ECG for the intensivists

KHALED FAROUK; MDA . P R O F E S S O R O F C R I T I C A L C A R E M E D I C I N E

C A I R O U N I V E R S I T Y

ECG for intensivests

A Story ?

You always need a storyWhen exactly in the timeline of your patient youintersect?Dose this changes his/her life?More life or life no More

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Asystole

V. FIB

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T.D.P

T.D.P

WCT

Wide Complex tachycardia

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Differentiating ventricular tachycardia

from svt with aberrancy

➢ Leads to correct initial therapy

➢ Avoids use of Verapamil which may precipitate hemodynamic collapse with V.T.

Cannot use rate or the presence or absence ofsymptoms as discriminator !

➢ Use ECG criteria for diagnosis

➢ Use presence of risk factors for V.T. as discriminator

What is WCT criteria is addressing?

I. A -V relationship dissociation, fusion, and captureII. Axis twist North west, LBBB+RAD, and RBBB+LADIII. Morphology criteria … Brugada Concordance Four leads concept

The Brugada Criteria

Morphology Criteria for VT

Four Negative Leads Concept

Farouk.K EHJ, 1999

The presence of predominantly negative QRS complex (QS,rS) in two out of four leads (LI, LII, V1 and V6)providedthat LI or V6 is included…..diagnose VT (sp. 100% sen.86%).

Otherwise consider SVT with aberration or antidromictachycardia.

WCT

Look at LI and V6

-ve +ve VT Look at V1

-ve +veVT SVT with aberration

L1 and V6 -ve L1 or V6 -ve L1 and V6 +ve

VT SVT

Look atLII

Other ECG Criteria

B.Axis twist

➢ North - west QRS axis deviation

➢ RBBB morphology with LAD > - 300

➢ LBBB morphology with RAD > + 900

C. A_V relationship

➢ Fusion beats, capture beats

➢ Ventriculoatrial conduction with block

➢ Previous ECG show MI or previous ECG show that duringsinus rhythm, bifascular block is present, which changes inconfiguration during tachycardia

Ventricular Tachycardia Concordance (different from “concordance” as used for ST-T vs QRS)

Step 1: Absence of RS in all precordial leads

Step 1: there is no absence of RS in all precordial leads (no concordance) (V5, V6)

Step 2: RS in V5 > 0.10 ms, therefore v tach

Step 3: No AV dissociation

Step 4: RBBB pattern (tall R in V1). Notching of this monophasic R indicates VT

Case 1A 67 year old male with history of previous infarct and reduced LVfunction presents with palpitations and dizziness.His blood pressure is 80/40.

A. Synchronized cardioversion for VT

B. I.V. Procainamide for Atrial Fibrillation with WPWsyndrome

C. Synchronized cardioversion for unstable SVT withaberrancy.

D. I.V. Amiodarone for SVT with aberrancy in a patientwith reduced LV function.

➢ This patient has ventricular tachycardia.

➢ An RS interval of greater than 100 msec is clearlyvisible.

➢ In addition, by history this patient is overwhelminglylikely to present with VT with a wide complex rhythm.

➢ Also this patient is not stable with relative hypotensionrequiring immediate cardioversion as opposed topharmacologic therapy.

Answer A

Concordance and Northwest Axis

Case 2A 42 year old smoker presents to the ED with palpitations.

His blood pressure is 100/60. The following rhythm strip is obtained.

A. Emergent cardioversion for polymorphic VT.

B. I.V. procainamideC. I.V. lidocaineD. Diltiazem drip to obtain rate control.

What Is It ?

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Answer B

➢ This patient has WPW with atrial fibrillation anda rapid ventricular response.

➢ He is stable, thus I.V. procainamide is indicatedto slow conduction down the accessory pathway.

➢ Diltiazem is contraindicated.

➢ Lidocaine will have no effect, as this is not VT.

WPW syndrome

Case 3

A previously healthy 15-year old boy presents to ED withsudden onset of palpitations while playing sport. On arrivalto ED he is alert and pain free with a good blood pressure.His ECG is shown below:

Antidromic tachycardia

• This ECG is an example of antidromic AVRT secondary to Wolff-Parksinson-White syndrome

• Electrophysiology testing confirmed pre-excitation with a right-sided accessory pathway (Type B WPW). Echocardiographyrevealed a structurally normal heart. He was discharged home onoral flecainide pending ablation of his accessory pathway.

Case 3

29 year old Female HxPresented to the ER after 3 episodes of palpitations over 3 days,and a feeling of impending doomHx of sudden cardiac death in uncle at age 45No hx of syncope PMHxHealthy Meds

No medications

Brugada syndrome

Brugada syndrome

• Described by Brugada and Pedro 1992• Frequent cause of death in pt. with normal hearts• Also a cause of sudden death in athletic population• More frequently diagnosed in males of South East Asian

descent• Characterized by ECG abnormalities in V1 to V3:• i ) incomplete RBBB• ii) ST segment elevation

Brugada syndrome

• Caused by a reduction of sodium current across cardiac sodiumchannels

• ST elevation thought to be due to rebalancing of currents active atend of phase 1

• Definitive treatment is by placement of Internal Cardio-defibrilator(ICD )

• Mortality at 10yrs is 0%for ICD and 26% for pharmocologicalagents(amiodorone,B-blockers )

• Pseudo-RBBB

(but noslurred S in

V6)• ST

ElevationV1-V3

• T waveinversion

= BrugadaSyndrome

ECG

Summary

• Think of Brugada syndrome in a patient with palpitationsor syncope!• Pseudo-RBBB• ST Elevation V1-V3• Family history of sudden cardiac death

• Send patients with suspicious ECGs to cardiology /electrophysiology for drug challenge or electrophysiologytesting.

Case 4

• 52 yr old man• No Hx of IHD• Known HPT on Rx• Presents with acute onset chest• Initial ECG normal• Cardiac enzymes normal• Admitted for observations

Wellens syndrome: note the biphasic T waves (positive-negative) in leads V2-V4. Upperarrow points at the positive deflection, negative arrow points at the negative deflection.

Wellens syndrome: note the deeply negative T wave (>5 mm) in V2-V4. We alsohave the biphasic shape in lead V2. ST segment is

Coronary angiogram

Case 5

• A 30-year old female with a history of Conn’s syndromesecondary to bilateral adrenal adenomas presents withgeneralised weakness and muscle pains after a change inher medications.

Hypokalemia

The ECG shows:1. Sinus rhythm at around 70 bpm2. Normal axis3. PR interval 200ms (upper limit of normal)4. Long QT (640ms, QTc 700ms)5. Widespread downsloping ST depression / T wave

inversion6. Prominent U waves, especially in the precordial leads

HARM NO ONE

Rule number one

Rule 1

• If you don’t have time shock or pace no more peace.• Most of the time you have good time, you are in peace.

Rule number two• Look at the toe

Rule 2

• Time is perfusion and flow don’t leave it low

Rule number three

• Master the key

Rule 3

Key may be:Hx.C/PCriteriaOwn records

Rule number four

• Never shut the door

Rule 4

• Arrhythmia patients are frequent comer and maycome late don’t use your hummer.

• Record your experience, send a free advice to yourcollege next visit, let him start where you finish .

Rule number five• Search the wife

Rule 5

Salt :Low salt brings insult.Excess K+ is not ok.Fat :Excess fat is always bad.Young widows are always sad.

Rule number six

• Use the tricks

Rule 6C.S.MValsalva

Leg upFluidsVasopressorRT chest leadsPacingEcho ProbeAsk questionsMake the call

Rule number seven

• All and above ask the haven