ECG/EKG INTERPRETATION FOR HOUSE OFFICERS

EKG recognition for new HO who will start working soon. To prepare HO for everyday life in medical emergencies.

1. ECG AND MANAGEMENT OF CARDIAC ARRYTHMIAS

2. OVERVIEW ARREST RHYTHMS – ASYSTOLE, PEA, PULSELESS VT, VF Shockable Non Shockable BRADYARRYTHMIAS Management of stable bradyarrythmias Management of unstable bradyarrythmias TACHYARRYTHMIAS Management of stable tachyarrythmias Management of unstable tachyarrythmias OTHER IMPORTANT ECGs

3. Case 1 A 60-year-old security guard collapses in front of the hospital lift near HTJS Hospimart . The man complained of chest discomfort before his collapse. 3

4. What’s next Danger – Wear PPE Response – Tap shoulder “Hello are you OK?” Shout – Call 4242 Code blue near Hospimart Ground floor Bring resus trolley and defib/AED Airway – Head tilt- chin lift Breathing – not breathing /gasping = CPR Circulation – High Q chest compression Defib – attach to monitor asap . Shockable ? 4

5. Ventricular Fibrillation 5

6. Ventricular Tachycardia 6

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8. Case 2 A 55 year old hospital cleaner collapsed while in the ward. Describe how you would direct the management of this patient. 8

9. What’s next D R S A B C D 9

10. Case 5: Asystole 10

11. Tachycardia Definition Heart rate > 100/min but pathological >150 Presence of pulse? Stable or unstable tachycardia? Morphology Narrow or wide QRS complexes? Regular or irregular rhythm? 11

12. Stable or unstable? 12 Unstable if: Ongoing chest pain Shortness of breath Low blood pressure Dizziness, lightheadedness or decreased level of consciousness (poor cerebral perfusion) Cool and clammy peripheries (peripheral vasoconstriction)

13. Regular Narrow-Complex Tachycardia Sinus tachycardia Caused by external factors, not cardiac Identify and treat the underlying systemic cause SVT (Supraventricular tachycardia) Junctional tachycardia 13

14. Case 3 30 year old lady, no known medical illnesses, complaining of palpitations for 2 days, no chest pain nor giddiness. BP 128/78mmHg PR 160/min. 14

15. Stable SVT 15

16. Treatment 16 Vagal stimulation: Carotid massage Ice on face Valsalva Adenosine if no CI

17. Adenosine Therapeutic and diagnostic Produces a transient block at AV node Slows AV conduction, to unmask atrial flutter or atrial fibrillation Give 6mg iv followed with 20ml saline flush If not converted, give 12mg iv Repeat 18mg once if still no conversion 17

18. Adenosine Transient side-effects Facial flushing Lightheadedness Sweating Nausea Caution Asthmatics (can cause bronchospasm) Wolff-Parkinson-White Syndrome Before administration, must have Cardioversion backup Resus drugs and equipments 18

19. Irregular Narrow-Complex Tachycardia 19 Atrial Fibrillation

20. Atrial Flutter 20

21. Wide-Complex Tachycardia 21

22. ? 22

23. Wide-Complex Tachycardia Regular VT until proven otherwise Irregular May be AF with Wolff-Parkinson-White Syndrome 23

24. Treating Stable Wide-Complex Tachycardia Amiodarone Load 150mg iv over 10-15min May be repeated once , whilst awaiting expert consultation Anticipate synchronise cardioversion Torsades de pointes Load Mg 2g over 20min 24

25. Case 4 Your patient: a 45-year-old woman CC: palpitations, difficulty breathing, severe pressure on her chest, extreme weakness “I feel like I’m going to faint.” 25

26. Electrical Synchronized Cardioversion Immediate electrical cardioversion is indicated for a patient with serious signs and symptoms related to the tachycardia. 26

27. Synchronized Cardioversion Premedicate with both a sedative and an analgesic if appropriate Sedatives Diazepam Midazolam Barbiturates Etomidate Ketamine Methohexital 27 Analgesics Fentanyl Morphine Meperidine

28. Synchronized Cardioversion Procedure 1. Attach monitor leads to patient 2. Apply conductive material to paddles if not using hands-free defibrillation pads 3.Turn on defibrillator 28 Defib pads Paddles

29. Synchronized Cardioversion Procedure (cont’d) 4. Turn on synchronization mode 5. Verify synchronization signal on monitor screen 6. Select energy level 7. Place defibrillator paddles on chest and apply pressure (if necessary) 8. Charge defibrillator 29

30. Synchronized Cardioversion Procedure (cont’d) 9. “CLEAR!” Check yourself Check patient Check bed/stretcher 10. Press both buttons until discharge occurs 11. Reassess patient 30

31. Synchronized Cardioversion 31

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33. Case 4 An 87-year-old woman reports feeling weak and short of breath for 2 hours while walking short distances. She feels exhausted moving from the car to the ED stretcher. On physical exam she is pale and sweaty; HR = 35 bpm ; BP = 80/60 mmHg; RR = 18 rpm. Rhythm: see next slide . 33

34. What Is This Rhythm? 34

35. Second AV block type 1 35

36. Second AV block type 2 36

37. 37 Third degree AV block

38. Treatment ABCD IV Atropine 0.5mg – 3.0mg titrating. Treat the cause ACS – if AMI for thrombolysis Drugs overdose Electrolyte imbalance SSS 38

39. Treatment Inotropic support +/- Transcutaneous Pacing 39

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41. Transcutaneous Pacing 41

42. Indications for Transcutaneous Pacing Hemodynamically unstable bradycardias In the setting of AMI: sinus node dysfunction, type II 2 nd -degree block, 3 rd -degree heart block 42

43. Transcutaneous Pacing Premedication and explanation to patient Switch on Pacing mode (TCP) Choose Demand mode vs Non Demand Select appropriate target heart rate eg 60/min Increase the energy (mA) from 0 slowly till all the paced spike produces electrical capture ie . Rate = 60/min Check pulse (mechanical capture)/ BP. 43

44. Transcutaneous Pacing: “Capture” vs “No Capture” 44 Pacing below threshold: no capture Pacing above threshold: with capture Pacing Spike Capture: Spike + broad QRS QRS: opposite polarity 25 Feb 88 Lead I Size 1.0 HR=41 25 Feb 88 Lead I Size 1.0 HR=43 35 mA 25 Feb 88 Lead I Size 1.0 HR=71 60 mA Bradycardia: No Pacing Pacing Below Threshold (35 mA): No Capture Pacing Above Threshold (60 mA): With Capture (Pacing-PulseMarker ) Bradycardia: no pacing

45. Using the Pitchbook Template SUMMARY ARREST RHYTHMS Shockable -PULSELESS VT, VF Non Shockable - ASYSTOLE, PEA BRADYARRYTHMIAS Management of stable bradyarrythmias – Drugs , treat causes, monitor Management of unstable tachyarrythmias – Inotrope +/- TCP, treat cause. TACHYARRYTHMIAS Management of stable tachyarrythmias – vagal, drugs. Aim for rate control<150/min, treat causes. Management of unstable tachyarrythmias - – Syn. cardioversion , treat causes

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48. Placement of posterior leads

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