Ecg in emergency room

ECG IN EMERGENCY ROOM

1. ECG IN EMERGENCY ROOM

2. The eye does not see what the mind does not know...

3. The EKG must be interpreted in the clinical context. Don’t order a test unless you know what to do with the results…

4. In this session we will discuss ECG abnormalities found in various miscellaneous conditions commonly presenting in ER (ACS & ARRHYTHMIAS– already covered; ACUTE PULMONARY EMBOLISM, COPD, CVA, TAMPONADE, PERICARDITIS, ELECTROLYTE ABNORMALITIES & DRUG TOXICITIES etc )

5. PULMONARY EMBOLISM 1) Sinus tachycardia 2 ) Stress on the right ventricle ○ Right atrial dilatation ○ Heart axis is to the right(RAD) ○ Right bundle branch block 3 ) S1Q3T3 PATTERN Deep S in lead I Q and negative T in lead III T wave inversion anterior leads Pulmonary embolism cannot be diagnosed using only an ECG, but it can be helpful.

6. ECG Signs of Acute Pulmonary Embolism Sinus tachycardia:8-73% P Pulmonale : 6-33% Rightward axis shift : 3-66% Inverted T-waves in right chest leads: 50% S1Q3T3 pattern: 11-50% (S1-60%, Q3-53% ,T3-20%) Clockwise rotation:10-56% RBBB (complete/incomplete): 6-67% AF or A flutter: 0-35% No ECG changes: 20-24% Am J Med 122:257,2009

7. ACUTE PULMONARY EMBOLISM

8. CARDIAC TAMPONADE

9. Hypokalemia results in: ● ST depression and flattened T waves ● QT prolongation ● Negative T waves ● A U wave may be visible If extra systoles occur in the T wave (example) the risk of Torsade de Pointes is high and rhythm monitoring is mandatory

10. HYPOKALEMIA

11. HYPOKALEMIA

12. DILATED CARDIOMYOPATHY(DCM) Common ECG associations with DCM Left atrial enlargement  - may progress to atrial fibrillation. Biatrial enlargement Left ventricular hypertrophy  or  biventricular enlargement Left bundle branch block  ( RBBB  can also occur). Left axis deviation. Poor R-wave progression  with QS complexes in V1-4 (“pseudo-infarction” pattern). Frequent  ventricular ectopics  and ventricular bigeminy (seen with severe DCM). Ventricular dysrhythmias ( VT  /  VF ).

13. DCM

14. Take home message Electrocardiograms can be useful in the emergency department setting when dealing with patients presenting with chest pain, syncope, palpitations, cyanosis & heart failure symptoms. Though the electrocardiogram may be helpful BUT it should be used as an adjunct diagnostic tool, not to be relied upon solely. Diagnoses cannot be excluded even in the presence of a normal electrocardiogram . Therefore, it is important to synthesize all data prior to coming to any conclusions.