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
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
Case 1: Palpitations! 54-year-old male with palpitations and mild dyspnea. Denies chest pain.! Here s his strip:
Case 1: Palpitations! 54-year-old male with palpitations and mild dyspnea. Denies chest pain.! Here s his strip:
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
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 )
Case 1: Rapid AF with WPW! Management? } Sync Cardioversion. Now. } Distant 2 nd choice: procainamide
Case 2: I m a little dizzy
Case 2: I m a little dizzy
Case 2: I m a little dizzy! 1) Ventricular tachycardia (VT)! 2) Ventricular tachycardia (VT)! 3) Ventricular tachycardia (VT)
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)
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)
Case 2: I m a little dizzy
Case 2: I m a little dizzy! UNSTABLE? Synchronized Cardioversion! Stable? Procainamide, Lidocaine
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)
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:
Case 3: I don t feel good
Case 3: Hyperkalemia Serum Potassium Level Mild hyperkalemia 5.5-6.5 meq/l Moderate hyperkalemia 6.5-8.0 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
Case 3: Hyperkalemia
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
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?
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?
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?
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
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
Case 4: I need some Tums! Cardiac stress test is contraindicated
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
Questions?