10 ECGs No Practitioner Can Afford to Miss. Objectives

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1 10 ECGs No Practitioner Can Afford to Miss Mary L. Dohrmann, MD Professor of Clinical Medicine Division of Cardiovascular Medicine University of Missouri School of Medicine No disclosures Objectives 1. Review basic principles 2. Have some fun with some ECGs 3. Go home with some motivation 1

2 Resources Complete Guide to ECGs 3 rd ed., 2009, ed. O Keefe et al: 88 practice ECGs Great website for practice Observation Stages of ECG expertise Observation + conclusion Above plus clinical context/application (takes into account all available information) 2

3 What is Normal? Not deviating from a norm, rule, or principle Conforming to a type, standard, or regular pattern The standard ECG Patient position Proper lead locations Voltage standardization Paper speed 3

4 Standard vs Non Standard ECG Non Standard limb leads Standard limb leads The Normal ECG 4

5 The Normal ECG Sinus rhythm (P QRS) P wave axis (+ I,II,III, avf) Rate bpm; paper speed 25 mm/sec QRS Axis +90 o (youth) to 30 o (elderly) Intervals: PR sec, QRS <.10 sec QT c <.46 sec (observed QT/ RR interval) QRS voltage (n/a < age 35)(use 10mV standard) Precordial R waves (transition V3 V4) ST segment (baseline or early repolarization pattern) T wave (concordant with frontal plane QRS vector) Normal ECG Is this person older or younger than pt in prior ECG? 5

6 Normal ECG This ECG is in an older individual than prior normal ECG why? axis is more leftward! Rhythm Sinus Not sinus Morphology Supravent. Ventricular 6

7 Morphology Hierarchy WPW > LBBB > LVH > MI 1 st ECG in ED in patient w/chest pain 7

8 A. Get a VQ scan B. Take the patient to the cath lab C. Repeat the ECG D. Get an echo Next steps? Repeat the ECG: Reversed V1 and V3 leads The R wave progression does not make sense! Negative P and T in V3 are clues that this V3 is really V1. Note: an isolated Q in III is NORMAL! 8

9 Prior ECG with V lead positions corrected now appears normal! 1 st ECG in ED in patient w/chest pain 9

10 A. Get a VQ scan B. Take the patient to the cath lab C. Repeat the ECG D. Get a CXR Next steps? 1 st ECG in ED in patient w/chest pain Patient with dextrocardia! A CXR would tell you this! Dextrocardia negative P wave in lead I; abnormal R wave progression with diminished voltage in V6 10

11 Dextrocardia ECG in same patient as previous Corrected leads for anatomy (purposely reversed arm leads and used right sided V leads) Reversed arm leads negative P in I, positive P in avr 11

12 Prior ECG with arm leads corrected 29 y/o with chest pain 12

13 What would you do? A. Take the patient to the cath lab B. Perform thorough cardiac exam (1 st ) C. Repeat ECG D. Obtain a STAT echocardiogram (2 nd ) 29 y/o with chest pain Diffuse ST elevation c/w pericarditis Note: PR segment depression Physical exam findings: 3-component friction rub, tachycardic, fever. Be sure patient does not have Kussmaul s, pulsus alternans or paradoxus 13

14 47 y/o male with chest pain Acute inferior MI 41 y/o male with severe SOB Extensive anterior/anterolateral MI 14

15 54 y/o male with exertional chest pain What test would you obtain? A. Cardiac catheterization B. Exercise stress test C. Exercise stress test combined with imaging D. Echocardiogram In a patient with angina and prior infarct, proceeding directly to cardiac catheterization would be the optimal choice; however, you might also want to get an echocardiogram prior to cardiac cath to assess LV function. 15

16 54 y/o male with exertional chest pain AMI, indeterminate age; RBBB ±LAFB Cath findings: 100% proximal LAD, 90% D1, 90% D2, 100% mid-rca; LVEF 25% 40 y/o resuscitated from VF 16

17 40 y/o resuscitated from VF Brugada syndrome This patient received an AICD Check out this website! 17

18 34 year old with syncope A. Admit for cardiac monitoring B. Obtain electrolytes C. Review current medications D. All of the above What s next? 18

19 34 year old with syncope Long QT syndrome Calculate the QTc using Basett s formula: QT corrected = QT observed RR Torsades de pointes 19

20 Drugs that can prolong QT Insulin dependent diabetic with nausea 20

21 If you could get one lab test what would it be? A. Cardiac enzymes B. ABGs C. Serum potassium D. Serum calcium Hyperkalemia (K=6.0) with peaked T waves With severe hyperkalemia, QRS and PR intervals widen, flattened P waves, junctional rhythm, progressing to idioventricular rhythm 21

22 Resolution of peaked T waves following treatment of hyperkalemia 40 y/o with chest pain & palpitations 22

23 The most likely diagnosis is: A. Right bundle branch block B. Acute inferior infarct C. Left bundle branch block D. Ventricular preexcitation (WPW) 40 y/o with chest pain & palpitations short PR/delta wave c/w preexcitation 23

24 WPW mimicking anterior infarct WPW mimicking inferior infarct (The inferior Qs are delta waves!) 24

25 48 y/o male with inferior MI What is your treatment? A. IV lidocaine B. No treatment needed unless symptomatic C. IV atropine bolus D. Put in a pacemaker 25

26 Accelerated idioventricular rhythm in context of inferior infarct May represent reperfusion arrhythmia; may be provoked by increased vagal tone and is as an escape rhythm; well tolerated clinically 80 y/o man with syncope 26

27 Right bundle branch block & LAD, 2:1 block and/or complete heart block, with ventricular escape complexes This patient needs a pacemaker! More fun ECGs to review at home! 27

28 2 nd degree AV block, Type I (Wenckebach) (Note the gradually increasing PR interval and subsequent nonconducted P resulting in a greater than 2 second pause) Atrial flutter 2:1 conduction 28

29 Same patient as previous ECG, atrial flutter with variable conduction Supraventricular tachycardia?retrograde P, suggests AV nodal reentry; ST depression cannot exclude ischemia 29

30 Junctional tachycardia with retrograde P waves Wide complex tachycardia = VT! 30

31 Multifocal atrial tachycardia (Note multiple P wave morphologies) 51 y/o male with chest pain ST elevation I, avl, V2 c/w acute injury/infarct (Note: reciprocal depression in II, III, avf) Patient had 100% occlusion of diagonal branch from the LAD 31

32 70 y/o with exertional chest pain ECG shows LBBB cannot interpret for ischemia or infarct! LBBB causes false positive exercise imaging! The stress test of choice would be an adenosine sestamibi. Right bundle branch block, left anterior fasicular block, and first degree AV block 32

33 I love to review ECGs. Contact me at 33

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