case scenarios •Rhythm strip • Rapid fire
- 3. Case 1 • 54year old chronic smoker presented ED with generalised tiredness and palpitation and missed beats . Initial vitals Pulse 89/ mt- irregular,BP 156/88 moof Hg, SpO2 94 in RA, RR 26/ mt and normal Temp.
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- 5. Your findings? • Rhythmirregular • No P wave • Wide and bizarre QRS • T Inverted • RR interval equal VPC
- 6. Diagnostic criteria Premature VentricularComplex. Rhythm that is irregular, with heart rate that is the underlying rate. P wave is absent PR interval is not measurable QRS is typically wide (> 0.10 sec) QRS isBizarre appearance. T Wave is inverted Compensatory Pause
- 8. Ventricular Ectopics Two PVCstogether are termed a couplet Three PVCs in a row with a fast rhythm is ventricular tachycardia.
- 9. What are the •Rate more than 10 / mt • Bigemini • Trigemini • Multifocal • R on T phenomenon
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- 12. R on T-Zoom In
- 13. Case 2 • 58year old man presented to ED with non specific chest discomfort and diaphoresis • Initial vitals HR 56/ mt, BP- 70/ 50 mm of Hg ,RR 28/mt, SpO2 - 87 in Room air
- 15. What are thefindings ? • Rate 56 / mt • Normal rhythm • Normal P wave • QRS - Normal • QRS follows P wave • Normal PR interval • ST elevation in leads II,III,aVF • ST depression in • leads I and aVL
- 16. What is yourdiagnosis? Which artery is involved ? What are the special problems ? • Inferior wall MI • Likely RCA proximal block • Need Primary Angioplasty or • re-vascularization therapy • Hypotension, RV dysfunction , • Complete heart block • Caution : with nitrates
- 17. LAD 1 st Diagonal Circumflex RCA Coronaryarteries and `ecg LCA
- 19. Case 3 A 30-yearold female with a history of Conn’s syndrome secondary to bilateral adrenal adenomas presents in ED with generalised weakness and muscle pains after a change in her medications.
- 21. Findings • Sinus rhythmat around 70 bpm • Normal axis • PR interval 200ms (upper limit of normal) • Long QT (640ms, QTc 700ms) • Widespread down sloping ST depression / T wave inversion • Prominent U waves, especially in the precordial leads
- 22. What is it? Markedlyprolonged QT interval Widespread ST depression T wave inversion Prominent U waves Pathognomonic of severe hypokalaemia.
- 23. This patient • Potassiumwas 1.7 mmol/L (she had recently stopped taking her spironalactone). • The muscle pain was rhabdomyolysis secondary to hypokalaemia. • She was treated in the high-dependency area for 3 days on a continuous potassium drip and made a good recovery.
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- 25. Case 4 • 25year old man turned up in health check up • He had one or two episode of palpitation • Normal vitals
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- 27. Short PR interval Deltawave Tall R wave in V1 Wide QRS
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- 31. Case 5 • 45year old lady presented to ED with generalised weakness • Known case of DM,Hypertension ,CKD • On dialysis , interrupted the last schedule
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- 36. Case 5 A 36-yearold marathon runner presenting to the ED with acute gastroenteritis. He was completely asymptomatic at the time the ECGs were taken, with normal blood pressure and no chest pain, palpitations or dizziness. Electrolytes were normal.
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- 38. ECG findings • Acceleratedidioventricular rhythm (AIVR) at around 60 bpm • Multiple sinus capture beats • Isorhythmic AV dissociation: Sinus P waves are buried in the QRS complexes and T waves at a similar rate to the ventricular rhythm • Sinus arrhythmia, with variation in the PP interval of up to 0.2 s
- 39. Why it isso? • Competing sinus and idio-ventricular pacemakers are present. • There is underlying sinus arrhythmia, with sinus capture occurring when the sinus rate exceeds the idio-ventricular rate.
- 40. Mechanism The likely mechanismof the AIVR in this patient is enhanced automaticity of an ectopic pacemaker in the ventricles coupled with sinus bradycardia and sinus arrhythmia due to athletic training. Athletic training leads to changes in the autonomic nervous system, with increased resting vagal tone and decreased sympathetic tone. This hyper vagotonic state causes suppression of impulse generation by the SA node and propagation by the AV node. Athletic individuals will commonly exhibit sinus bradycardia and low- grade AV blocks (e.g. 1st degree heart block, Mobitz I).
- 41. Pacemaker potential There arepacemaker cells at various sites throughout the conducting system, with each site capable of independently sustaining the heart rhythm. The rate of spontaneous depolarisation of pacemaker cells decreases down the conducting system: • SA node (60-100 bpm) • Atria (< 60 bpm) • AV node (40-60 bpm) • Ventricles (20-40 bpm)
- 42. Case 6 An 18-yearold male is brought to ED by ambulance following a generalised seizure at home. He has a further witnessed seizure en route in the ambulance. By the time of arrival to ED he is comatose with a GCS of 3 and poor respiratory effort. Pupils are symmetrically dilated. Blood sugar is normal. BP is 70/40.
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- 44. ECG Finding • Regularbroad complex tachycardia • Rate 130 bpm • Right axis deviation (+120 degrees) • Hidden P waves buried in the ST-segments / T waves (best seen in leads II, aVF). These could be retrograde P waves from a junctional / ventricular rhythm or sinus P waves with an extremely long PR interval (360ms)
- 45. ECG Finding • Verybroad QRS complexes (160ms) • Terminal R wave in aVR > 3mm; R/S ratio in aVR > 0.7 • Atypical RBBB pattern in V1-2 (bizarre morphology with left rabbit ear higher than the right) • QT 400ms with markedly prolonged QTc 590 ms • Non-specific T wave abnormalities with T-wave inversions in V1-2 & lead III
- 46. What is thediagnosis? The combination of Tachycardia QRS and QTc prolongation Right axis deviation Terminal R wave in aVR > 3mm Highly specific for poisoning with sodium-channel blocking drugs, in particular the tricyclic antidepressants.
- 47. TCA OD presentation •Sedation and coma • Seizures • Hypotension • Tachycardia • Broad complex dysrhythmias • Anticholinergic syndrome This patient had attempted suicide by deliberate self-poisoning with around 35mg/kg of Doxepin (a tricyclic antidepressant) an hour prior to presentation
- 48. Cardio toxic effects Tricyclicsmediate their cardio toxic effects 1-Blockade of myocardial fast sodium channels (QRS prolongation, tall R wave in aVR) 2.Inhibition of potassium channels (QTc prolongation) 3.Direct myocardial depression 4.Other toxic effects Blockade at(A) Muscarinic (M1),(B)Histamine (H1) and (C )α1-adenergic receptors.
- 49. •QRS > 100ms is predictive of seizures •QRS > 160 ms is predictive of ventricular arrhythmias (e.g. VT) Degree of QRS broadening on the ECG is correlated with adverse events:
- 50. Risk assessment -Doxipen OD • < 5 mg/kg — Minimal symptoms • 5-10 mg / kg — Drowsiness and mild anticholinergic effects; major toxicity not expected • > 10 mg / kg — Potential for all major toxic effects to occur within 1-2 h of ingestion • > 30 mg / kg — Severe toxicity with pH- dependent cardio toxicity and coma > 24 h
- 51. Quick management tips •Administer IV sodium bicarbonate 100 mEq (1-2 mEq / kg); repeat every few minutes until BP improves and QRS complexes begin to narrow. • Intubate as soon as possible. • ? Hyperventilate to maintain a pH of 7.50 – 7.55 • Once the airway is secure, place a nasogastric tube and give 50g (1g/kg) of activated charcoal. • Treat further seizures with IV benzodiazepines (e.g. diazepam 5-10mg).
- 52. Quick management tips •Treat hypotension with a crystalloid bolus (10-20 mL/kg). • Unsuccessful in restoring BP then consider starting vasopressors (e.g. noradrenaline infusion). • If arrhythmias occur, the first step is to give more sodium bicarbonate. Lidocaine (1.5mg/kg) IV is a second line agent once pH is > 7.5. • Avoid Ia (procainamide) and Ic (flecainide) antiarrhythmics, beta-blockers and amiodarone as they may worsen hypotension and conduction abnormalities
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- 55. What is it? •Runs of tachycardia interspersed with long sinus pauses (up to 6 seconds). • The sinus rate is extremely slow, varying from 40 bpm down to around 10 bpm in places. • Sinus beats are followed by paroxysms of junctional tachycardia at around 140 bpm. sick sinus with the “tachy-brady” syndrome
- 56. What will youdo next? This patient needs a pacemaker, stat! Admit to a monitored bed on a coronary care unit. Commence temporary pacing via external pads or pacing wire until a permanent pacemaker can be arranged.
- 57. Rhythm strip 2 Whatis it?
- 58. Interpretation • Six beatsof sinus rhythm at 90 bpm. • The 7th beat is a premature atrial complex (PAC) with different morphology P, QRS and T waves, which initiates a run of a supra ventricular tachycardia at 150bpm. • The onset of the SVT is typical of an AV- nodal re-entry tachycardia (AVNRT), although with the rate of 150bpm, atrial flutter with a 2:1 block is also a possibility.
- 59. What is next? •Scrutinise the 12-lead ECG for flutter waves. • Try adenosine (or vagal stimuli such as a Valsalva manoeuvre or carotid massage); this should unmask any flutter waves and may convert AVNRT to sinus rhythm. • Flutter may require DC cardioversion or treatment with anti-arrhythmics (e.g. amiodarone).
- 60. Rhythm Strip 3 Whatis it?
- 61. What is it? A narrow complex tachycardia is interrupted by a run of polymorphic VT, which rapidly deteriorates into ventricular fibrillation.
- 62. What is next? • DC shock [ 200 J Biphasic or 360 Joule Mono phasic ] • Start CPR - ACLS
- 63. Rhythm strip 4 Whatis it?
- 64. What is it? • Sinus rhythm, or possibly ectopic atrial rhythm (biphasic / inverted P waves in lead II) • Rate of 90 bpm • Prolonged QTc interval of 540 ms (greater than half the R-R interval) • Ventricular ectopics with ‘R-on-T’ phenomenon • The second ventricular ectopic initiates a run of torsades de pointes
- 65. What is next? •DC cardioversion if unstable. • Load with magnesium (e.g. 2 g over 1-2 minutes) and start a magnesium infusion. • Correct hypokalemia. • Consider: ◦ Overdrive pacing to achieve a ventricular rate of 90-120 bpm. ◦ Isoprenaline infusion ?
- 66. Rhythm strip 5 Whatis it?
- 67. •AV-nodal re-entry tachycardia (AVNRT)at 140 bpm •A pause in the middle of the strip with several ventricular escape complexes •Cardioversion to sinus rhythm at 90 bpm at the end of the strip Typical ECG recording of a patient receiving a bolus of adenosine for AVNRT.
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- 69. What is it? Completeheart block
- 70. What is it? Atrial Flutter
- 71. What is it? Sinus Arrest
- 72. What is it? MultifocalAtrial Tachycardia -MAT
- 73. What is it? Bundle branch block
- 74. What is it? VentricularFibrillation
- 75. What is it? Pacemaker Rhythm - AV sequential
- 76. What is it? Second degree Heart block - Type 1
- 77. What is it? Pacemaker rhythm - Single chambers - Atrial
- 78. What is it? Sinus Arrhythmia
- 79. What is it? Atrial Fibrillation
- 80. What is it? First degree Heart block
- 81. What is it? Supra ventricular Tachycardia
- 82. What is Electrocardiograph? Thank youso much for your patient listening [email protected] Ans: ECG Machine