Advanced ECG Interpretation Pt. II

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 amalmattu@comcast.net

A Few Points To Start Advanced content We ll skip the basics

A Few Points To Start Workshop Questions? amalmattu@comcast.net Writing Handout/PDF Lectures.umem.org/ekg Weekly video cases for extra practice: www.ekg.umem.org

Why is this important?

Why is this important? This is high-risk but high payoff! Very good outcome vs. very bad outcome

Dysrhythmias

#1: 70 yo. woman with 4 days of N/V, malaise; SBP 80.

#1: ST, Mobitz I, VR 94

#2: 62 yo. man with SOB and chest pain; SBP 80.

#2: ST, 3 rd degree AVB, JER, VR 48

#3: 85 yo. woman with syncope; SBP 120.

#3: SR, Mobitz II with 3:2 conduction, VR 50, LBBB

#4: 62 yo. man c/o LH; SBP 85.

#4: Hyperkalemia (K + 8.0)

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

Severe Hyperkalemia

Hyperkalemia (10.2)

Moderate Hyperkalemia

Atropine/TCP no effect

After treatment

Severe Hyperkalemia (K + 8.5 Ts not that bad!)

Severe Hyperkalemia (K + 8.9) (machine Afib )

Hyperkalemia (K + 7.6) (atropine, TCP ineffective)

Hyperkalemia (K + 8.5)

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

#5: 42 yo. woman with weakness; SBP 120.

#5: Mobitz II?

Mobitz I

Mobitz II

#5: 42 yo. woman with weakness; SBP 120.

#5: SB, nonconducted PACs, VR 37

Nonconducted PACs misdiagnosed as Mobitz II

#6: 39 yo. man with palpitations and LH; SBP 130

#6: Atrial flutter, 2:1 cond, VR 140 (misdx d as ST)

Atrial Flutter Misdiagnosis Always look for atrial flutter when the ventricular rate is 150 + 20! Look for the flutter waves in all 13 leads, especially V1!

Atrial Flutter Misdiagnosed As Sinus Tachycardia

Atrial Flutter Misdiagnosed As SVT

Atrial Flutter Misdiagnosed As Sinus Tachycardia

Atrial Flutter Misdiagnosed As SVT

Atrial Flutter Misdiagnosed As Sinus Tachycardia

#9: 65 yo. man with COPD exacerbation; SBP 75.

#9: MAT, VR 130

#10: 45 yo. man with history of CAD; SBP 120.

#10: VT, rate 180

#11: 38 yo. woman with palpitations and LH; SBP 110.

#11: SVT, VR 210

#12: 47 yo. man with chest pressure; SBP 85.

#12: Atrial flutter with variable AV conduction, VR 167

#13: 55 yo. woman c/o 24 hours of palps and LH; SBP 75.

#13: Atrial fibrillation, VR 152

#14: 57 yo. man 1 hour after lytics for AMI; SBP 115.

#14: AIVR, VR 105

#15: 26 yo man with palpitations, LH, SBP 80

#15: Atrial fibrillation and WPW

WPW Syndrome

WPW Syndrome Ventricular pre-excitation 0.1 3% population Classic triad shortened PR interval widened QRS interval delta wave

From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998. Normal Conduction

From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998. WPW Syndrome

WPW Syndrome NSR

WPW with SVT 2 types

WPW with Orthodromic SVT Courtesy Dr. Justin Cook

WPW with Orthodromic SVT Courtesy Dr. Justin Cook After Conversion

WPW with SVT 2 types

WPW with Antidromic SVT Courtesy Dr. Phil Magidson

WPW with Antidromic SVT Courtesy Dr. Phil Magidson After Conversion

From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998. WPW with SVT 2 types

Normal Atrial Fibrillation From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998.

WPW With Atrial Fibrillation From Marriott, Advanced Concepts in Arrhythmias, Mosby 1998.

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!

WPW With Atrial Fibrillation

WPW With Atrial Fibrillation Courtesy Adam Friedlander, MD

After electrical cardioversion Courtesy Adam Friedlander, MD

WPW With Atrial Fibrillation Courtesy Alison Suarez, MD

WPW With Atrial Fibrillation Courtesy Chuck Sheppard, MD

WPW With Atrial Fibrillation Courtesy Rick Nunez, MD

WPW With Atrial Fibrillation

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)

Atrial Fibrillation With RBBB

Atrial Fibrillation With LBBB

Atrial Fibrillation With WPW ECG appearance Irregularly irregular tachycardia Wide QRS complexes QRS morphologies vary Rates may approach 300 BPM

Remember Just because electrocardiography is a basic skill in EM

Remember Just because electrocardiography is a basic skill in EM doesn t mean that our skills should be basic.

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!

Thanks! amalmattu@comcast.net lectures.umem.org/ekg for slides www.ekg.umem.org for extra cases