DECIPHERING COMMON ECG FINDINGS IN ED.pptx

ECG in ED. What usually missed and underestimate ECG. STEMI equivalent ST depression. Tachy and brady.
A doctor in ED must know this.

1. DECIPHERING COMMON ECG FINDINGS IN EMERGENCY DEPARTMENT Dr Sazwan Reezal Bin Shamsuddin Consultant Emergency Physician & Head, Emergency & Trauma Department, Hospital Sultan Haji Ahmad Shah, Temerloh , Pahang DM.

2. Ischemia/Infarction Arrythmia (Tachyarrhythmia, Bradyarrhythmia) Electrolyte imbalance Special medical condition

3. The Eyes See What the Mind Knows ECG is a tool. It still need a good history taking and physical examination. Indication? Expectation?

4. Tonight is experience sharing of real cases. Cases missed or detected despite atypical presentation.

5. Basics ……

6. Confirm the rate ….

7. 30 squares = 6 second = 15 cm In this example R wave = 6 ………. 6x 10 = 60/min Always do this before interprete ECG : patient details/name in the ECG verify the correct time and date verify correct paper speed (25 mm/sec) and amplitude (10 mm/mv)

8. Case 1 52/Male No known illness (seldom fall sick), heavy smoker+ c/o epigastric discomfort after meal, pressing in nature+, nausea+, initially sweating+ Had asam pedas earlier. FHx – brother was told to have ‘ sakit jantung ’ Rushed to EU in a district hospital. Hemodynamically stable, pain score 5 ECG stat

9. ECG

10. Imp: GERD Rx : Syp MMT 30 mls stat IV Omeprazole 40 mg stat Pain score 2 after 1 H observation Discharge with medication 6 hours later, patient came back.

11. What was missed? The risk factor was not take into consideration. Serial ECG Cardiac enzyme after 4 H chest pain SC Fundaparinux ?unstable angina

12. Case 2 28/F, G3P2 @ 28/52 POA. SN just finished her evening shift c/o easily feels lethargy & breathless x 4/7. Claimed that the gravid uterus pushed her diaphragm. Bilateral leg pain is as her previous pregnancy. No other symptoms. V/S BP 106/68 mmHg, PR 110, RR 26/min, T 37 C, Pain score 0

13. Sinus tachycardia RBBB T-wave inversions in the right precordial leads (V1-3) as well as lead III

14. PE ECG findings: Sinus tachycardia Complete or incomplete RBBB  Right ventricular strain pattern –  T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF ). This pattern is associated with high pulmonary artery pressures (34%) Right axis deviation  Dominant R wave in V1  Right atrial enlargement (P pulmonale)  S I  Q III  T III   pattern  – deep S wave in lead I, Q wave in III, inverted T wave in III (20%). This “classic” finding is neither sensitive nor specific for PE

15. Progress: The calf feels ‘tense’ & tender R>L POCUS –The 2-point technique tests the compressibility of the common femoral vein (CFV)  R side not compressible. CT pulmonary angiogram  present of thrombus. Treatment as per protocol Highlight : risk factor, some patient in GZ need further evaluation

16. Case 3 48/M, HPT+, hypercholesterolemia, smoker+ When to district hospital EU c/o central chest pain x 2 hours, heaviness+, nausea+, vomiting+ p/e- DRNM, lungs clear, no pedal edema Hemodynamically stable. Troponin NEGATIVE SL GTN, Aspirin, Clopidogrel was given.

17. Widespread ST segment depression in leads II, III, aVF , V4, V5, and V6

18. Pt was admitted to the ward. SC Fundaparinux given 2 hours later patient become restless, sweating++ asystole This pattern of ECG findings is consistent with left main coronary artery occlusion.

19. STEMI equivalent patterns It is now recognized that ECG patterns which do not meet the traditional diagnostic criteria for STEMI may represent significant AMI. these patterns are generally referred to as the STEMI equivalent patterns

20. ST segment elevation in leads aVL and V2 ST segment depression in leads III and aVF This ECG pattern is consistent with a first diagonal, or D1, lesion. The first diagonal branch (D1) of the LAD supplies blood to the anterolateral wall of the left ventricle

21. ST segment depression with J point depression in leads V2 to V5 prominent T waves are noted in leads V2 to V4 ST segment elevation is seen in lead aVR This ECG pattern is termed the de Winter finding and is consistent with a proximal LAD occlusion.

22. biphasic T wave abnormalities in leads V1 to V4. Biphasic refers to both upright and inverted T wave abnormalities in a single T wave Wellen’s syndrome and is consistent with proximal LAD occlusion.

23. The clinical relevance of Wellens’ Syndrome Patients may be pain free by the time the ECG is taken, and have normal or minimally elevated cardiac enzymes . However, they are at extremely high risk for extensive anterior wall MI within the subsequent days to weeks Due to the critical LAD stenosis, these patients usually require invasive therapy, do poorly with medical management, and may suffer MI or cardiac arrest. The T wave changes, being the most important diagnostic feature of Wellens ’ Syndrome, consist of two distinct patterns in leads V2 and V3. The more common abnormality (75% of cases) consists of deeply inverted and symmetric T waves. the second subtype consists of biphasic T waves (25% of cases)

24. Wellens pattern A : Biphasic T waves Wellens pattern B : Deeply inverted T waves

25. Case 4 54/F Central chest pain (classical) x 6 hours progressively worsening. No other sx P/e BP 136/82 mmHg, PR 76/min, RR 20/min. Pain score 6 ECG : ………… Trop: - ve Rx : SL GTN, Aspirin, Clopidogrel, SC Fundaparinux Admit

26. Next step?

27. Isolated posterior MI is less common (3-11% of infarcts). Isolated posterior infarction is an indication for emergent coronary reperfusion. However, the lack of obvious ST elevation in this condition means that the diagnosis is often missed.

28. STEMI equivalent patterns ECG

29. Case 5 65 years old presented with central chest pain describe as ‘somebody shoots from front to back’. Associated with nausea+ sweating ++ o/e BP 210/110 mmHg PR RR 28/min SpO2 98% OA T 37C ECG stat SL GTN 1/1 Aspirin served after ECG

30. Decision : fibrinolytic therapy Aim BP < 160 mmHg before therapy. Trace RP, CXR

31. Case 6 16/M c/o syncope at school during assembly. Not eat breakfast today. Previously well. FHx – father passed away at 38 y.o , brother passed away at 22 years old. BP standing & lying 110/70 mmHg PR 86/min, RR 16, Pain sore 0 Dsix 5.2 ECG ……

32. Brugada Syndrome

33. Brugada Syndrome is an ECG abnormality with a high incidence of sudden death in patients with structurally normal hearts. Incidence high in Southeast Asia where it had been previously described as Sudden Unexplained Nocturnal Death Syndrome (SUNDS). The only proven therapy is an implantable cardioverter – defibrillator (ICD). Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave. (Type I) >2mm of saddleback shaped ST elevation. (Type II) <2mm of ST segment elevation (Type III)

34. Case 7 A 58/M presented with dizziness, mild breathlessness. BP 200/120 mmHg, HR 180/min Patient diagnosed as unstable SVT, sync cardioversion was given. 1 st dose 50 J – not revert 2 nd dose 100 J – not revert 3 rd dose 150 J - succesful

35. Tachyarrythmia HR > 150/min

36. Regularity

37. Why important to differentiate? AF  risk for thrombus Might need assessment prior to sync cardioversion. Higher energy for sync Pharmacological treatment different

38. Case 8: Bradyarrhythmia

39. Why need to differentiate? 3rd degree (complete) heart block most probably will need TCP 2 nd degree heart block (Mobitz Type II) increased risk to be 3rd degree …….. Transfer of patient must be with TCP standby

40. PR interval > 200ms (five small squares) Athletic training Inferior MI Mitral valve surgery Myocarditis Electrolyte disturbances (e.g. Hyperkalaemia) AV nodal blocking drugs (beta-blockers, calcium channel blockers, digoxin, amiodarone) May be a normal variant

41. PR interval is longest immediately before dropped beat PR interval is shortest immediately after dropped beat Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone Increased vagal tone (e.g. athletes) Inferior MI Myocarditis Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)

42. A form of 2nd degree AV block in which there is intermittent non-conducted P waves without progressive prolongation of the PR interval Anterior MI (due to septal infarction with necrosis of the bundle branches) Cardiac surgery, especially surgery occurring close to the septum e.g. mitral valve repair Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease) Autoimmune (SLE, systemic sclerosis) Infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis) Hyperkalaemia Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone

43. complete AV dissociation, with independent atrial and ventricular rates Inferior myocardial infarction AV-nodal blocking drugs (e.g. calcium-channel blockers, beta-blockers, digoxin) Idiopathic degeneration of the conducting system ( Lenegre’s or Lev’s disease), causing true trifascicular block Patients with third degree heart block are at high risk of ventricular standstill and sudden cardiac death They require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker

44. Take home messages Normal ECG doesn't mean everything is fine. Don’t simply blame sinus tachycardia because patient walk in from parking lot. ST elevation not always Myocardial Infarction Before administer fibrinolytic therapy in STE ECG, examine for anaemia & feel the pulses. ST depression is NOT a benign condition. Must confirm regularity manually. 3 rd degree heart block by exclusion.

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