You Don t Want to Miss This One! Focus on can t miss EKG tracings

Transcription

1 You Don t Want to Miss This One! Focus on can t miss EKG tracings Renaissance St. Louis Grand Hotel Convention Center October 23, 2014 David K. Tan, M.D., EMT-T, FAAEM EMS Section Chief, Division of Emergency Medicine Washington University School of Medicine

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4 Objectives! Review important findings of high risk EKGs that are easy for medics (and doctors!) to miss! Discuss appropriate management of these conditions! Advocate for a change in the way you approach the interpretation of your 12-lead tracings

5 Case 1: Palpitations! 54-year-old male with palpitations and mild dyspnea. Denies chest pain.! Here s his strip:

6 Case 1: Palpitations! 54-year-old male with palpitations and mild dyspnea. Denies chest pain.! Here s his strip:

7 Case 1: Rapid AF with WPW! Irregularly Irregular must be atrial fibrillation! Wide and changing morphologies suggests an accessory pathway like Wolfe-Parkinson-White (WPW) Syndrome

8 Case 1: Rapid AF with WPW! Here s the scary part: } AV Nodal Blockers (diltiazem, adenosine, amiodarone, lidocaine, beta blockers) are contraindicated and, if given, may cause VFib (that s bad )

9 Case 1: Rapid AF with WPW! Management? } Sync Cardioversion. Now. } Distant 2 nd choice: procainamide

10 Case 2: I m a little dizzy

11 Case 2: I m a little dizzy

12 Case 2: I m a little dizzy! 1) Ventricular tachycardia (VT)! 2) Ventricular tachycardia (VT)! 3) Ventricular tachycardia (VT)

13 Case 2: I m a little dizzy! 1) Ventricular tachycardia (VT)! 2) PSVT [AV nodal re-entry tachycardia (AVNRT, 60% of PSVT), orthodromic WPW (30% of PSVT)] with aberrancy (RBBB, LBBB, IVCD)! 3) Sinus Tach with RBBB! 4) A flutter with RBBB and 2:1 conduction! 5) Antidromic reciprocating tachycardia (ART)

14 Case 2: I m a little dizzy! 1) Ventricular tachycardia (VT)! 2) PSVT [AV nodal re-entry tachycardia (AVNRT, 60% of PSVT), orthodromic WPW (30% of PSVT)] with aberrancy (RBBB, LBBB, IVCD)! 3) Sinus Tach with RBBB! 4) A flutter with RBBB and 2:1 conduction! 5) Antidromic reciprocating tachycardia (ART)

15 Case 2: I m a little dizzy

16 Case 2: I m a little dizzy! UNSTABLE? Synchronized Cardioversion! Stable? Procainamide, Lidocaine

17 Case 2: I m a little dizzy! UNSTABLE? Synchronized Cardioversion! Stable? Adenosine may convert some VTach (and is safe); ACLS is wrong (adenosine doesn t diagnose SVT)

18 Case 3: I don t feel good! 69 year-old male who awoke with severe generalized fatigue and weakness! Pt has extensive medical history and also complains of dyspnea! He missed a couple of hemodialysis appointments! You obtain a 12-lead tracing on scene:

19 Case 3: I don t feel good

20 Case 3: Hyperkalemia Serum Potassium Level Mild hyperkalemia meq/l Moderate hyperkalemia meq/l Severe hyperkalemia >8.0 meq/l Expected ECG Changes Tall, tent shaped ( peaked ) T-waves with narrow bases, best seen in precordial leads Peaked T-waves Prolonged PR interval Decreased amplitude of P-waves Widening of QRS complex Absence of P-waves Intraventricular blocks, fascicular blocks, bundle branch blocks, QRS axis shift Progressive widening of the QRS complex resulting in bizarre QRS morphology Eventual sine-wave pattern (sinoventricular rhythm), VF, asystole

21 Case 3: Hyperkalemia

22 Case 3: I don t feel good! May not always have the missed dialysis clue maintain a high index of suspicion! Management: } Calcium } Bicarb } Rapid Transport

23 Case 4: I need some Tums! 46-year-old male with chest pains! Admits to extra jalapeño s on his burger! Wife called 9-1-1! Just get a refusal?

24 Case 4: I need some Tums! 46-year-old male with chest pains! Admits to extra jalapeño s on his burger! Wife called 9-1-1! Just get a refusal?

25 Case 4: I need some Tums! 46-year-old male with chest pains! Admits to extra jalapeño s on his burger! Wife called 9-1-1! Just get a refusal?

26 Case 4: I need some Tums! Wellen s Syndrome } Biphasic T-wave in the anterior leads (most commonly V2 and V3) with a steep downward slope } No loss of R-wave progression in the anterior leads } No Q-waves in the anterior leads, except possibly V1

27 Case 4: Wellen s Syndrome! If these changes are present during a pain-free period of a patient with cardiac symptoms } 100% chance of greater than 50% occlusion in the proximal left anterior descending artery (LAD) } 75% chance of at least an occlusion of 70% } 50% chance of a greater than 90% LAD occlusion

28 Case 4: I need some Tums! Cardiac stress test is contraindicated

29 Summary! There are dozens of can t miss EKG tracings out there, but Rapid AF with WPW, VTach, Hyperkalemia, and Wellen s Syndrome are especially important! Maintain a systematic and standardized approach to the interpretation of your tracings to avoid missed clues and missed diagnoses

30 Questions?