Transcript
ECG EssentialsSteven J. Sager, MPAS, PA-CPAC5229 - Electrocardiography
Learning Objectives
Upon satisfactory completion of the course, and in conjunction with textbooks, lecture handouts, and any recommended internet Web Sites, the student will be able to: Recognize the components of the following lists:
List #1 – Causes of regular, narrow-complex tachycardia List #2 – Causes of regular, wide-complex tachycardia List #3 – Common causes of prolonged QT interval List #4 – Common causes of ST segment depression List #5 – Common causes of a tall R wave in lead V1
List #6 – Causes of anterior ST segment depression in the setting of acute inferior infarct
Learning Objectives
Discuss the pathophysiology of dysrhythmias List the factors which determine if a patient is
hemodynamically stable List the advantages of 12-lead vs. single lead
ECGs Explain the importance of ECG comparisons Describe the benefits and limitations of ECG
interpretation by computer analysis Recognize common dysrhythmias
Six Essential Lists
List #1 – Causes of regular, narrow-complex tachycardia
List #2 – Causes of regular, wide-complex tachycardia
List #3 – Common causes of prolonged QT interval
List #4 – Common causes of ST segment depression
List #5 – Common causes of a tall R wave in lead V1
List #6 – Causes of anterior ST segment depression in the setting of acute inferior infarct
Evaluating regular, narrow-complex tachycardia
P = P waves?
Q = QRS wide or narrow?
R = Regular rhythm?
S = P waves & QRS complexes “Single”?
Hemodynamically stable?
Symptomatic? Chest pain Dyspnea/SOB Altered mental status Hypotension Shock Heart failure Pulmonary edema AMI
Causes of regular, narrow-complex tachycardia
Treatment of regular, narrow-complex tachycardia
Vagal Maneuver May transiently slow the ventricular response Will either convert PSVT to sinus rhythm or have no affect at all Types:
Carotid sinus massage Valsalva Facial submersion in ice Gagging Ocular pressure Digital rectal massage Squatting and bearing down
Adenosine “chemical Valsalva” almost immediate slowing of ventricular response
Causes of regular, wide-complex tachycardia (WCT)
Treatment of regular, WCT
Hemodynamically unstable Cardiovert (synchronized)
Hemodynamically stable Determine etiology Review prior tracings If in doubt, treat for VT
Procainamide
QT prolongation
Prolongation of the QT interval on the ECG is the major marker for Long QT Syndrome
Long QT syndrome is one of the causes of sudden death in adolescents and young adults “sudden death” = unexpected death that occurs in a
someone who is apparently healthy Long QT Syndrome is thought to be the cause when
sudden death occurs from ventricular fibrillation
QT prolongation
It most frequently occurs during sporting events and is usually attributed to a sudden, unpredictable disturbance in the rhythm of the heart. the symptoms can occur during less strenuous
activities and even on awakening from sleep may become apparent when a young person with
fainting or secondary seizures has an ECG as part of their evaluation
it is especially important to look for the syndrome when the fainting or seizures are excercise-related
Causes of QT prolongation
Ischemia
Infarction
Drugs Type IA and type III antiarrhythmic agents TCAs Phenothiazines
Causes of QT prolongation
Electrolyte deficiencies hypokalemia hypomagnesia hypocalcemia
Catastrophic CNS event CVA intracerebral hemorrhage seizures
Common causes of ST segment depression
Ischemia - symmetric
“Strain” - asymmetric
Digitalis effect – scooped or strain pattern
Hypokalemia
Hypomagnesia
ST-segment depression
Common causes of a tall R wave in lead V1
Wolff-Parkinson-White (WPW) syndrome
Right bundle branch block (RBBB)
Right ventricular hypertrophy (RVH)
Acute infero-postero-lateral infarction
Hypertrophic cardiomyopathy
Muscular dystrophy
Dextrocardia
Normal variant
Differentiate the causes of a tall R wave in lead V1
Causes QRS ECG ∆’s
W-P-W Widened Delta waves Short PR interval
RBBB Widened rSR´ in V1 Wide terminal S wave in I and V6
RVH Normal RAD R ventricular strain
Infarct Normal Changes in inferior leads
Positive “mirror test”
60 y.o. ♂ with history of heart disease.72 y.o. ♀ with history of palpitations.28 y.o. ♂ with no medical problems or heart disease.66 y.o. ♂ 2ppd smoker with history of COPD.48 y.o. ♂ with new onset chest pain.
Causes of anterior ST segment depression in the setting of acute inferior
infarct Reciprocal changes Concomitant anterior ischemia Posterior infarction
Mirror test
Combination of above
∆’s (ST depression)common in: V1, V2, and V3
Why 12-lead vs. 1-lead?
12-lead provides more information improves arrhythmia interpretation
CXR?
ABG?
60 y.o. c/o rapid heart beat.♀Denies CP. No meds.B/P = 140/90mmHg
Rate? P? Q? R? S?
50 y.o. with CAD c/o rapid heart beat. ♂Denies CP. B/P = 160/100mmHg
Rate? P? Q? R? S?
60 y.o. with COPD c/o wheezing & mild ♂dyspnea. Hx of rapid heart beats.
B/P = 130/80mmHg.
60y.o. c/o “palpitations”♂
Comparing Tracings
1. Find as many as possible2. Evaluate previous tracings
a) valid regardless of age and interval
3. Evaluate new tracing4. Compare the two most recent tracings
l systematically move from one lead to the next
l start at I and proceed through V6
l Comment on ANY and ALL differences!
Important Comparison Points to Consider
Review all available tracings request old charts look for “patterns”
Lead placement variables may alter axis, wave amplitude/morphology, etc.
Request serial ECGs when appropriate angina evolving MI interval?
Benefits of Computer Analyses
Save time Accurate calculations of:
heart rate intervals axis
Provide legible interpretations May suggest additional findings
write your interpretation first, then compare Educational
improve provider accuracy
Are Computer Analyses Accurate?
Sometimes only as good as their programming! reliably recognize sinus/normal tracings
Most accurate in computing values Routinely miss subtle infarctions Tend to overinterpret Should be used to enhance the provider’s
interpretation provide a good “second opinion”
Reviewing a Computer Analysis
√√
Intervals/durations in milliseconds
Date & time are CRITICAL! Includes patient identification
Thought for the day!
Our background and circumstances may have influenced who we are,
but only we are responsible for who we
become!
Mirror test
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