Advanced ECG Interpretation Pt. II
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1 Advanced ECG Interpretation Pt. II Dysrhythmias Amal Mattu, MD, FAAEM Professor and Vice Chair Director, Emergency Cardiology Fellowship Department of Emergency Medicine University of Maryland School of Medicine
2 Advanced ECG Interpretation Pt. II Dysrhythmias Amal Mattu, MD, FAAEM Professor and Vice Chair Director, Emergency Cardiology Fellowship Department of Emergency Medicine University of Maryland School of Medicine
3 A Few Points To Start Advanced content We ll skip the basics
4 A Few Points To Start Workshop Questions? Writing Handout/PDF Lectures.umem.org/ekg Weekly video cases for extra practice:
5 Why is this important?
6 Why is this important? This is high-risk but high payoff! Very good outcome vs. very bad outcome
7 Dysrhythmias
8 #1: 70 yo. woman with 4 days of N/V, malaise; SBP 80.
9 #1: ST, Mobitz I, VR 94
10 #2: 62 yo. man with SOB and chest pain; SBP 80.
11 #2: ST, 3 rd degree AVB, JER, VR 48
12 #3: 85 yo. woman with syncope; SBP 120.
13 #3: SR, Mobitz II with 3:2 conduction, VR 50, LBBB
14 #4: 62 yo. man c/o LH; SBP 85.
15 #4: Hyperkalemia (K + 8.0)
16 ECG Findings in Hyperkalemia Peaked Ts Widening of the QRS Prolonged PR Flattening and eventual loss of Ps Advanced AV blocks and sinus pauses Pseudo-ACS new BBBs, ST changes Tachy- and brady-arrhythmias Sine wave
17 ECG Findings in Hyperkalemia Peaked Ts Widening of the QRS Prolonged PR Flattening and eventual loss of Ps Advanced AV blocks and sinus pauses Pseudo-ACS new BBBs, ST changes Tachy- and brady-arrhythmias Sine wave
18 Severe Hyperkalemia
19 Severe Hyperkalemia
20 Severe Hyperkalemia
21 Severe Hyperkalemia
22 Severe Hyperkalemia
23 Severe Hyperkalemia
24 Hyperkalemia (10.2)
25 Moderate Hyperkalemia
26 Atropine/TCP no effect
27 After treatment
28 Severe Hyperkalemia (K Ts not that bad!)
29 Severe Hyperkalemia (K + 8.9) (machine Afib )
30 Hyperkalemia (K + 7.6) (atropine, TCP ineffective)
31 Hyperkalemia (K + 8.5)
32 ECG Findings in Hyperkalemia Peaked Ts Widening of the QRS Prolonged PR Flattening and eventual loss of Ps Advanced AV blocks and sinus pauses Pseudo-ACS new BBBs, ST changes Sine wave
33 #5: 42 yo. woman with weakness; SBP 120.
34 #5: Mobitz II?
35 Mobitz I
36 Mobitz I
37 Mobitz I
38 Mobitz I
39 Mobitz I
40 Mobitz I
41 Mobitz II
42 Mobitz II
43 Mobitz II
44 Mobitz II
45 Mobitz II
46 Mobitz II
47 Mobitz II
48 #5: 42 yo. woman with weakness; SBP 120.
49 #5: 42 yo. woman with weakness; SBP 120.
50 #5: 42 yo. woman with weakness; SBP 120.
51 #5: 42 yo. woman with weakness; SBP 120.
52 #5: 42 yo. woman with weakness; SBP 120.
53 #5: 42 yo. woman with weakness; SBP 120.
54 #5: SB, nonconducted PACs, VR 37
55 Nonconducted PACs misdiagnosed as Mobitz II
56 Nonconducted PACs misdiagnosed as Mobitz II
57 Nonconducted PACs misdiagnosed as Mobitz II
58 Nonconducted PACs misdiagnosed as Mobitz II
59 Nonconducted PACs misdiagnosed as Mobitz II
60 Nonconducted PACs misdiagnosed as Mobitz II
61 Nonconducted PACs misdiagnosed as Mobitz II
62 Nonconducted PACs misdiagnosed as Mobitz II
63 Nonconducted PACs misdiagnosed as Mobitz II
64 Nonconducted PACs misdiagnosed as Mobitz II
65 Nonconducted PACs misdiagnosed as Mobitz II
66 Nonconducted PACs misdiagnosed as Mobitz II
67 Nonconducted PACs misdiagnosed as Mobitz II
68 Nonconducted PACs misdiagnosed as Mobitz II
69 Nonconducted PACs misdiagnosed as Mobitz II
70 #6: 39 yo. man with palpitations and LH; SBP 130
71 #6: 39 yo. man with palpitations and LH; SBP 130
72 #6: Atrial flutter, 2:1 cond, VR 140 (misdx d as ST)
73 Atrial Flutter Misdiagnosis Always look for atrial flutter when the ventricular rate is ! Look for the flutter waves in all 13 leads, especially V1!
74 Atrial Flutter Misdiagnosed As Sinus Tachycardia
75 Atrial Flutter Misdiagnosed As SVT
76 Atrial Flutter Misdiagnosed As Sinus Tachycardia
77
78
79 Atrial Flutter Misdiagnosed As Sinus Tachycardia
80 Atrial Flutter Misdiagnosed As Sinus Tachycardia
81 Atrial Flutter Misdiagnosed As SVT
82 Atrial Flutter Misdiagnosed As SVT
83 Atrial Flutter Misdiagnosed As Sinus Tachycardia
84 Atrial Flutter Misdiagnosed As Sinus Tachycardia
85 Atrial Flutter Misdiagnosed As Sinus Tachycardia
86 Atrial Flutter Misdiagnosed As Sinus Tachycardia
87 Atrial Flutter Misdiagnosed As Sinus Tachycardia
88
89 #9: 65 yo. man with COPD exacerbation; SBP 75.
90 #9: MAT, VR 130
91 #10: 45 yo. man with history of CAD; SBP 120.
92 #10: VT, rate 180
93 #11: 38 yo. woman with palpitations and LH; SBP 110.
94 #11: SVT, VR 210
95 #12: 47 yo. man with chest pressure; SBP 85.
96 #12: 47 yo. man with chest pressure; SBP 85.
97 #12: Atrial flutter with variable AV conduction, VR 167
98 #13: 55 yo. woman c/o 24 hours of palps and LH; SBP 75.
99 #13: Atrial fibrillation, VR 152
100 #14: 57 yo. man 1 hour after lytics for AMI; SBP 115.
101 #14: AIVR, VR 105
102 #15: 26 yo man with palpitations, LH, SBP 80
103 #15: Atrial fibrillation and WPW
104 WPW Syndrome
105 WPW Syndrome Ventricular pre-excitation 0.1 3% population Classic triad shortened PR interval widened QRS interval delta wave
106 From Marriott, Advanced Concepts in Arrhythmias, Mosby Normal Conduction
107 From Marriott, Advanced Concepts in Arrhythmias, Mosby WPW Syndrome
108 WPW Syndrome NSR
109 WPW with SVT 2 types
110 WPW with SVT 2 types
111 WPW with Orthodromic SVT Courtesy Dr. Justin Cook
112 WPW with Orthodromic SVT Courtesy Dr. Justin Cook After Conversion
113 WPW with SVT 2 types
114 WPW with Antidromic SVT Courtesy Dr. Phil Magidson
115 WPW with Antidromic SVT Courtesy Dr. Phil Magidson After Conversion
116 From Marriott, Advanced Concepts in Arrhythmias, Mosby WPW with SVT 2 types
117 Normal Atrial Fibrillation From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998.
118 WPW With Atrial Fibrillation From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998.
119 WPW Syndrome Atrial fibrillation Very rapid irregularly irregular tachycardia (rates may approach 300 beats/min.) Often misdiagnosed as SVT, VT or atrial fibrillation with BBB Misdiagnosis and treatment with AVN blockers can be deadly!
120 WPW With Atrial Fibrillation
121 WPW With Atrial Fibrillation
122 WPW With Atrial Fibrillation
123 WPW With Atrial Fibrillation Courtesy Adam Friedlander, MD
124 After electrical cardioversion Courtesy Adam Friedlander, MD
125 WPW With Atrial Fibrillation Courtesy Alison Suarez, MD
126 WPW With Atrial Fibrillation Courtesy Chuck Sheppard, MD
127 WPW With Atrial Fibrillation Courtesy Rick Nunez, MD
128 WPW With Atrial Fibrillation
129 WPW With Atrial Fibrillation
130 WPW With Atrial Fibrillation
131 WPW With Atrial Fibrillation
132 WPW With Atrial Fibrillation
133 WPW With Atrial Fibrillation
134 WPW With Atrial Fibrillation
135 WPW With Atrial Fibrillation
136 WPW With Atrial Fibrillation
137 WPW With Atrial Fibrillation
138 WPW With Atrial Fibrillation
139 WPW With Atrial Fibrillation Treatment with amiodarone resulted in patient decompensation Boriani, et al (Am Heart J, 1996) Gaita, et al (Drugs, 1992) Schutzenberger, et al (Int J Cardiol, 1987) Sheinman, et al (BMJ, 1982) Tijunelis, et al (Can J Emerg Med, 2005)
140 Atrial Fibrillation With RBBB
141 Atrial Fibrillation With LBBB
142 Atrial Fibrillation With WPW ECG appearance Irregularly irregular tachycardia Wide QRS complexes QRS morphologies vary Rates may approach 300 BPM
143
144
145 Remember Just because electrocardiography is a basic skill in EM
146 Remember Just because electrocardiography is a basic skill in EM doesn t mean that our skills should be basic.
147 Remember Just because electrocardiography is a basic skill in EM doesn t mean that our skills should be basic. You must be the experts in electrocardiography!
148 Thanks! lectures.umem.org/ekg for slides for extra cases
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