Top Ten _or 11_ EKG Killers by dffhrtcv3

VIEWS: 58 PAGES: 84

									Top Ten (or 11) EKG Killers
      Micelle Haydel, MD
     LSUHSC New Orleans
           Credit to Amal Mattu, MD
   Lectures:
       ACEP
       EmedHome Podcasts
       Visiting Lectures

   Books:
       ECG's for the Emergency Physician 1 by Mattu & Brady
       ECGs for the Emergency Physician 2 by Mattu & Brady
       Electrocardiography in Emergency Medicine by Amal Mattu
The EKG must be interpreted in
the clinical context.

 Don’torder a test unless you
 know what to do with the
 results…
The Normal Adult EKG




   Majority QRS complexes are positive (have tall R waves)
       Except AVR & V1-2; r-wave progression across the precordium
       T wave in V1 should be small, flat or flipped
    Differential Dx of Tall R waves in V1
   Posterior MI
   RBBB
   Right Strain
        PE
        COPD
        Cor Pulmonale
   RBBB mimics
        PE
        Brugada
        ARVD
        WPW
   Pediatric EKG (tall R-wave
    and flipped t-wave V1-3)
Specific causes of non-specific flipped T-Waves


   CAD/ischemia
   Cardiomyopathies
   Myocarditis, pericarditis
   PE
   Valvular disorders
   CNS bleed



   LVH, BBB, paced
Differential Diagnosis: Tall t-waves
 HyperacuteT-waves/ischemia
 HyperKalemia



 BER
 LVH, BBB,
Paced
Low voltage: qrs <10mm precordial
   Obese patient      The New Orleans’ Special
   Restrictive cardiomyopathy
   Pericardial effusion
   Hypothyroid
   Hypothermia
   Myocarditis
The EKG must be interpreted in
the clinical context.

 Don’torder a test unless you
 know what to do with the
 results…
EKG in Syncope, PreSyncope,
        Palpitations
Is it Syncope--
    or is it a sentinel death event??
    Cardiomyopathies                              Other Biggies
         Dilated                                       MI
         Hypertrophic                                  Pulmonary
         Restrictive                                    Embolism
         ARVD/C Arrhythmogenic Right
          Ventricular Dyplasia/Cardiomyopathy
    Primary arrhythmic syndromes
         WPW
         QT intervalopathies
         Brugada
         ARVD
         CPVT Catecholaminergic Polymorphic
          Ventricular Tachycardia
         Not-so BER
 Sudden Cardiac Death: unexpected death within
 1 hour of symptoms
 Final, common pathway: Vtach/fib 90%

~300,000/yr in US
       Over 35 years
            ~80% due to CAD
            ~15% Cardiomyopathy




NEJM Huikuri et al. 345 (20):
  1473, November 15, 2001
    Sudden Cardiac Death: 1-35 yrs
    Final, common pathway: Vtach/fib 90%
~3,000/yr U.S.
   ~70% have a structural abnormality
      Cardiomyopathies

      Coronary Anomalies                      Identified Causes SCD 1-35 years
      Myocarditis

      Valvular Disorders                30%                           HCM

   Primary arrhythmic syndromes         25%                           Coronary
        Accessory pathways                                            Anomalies
                                         20%
                                                                       Myocarditis
        QT intervalopathies
                                         15%
        Ion channelopathies                                           Valvulopathies
                                         10%
                                                                       Primary arrhythmic
                                         5%                            syndromes
                                                                       ARVD
                                         0%
EKG findings in Sentinel Death Events

   Cardiomyopathies: (flipped T waves plus…)
       Hypertrophic Cardiomyopathy (LVH)
       Dilated (LVH)
       Restrictive cardiomyopathy (low voltage,a-fib,
        conduction disturbances)
       Arrhythmogenic Right Ventricular Dysplasia
        /Cardiomyopathy (Epsilon waves, RBBB
        pattern)
EKG findings in Sentinel Death Events

   Primary arrhythmic syndromes
      Brugada coved/saddle deformity ST V1 &V2

      WPW Delta waves, short PR interval, RBBB pattern

      Prolonged/shortened QT

      Not so-BER inferior-lateral j-point elevation
      Catecholaminergic Polymorphic Ventricular
       Tachycardia: Normal RESTING EKG/ECHO with recurrent syncope
       starting in childhood related to exertion/emotions.
EKG findings in Sentinel Death Events
   Myocarditis (diffuse flipped T waves)
   Congenital coronary-artery anomalies (large p waves)
   Coronary artery disease: (Wellen’s Sign, Hyperacute T
    waves, Too tall T-waves)
   Valvular disorders (AS: LVH; MVP: normal or flipped T
    waves inferiorly)
Heart racing, I feel ok now…
         Delta waves, short PR interval

WPW   
      
          tall R-waves in V1, RBBB pattern
          Pseudoinfarction pattern inferiorly
Fainted…
Prolonged qt interval
Prolonged QT
QT interval

    Depending on the
     rate, ~normally
     about the size of
     two big blocks
Woozy, I feel ok now…
Congenital SHORT QT syndrome
(<320ms) --- vtach, syncope, SCD
Weekend warrior, passed out
Hypertrophic CardioMyopathy
   The most common ECG abnormalities
       left ventricular hypertrophy
       abnormal ST-segments
            Deeply flipped T-wave, tall R apical leads, deep Q waves laterally
Hypertrophic CardioMyopathy
   Asymmetrical thickening of the ventricular septum
   Patients may experience syncope, angina,
    palpitations, dyspnea
Chief Complaint: Palpitations
Restrictive cardiomyopathy:
Low Voltage with flipped anterior Twaves
    Restrictive cardiomyopathy:
  Amyloidosis, sarcoidosis, hemochromatosis, etc
 Ventricles become rigid and lack the flexibility to expand during diastole.
 SOB, fatigue, palpitations & syncope
other common findings : atrial fib, conduction delays
Specific causes of non-specific flipped T-Waves


   CAD/ischemia
   Cardiomyopathies
   Myocarditis, pericarditis
   PE
   Valvular disorders
   CNS bleed



   LVH, BBB, paced
The eye does not see what the
mind does not know...
Seizure vs. syncope…
Brugada




    Na ion channelopathy that
    predisposes to v-tach/fib


                                Coved or Saddle types
Almost passed out, I feel ok now…
Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy
• Replacement of RV muscle by fibro-fatty tissue
• Associated with VT and ventricular fibrillation
Arrhythmogenic Right Ventricular
Dysplasia/Cardiomyopathy AVRD/C

   May have Epsilon waves: sharp discrete
    deflections at the terminal portion of the QRS
    complex in V1-2
   Inverted T waves in the anterior leads
   Incomplete or complete RBBB



                                    Blips or wiggles in the
                                    terminal part of the QRS
Passed out, I feel better now…
    BER vs Not-so-Benign Early Repolarization
   Classically BER is found in the mid- precordial leads
   Notching, smiley face upward deflection
   Not-so BER: NEJM 358:2016-2023 Haïssaguerre et al, showed that
    inferior-lateral ST elevation was associated with v tach/fib.
 BER, with inferior-lateral J point
 elevation
• Similar j point elevation & notching has been noted in ARVD, WPW & Brugada.

• The jury is still out: BER in the inferior-lateral leads can be considered benign,
unless the patient presents with syncope, palpitations, family hx sudden death.
Is it Syncope--
    or is it a sentinel death event??
    Cardiomyopathies                              Other Biggies
         Dilated                                       MI
         Hypertrophic                                  Pulmonary
         Restrictive                                    Embolism
         ARVD/C Arrhythmogenic Right
          Ventricular Dyplasia/Cardiomyopathy
    Primary arrhythmic syndromes
         WPW
         QT intervalopathies
         Brugada
         ARVD
         CPVT Catecholaminergic Polymorphic
          Ventricular Tachycardia
         Not-so BER
 EKG in Chest Pain and/or SOB


• Ischemia
• Pericarditis/Myocarditis
• PE
• Tamponade
Passed out, I feel ok now…
PE
   S1,Q3,T3
   Rt strain (RBBB pattern)
   Flipped anterior t-waves
Dogma: The most common ECG abnormalities in PE are
tachycardia and nonspecific T wave abnormalities.


   Recent studies: The most common ECG finding in PE is anterior T-
    wave inversion.
   Mattu: the combination of flipped t-waves anteriorly and inferiorly is very
    specific for PE.
    Flipped T waves in Pulmonary Embolism

   Number of Leads with T
    Wave inversion
    correlating with RV
    dysfunction on Echo:
      ≤ 3 = 47%

      4-6 = 92%

      ≥ 7 = 100%

   Kosuge et al. Circ J 2006
Severe Shortness of breath
Tamponade
Low voltage: qrs <10mm precordial
   Obese patient The New Orleans’ Special
   Restrictive cardiomyopathy
   Pericardial effusion
   Hypothyroid
   Hypothermia
   Myocarditis
I had chest pain, but I am ok now…
Wellen’s Sign
• Associated with a critical, proximal LAD lesion
• Classically, occurs during a pain-free period
Chest Pain
HyperAcute T-waves
   HyperAcute T-waves in the anterior leads
       Poor R- wave progression
       T-waves are asymmetrical and broad-based
       Follows a pattern of injury
Differential Diagnosis: Tall t-waves
   Hyperacute T-waves (broad, asym)
   HyperKalemia (narrow, pointy)
   BER (usually associated with tall r-waves)
   LVH (usually assoc with prwp)
   LBBB (prwp, wide)
I had chest pain, but I am ok now…

Today




One week
ago
HyperAcute T-wave in V1
The normal ECG has a small, flat or inverted T-wave in lead V1 and if
  upright or larger in V1 than V6 in the setting of ACS:
        Suggests significant underlying CAD or acute ischemia if new
             may precede other expected ECG changes
   Tall t-waves don’t belong in V1 except:
        LBBB
        LVH
Chest Pain
ST elevation in V1,
plus ST elevation AVR
 AVR & Left Main lesions:
 is it magic or is it simply reversal of V6?
 




Fu, et al, The American Journal of Cardiology, Volume 99, Issue 7 reported
higher mortality risk in patients with flipped T & ST depression in the V5-6.
Mattu: aVR




A. ST-segment elevation in lead aVR suggestive of LMCA occlusion: in NonSTEACS pts,
increased 30 day mortality: Yan, American Heart Journal - Volume 154, Issue 1
B. PR-segment elevation suggestive of acute pericarditis.
C. Prominent R′ wave suggestive of TCA poisoning.
D. Rapid, regular, narrow QRS complex tachycardia with ST-segment elevation suggestive
of WPW-related tachycardia.
I had chest pain, but I am ok now…
Pericarditis
CP, SOB…




25yo, low grade fever, dyspnea, uri symptoms, chest pain…
Myocarditis: SOB, CP, fever
   Diffuse T-wave inversions with or without ST segment abnormality

   Incomplete atrioventricular conduction blocks or Intraventricular
    conduction blocks (usually transient)
 EKG in Chest Pain and/or SOB


• Ischemia
• Pericarditis/Myocarditis
• PE
•Tamponade
EKG in Weak & Dizzy
Electrolytes
I feel weak…
Hyperkalemia
“SLOW Vtach”?   It ain’t tach, if it ain’t tachy
                V-tach >120bpm….
                    • Severe hyperkalemia
                    • Idioventricular/reperfusion dysrhythmias
                                  • Type IA medication toxicity
                             TCA toxicity
                             Cocaine toxicity
I feel weak…
Hypocalcemia– prolonged QT
EKG in Weak & Dizzy
   Electrolytes
EKG in Overdose
        Na Channel Blockade
            Widen QRS
        K+ efflux blocker
            Prolongs qt interval
        AV nodal blocker
            Depresses inotropy
            Depresses chronotropy
        Digitalis: Na/K pump
            AV nodal blockage
            Increased automaticity
Depressed, AMS…
  TCA overdose




Sodium channel blockade: TCA, Cocaine, Benadryl, anticholinergic, dilantin
SALT: shock, AMS, Long QT & Terminal slurring R in AVR
Sympathetomimetics/Cocaine




 Typically more tachy than TCA OD b/c less potassium efflux blockade
Depressed, took something….
Potassium efflux blockers:
Medication induced long qt
Medication induced long qt
Depressed, AMS…
B-blocker/Ca-Channel blocker
Digitalis
Acute: AV block

Chronic: Increased
  automaticity
EKG in Overdose
   TCA
   Sympathetomimetics/Cocaine
   B-blocker/Ca-Channel blocker
   Digitalis
EKG Stat!!




     ECG, Willem Einthoven, assigning P, Q, R, S and T to the various
     deflections and awarded the 1924 Nobel Prize

								
To top