AUGUST 25-27, 2017 UPDATE & BOARD REVIEW. acofp INTENSIVE. EKG Case Review in Family Medicine. Steve Louvet, DO INNOVATIVE COMPREHENSIVE HANDS-ON

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1 acofp INTENSIVE UPDATE & BOARD REVIEW AUGUST 25-27, 2017 Loews Chicago O'Hare Hotel Rosemont, IL INNOVATIVE COMPREHENSIVE HANDS-ON EKG Case Review in Family Medicine Steve Louvet, DO acofp Am eric an College of Osteopathi c Family Physicians The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

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3 EKG Case Review in Family Medicine Steve Louvet, DO ACOFP Intensive Update & Board Review August 2017 Objectives 1. To review not to miss EKG findings to deliver optimal care for our patients in family medicine. 2. To assess the next best step when presented with an EKG that is not normal. 3. To review the recommended algorithms of care consistent with the guidelines for Advanced Cardiac Life Support. Cardiac Anatomy 1

4 EKG Regions Coronary Anatomy: V1, V2: posterior wall V1, V2, V3: anterior septum V4: apex V5, V6: low lateral wall I, avl: high lateral wall II, III, avf: inferior wall (possible RV) ges/ecg_regions_old.gif Rate Rule of 300- Divide 300 by the number of boxes between each QRS = rate Rate Normal Rate < 60 Bradycardia Rate >100 Tachycardia Axis 2

5 Intervals Case 1 A 15 yo F with history of depression, presents to your office with complaint of dizziness x 1 day. She has been on citalopram for depression for the past 3 months and was recently treated with zithromax at a local ED for community acquired pneumonia. She is neurologically intact, and denies chest pain or shortness of breath. She presents to your office with these vitals: VS: T 98.7, HR 42, BP 100/60, SpO2 98% Case 1 3

6 Case 1 Diagnostic approach for a patient with this EKG likely includes all of the following EXCEPT: A) Serum potassium and magnesium levels B) TSH level C) D-Dimer level D) Serum calcium level E) A review of daily medications Drugs that Prolong the QT interval Antipsychotics Type IA antiarrhythmics Type IC antiarrhythmics Class III antiarrhythmics Chlorpromazine Haloperidol Droperidol Quetiapine Olanzapine Quinidine Procainamide Disopyramide Flecainide Encainide Sotalol Amiodarone Amisulpride Tricyclic Other Antihistamines Other Thioridazine antidepressants antidepressants Amitriptyline Doxepin Imipramine Nortriptyline Desipramine Mianserin Citalopram Escitalopram Venlafaxine Bupropion Diphenhydramine Astemizole Loratidine Terfanadine Chloroquine Hydroxychloroquin e Quinine Macrolides Moclobemide Erythromyci n Clarithromy cin 4

7 Case 1 The patient soon becomes hypotensive in your office and begins to look clammy. She is controlling her own airway. An initial strategy for intervention is: A) Administer 0.5 mg atropine IV B) Administer 6 mg adenosine IV C) Administer 12 mg adenosine IV D) Administer 150 mg amiodarone IV E) Administer 300 mg amiodarone IV 5

8 Case 1 Two weeks later the same 15 yo F is brought to a community ED by her parents due to an attempted drug overdose on sotalol. A definitive airway is in place and the patient has regained pulses after CPR in the field, with this rhythm strip on the cardiac monitor: Case 1 Administration of which of the following agents is recommended in ACLS for this rhythm? A) 0.5 mg atropine IV B) 0.25 mg/kg cardizem IV C) 0.35 mg/kg cardizem IV D) 1 gram epinephrine IV E) 2 grams magnesium sulfate IV 6

9 Case 2 A 65 yo M with recent diagnosis of mediastinal lymphadenopathy by CT presents with complaint of feeling palpitations for the past week. He has a known history of diabetes and HTN. He is currently undergoing workup with oncology. He denies acute chest pain or shortness of breath in your office. VS: T 98.3, HR 75, BP 130/72, SpO2 98% Case 2 Case 2 Initial approach to disposition of this patient from your office includes: A) Discussion of immediate rate control with the emergency department with metoprolol 5 mg IV B) Discussion of immediate cardioversion with the patient in the office C) Discussion of thromboembolism risk with a cardiologist and consideration of oral anticoagulation D) Discussion of transfer of patient to a facility for immediate percutaneous intervention E) Discussion of necessity of STAT CT angiogram of chest with the radiologist 7

10 Atrial Fibrillation The CHADS 2 scoring system is used to stratify stroke risk in patients with nonvalvular atrial fibrillation. Guidelines (Circulation 2006; 114:e257) recommend aspirin for patients with CHADS 2 scores of 0 (low risk), warfarin or aspirin for patients with scores of 1 (intermediate risk), and warfarin for patients with scores of 2 (high risk). CHADS 2, however, classifies many patients as intermediate risk, and clinicians struggle with committing these patients to long-term warfarin anticoagulation. CHA 2 DS 2 -VASc is better than CHADS 2 at predicting which patients with nonvalvular atrial fibrillation are at high risk for thromboembolism. CHA 2 DS 2 -VASc also appears to be better at predicting which patients are truly at low risk. Broad use of the CHA 2 DS 2 -VASc scoring system could lower the number of patients treated with vitamin K antagonists who will not benefit from them and raise the number of patients treated with vitamin K antagonists who will. Olesen JB et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide cohort study. BMJ 2011 Jan 31; 342:d124. 8

11 Case 3 A 42 yo F with history of hyperthyroidism presents to your office with the complaint of feeling lightheaded with her heart racing for the past several hours. She denies active chest pain or shortness of breath. VS: T 98.0, HR 150, BP 104/64, SpO2 99% Case 3 9

12 Case 3 Initial ACLS management of this rhythm in a patient with normal mental status includes: A) 6 mg adenosine IV B) 1 mg epinephrine IV C) 1.5 mg/kg lidocaine IV D) Synchronized Cardioversion with 50 Joules E) Synchronized Cardioversion with 200 Joules Case 4 The 42 yo F with history of hyperthyroidism who initially presented to your office with the complaint of feeling lightheaded with her heart racing for the past several hours is now lying on the exam table hooked up to the EKG machine. The ambulance is on their way to pick up the patient from your office. They give you a 5 minute estimated time of arrival. In the mean time her rhythm changes as she tells you, Doctor I don t feel well. VS: T 98.0, HR 188, BP 90/40, SpO2 97% 10

13 Case 4 Case 4 Optimal management for this patient includes: A) Encouraging the patient to use vagal maneuvers to break the rhythm B) Preparing the patient for a shock delivered through the AED machine C) Discussing with the patient the need to transfer to a facility for immediate percutaneous intervention D) Discussing with the patient the need to transfer to a facility for immediate cardioversion E) Discussing with cardiology for transfer to the emergency room 11

14 Case 5 56 yo M with history of diabetes, HTN, and hyperlipidemia complains of a dull ache to the chest that started 24 hours ago. VS: T 98.8, HR 66, BP 98/62, SpO2 98% Case 5 12

15 Case 5 A hallmark sign of his EKG that would suggest posterior MI would be: A) Diffuse ST elevation B) Peaked T waves in II, III, and avf C) ST depressions in V1 V3 D) ST elevations in V1 V3 E) ST elevations in II, III, and avf Case 5 Appropriate lead placement to further confirm a posterior STEMI includes: A) V9 is at the left paraspinal level at the same level as V6 B) V8 is halfway between V7 and V9, at the midscapular line C) V7 is at the posterior axillary line at the same level as V4 V6 D) all of the above 13

16 Lead Placement: Normal 14

17 Case 6 25 yo male presents to your office with chest pain that he noticed while sitting at his desk at work. He describes the pain as sharp and worse when he takes a deep breath. The pain decreases in intensity when the patient sits up and leans forward. He denies family history of early cardiac disease. He is afebrile with an otherwise non-toxic appearance. VS: T 98.5, HR 102, BP 126/74, SpO2 98% Case 6 Case 6 What is your initial treatment of choice? A) NSAIDS B) Oxycodone C) Amoxicillin D) Acetaminophen E) Heparin 15

18 Causes of Pericarditis Malignancy Infection: Viral, Bacterial (tuberculosis), Fungal Drugs: Hydralazine, Procainamide, Isoniazid Postcoronary intervention Trauma Cardiovascular surgery: Sternal biopsy, Transvenous Pacemaker Implantation Post Myocardial Infarction: Dressler Syndrome Case 7 A 61 yo F with history of diabetes presents to your office with feeling lightheaded with occasional dizziness on and off for the past 3 days. She denies active chest pain or shortness of breath. She denies headaches. Her capillary blood glucose in the office is 98 mg/dl. VS: T 98.2, HR 85, BP 80/40, SpO2 98% 16

19 Case 7 Case 7 Disposition of this patient from your office includes: A) Discussion with cardiology for transfer to the ED for consideration of a temporary pacemaker B) Discussion with cardiology for transfer to the ED for immediate cardioversion C) Discussion with cardiology for transfer to the ED for IV cardizem drip D) Discussion with cardiology for transfer to a facility for percutaneous intervention E) Discussion with cardiology for outpatient management with anticoagulation 17

20 Case 7 The 61 yo F in your office begins to look flushed and grabs her chest stating Call 911! Her rhythm strip looks like this: VS: T 98.2, HR 42, BP 80/44, SpO2 96% Case 7 The 61 yo F begins to garble in your office and becomes unresponsive on your exam table. No pulses are detected. EMS is already on their way. 18

21 Case 7 Initial strategies to promote best ACLS practices include: A) Immediate airway management B) Immediate high quality CPR C) Immediate defibrillation D) Immediate cardioversion E) Immediate IV epinephrine Heart Blocks 19

22 Rhythm, Buzzwords, & ACLS Normal Sinus Rhythm: Originating from SA node, P wave before every QRS, P wave in same direction as QRS Sinus Bradycardia: stable vs unstable, atropine, prepare for transcutaneous pacing, consider epinephrine or dopamine Sinus Tachycardia: determine etiology Atrial Fibrillation, irregularly irregular : stable vs unstable, control rate vs cardioversion, diltiazem or betablockers, avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil) in setting of AF + WPW Atrial Flutter, sawtooth pattern : stable vs unstable, control rate vs cardioversion, diltiazem or betablockers Supraventricular Tachycardia (SVT), narrow complex tachycardia : stable vs unstable, control rate vs cardioversion, vagal maneuvers, adenosine Torsades de Pointes, twisting of the points, : magnesium Ventricular Tachycardia, wide complex tachycardia, : with or without a pulse, without = defibrillation, with = amiodarone, synchronized cardioversion Ventricular Fibrillation, erratic tracing : defibrillation References Ann Intern Med. 2017;166(5):ITC33-ITC Olesen JB et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide cohort study. BMJ 2011 Jan 31; 342:d124. Onlineaha.org Tintinalli, Judith, Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 8 th Edition, Chapter 18: Cardiac Rhythm Disturbances, pp Tintinalli, Judith, Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 8 th Edition, Chapter 24: Advanced Cardiac Life Support, pp , 2015 Tintinalli, Judith, Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 8 th Edition, Chapter 49: Acute Coronary Syndromes, pp Tintinalli, Judith, Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 8 th Edition, Chapter 55: Cardiomyopathies and Pericardial Disease, pp