syncopesyncopesyncopeandtheecg-180322072138.pptx

syncope

1. Abnormal ECG in Syncope

2. common; about 3–5% of ED visits and 1–6% of hospital admission underlying cause: unknown (34-36%), vasovagal (18-21%), and cardiac (9.5-18%) 4 Diagnostic categories: Reflex-mediated Orthostatic Cardiac Cerebrovascular

3. a rule for evaluating the risk of adverse outcomes in patients presenting with syncope CHESS Congestive heart failure Hematocrit < 30% Abnormal ECG Shortness of breath Triage systolic blood pressure < 90

4. ABCDE LeftRight AV blocks Brugada Pattern qtC prolongation Delta wave (WPW) Epsilon waves Left ventricular hypertrophy Right ventricular strain Cardiac ischemia

5. Age History of arrhythmias, IHD, structural Heart disease Diabetes newly abnormal ECG Elevated troponin level History of Cardiac disease Patients with pacemakers or other cardiac devices: have a high index of suspicion in these patients for arrhythmia and / or cardiac device malfunction All patients with pacemakers with unexplained collapse must be admitted until such time as their pacemaker can be checked Most devices can be interrogated for a record of significant arrhythmia over an extended period of weeks

6. 65 year old male with history of hypercholesterolaemia, HTN and T2DM presents with epigastric pain. What do we do?

7. 74 year old male with history of COPD, HTN and IHD presents with sharp/central chest pain of 30 mins duration and then a short syncope. HR 72, BP 105/62,sats 95% RA What do we do? Image from ref 2

8. 40-50% of all myocardial infarctions Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction can develop severe hypotension in response to nitrates and generally have develop significant bradycardia due to second-or third-degree AV block RV infarction suggested by ST elevation in lead III > lead II Presence of reciprocal ST depression in lead I Signs of right ventricular infarction: STE in V1 and V4R

9. 48 year old female with a history of IHD presents with left sided chest pain radiating to jaw. Not relieved by GTN What do we do? Image from ref 1

10. Widespread horizontal ST depression, most prominent in leads I, II and V4-6 ST elevation in aVR ≥ 1mm Requires Urgent referral to Cardiology for PCI

11. 65 year old male with history of T2DM and smoking self presents after an episode of chest pain + syncope. The chest pain resolved 30 mins prior to arrival in ED

12. pattern of deeply inverted or biphasic T waves in V2-3, specific for a critical stenosis of the left anterior descending artery (LAD) Patient may be pain free by the time ECG is taken but they are at extremely high risk for extensive anterior wall MI within the next few days to weeks. Require PCI

13. TACHYCARDIA AND SYNCOPE

14. 35 year old male with no previous medical history presents after his birthday party with palpitations and presyncope.

15. most common sustained arrhythmia Lifetime risk over the age of 40 years is ~25% Ischaemic heart disease Hypertension Valvular heart disease (esp. mitral stenosis / regurgitation) Acute infections Electrolyte disturbance (hypokalaemia, hypomagnesaemia) Thyrotoxicosis Drugs (e.g. sympathomimetics) Pulmonary embolus Pericardial disease Acid-base disturbance Pre-excitation syndromes Cardiomyopathies: dilated, hypertrophic. Phaeochromocytoma Reference 2

16. 47 year old accountant presents with SOB plus presyncopal

17. The atria contract at 300 beats per minute causing a ‘seesaw’ baseline. Beats are transmitted with a 2:1, 3:1 or 4:1 block, leading to ventricular rates of 150, 100 and 75 BPM respectively. Vagal manouvers +/- Adenosine. A flutter will not usually respond to this. This will often give a transient period of increased AV block during which flutter waves may be unmasked. Reference 2

18. 82 year old male with COPD presents with fever and cough - green sputum.

19. occurs in respiratory disease and reflects an aberrant foci of atrial excitation typically a transitional rhythm between frequent premature atrial complexes (PACs) and atrial flutter / fibrillation At least 3 distinct P-wave morphologies in the same lead Thought to be a result of: Right atrial dilatation (from cor pulmonale ) Increased sympathetic drive Hypoxia and hypercarbia Beta-agonists Reference 2

20. 65 year old man with a history of ischaemic heart disease presents with SOB and presyncope What do we do?

21. Treatment of FBI: Unstable Cardioversion! Stable IV chemical cardioversion e.g procainamide Avoid all AV nodal blockers! 🞄 Adenosine 🞄 Verapamil 🞄 Diltiazem 🞄 Beta-blockers 🞄 Digoxin 🞄 Amiodarone

22. 50 year old lady comes to the emergency department from her husband’s funeral with a sensation of ‘fluttering’ in her chest. She is feeling very anxious. What do we do?

23. 2 main types. AVNRT (left) and AVRT (right) Reference 2

24. 18 year old male signs up for the army and has a routine ECG

25. Due to a mutation in the cardiac sodium channel gene Type 1 Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave Type 2: 2mm of saddleback shaped ST elevation Diagnosis must be coupled with clinical criteria: VF, FHX sudden death, Syncope The only proven therapy is an implantable cardioverter – defibrillator (ICD)

26. 24 year old male syncoped 1 minute in to his run. Has happened previously

27. Number one cause of sudden cardiac death in young athletes. Annual mortality is estimated at 1-2 % Left ventricular hypertrophy (LVH), occurring in the absence of any inciting stimulus such as hypertension or aortic stenosis ECG Signs: LVH deep, narrow (“dagger-like”) Q waves in the lateral (V5- 6, I, aVL) and inferior (II, III, aVF) leads

28. A 25 year old man presents with a collapse which occurred as he was playing in a football match. He has suffered episodes of fainting in the past

29. PR interval <120ms Delta wave – slurring slow rise of initial portion of the QRS QRS prolongation >110ms

30. 16 year old boy presents to ED after an episode of syncope

31. Calculate the QTc Bazetts formula (med calc) Fredericas formula The QT shortens at faster heart rates The QT lengthens at slower heart rates Bazetts formula not as accurate outside HR 60-100BPM 🞂 QTc is prolonged if > 440ms in men or > 460ms in women QTc > 500 is associated with increased risk of torsades de pointes A useful rule of thumb is that a normal QT is less than half the preceding RR interval

32. Causes: Hypokalaemia Hypomagnesaemia Hypocalcaemia Hypothermia Myocardial ischemia Post-cardiac arrest Raised intracranial pressure Congenital long QT syndrome DRUGS

33. K+ channelopathy QTc (<300-350) Short QT interval Lack of the normal changes in QT interval with heart rate Peaked T waves, particularly in the precordial leads Short or absent ST segments Episodes of atrial or ventricular fibrillation

34. 20 year old male presents with palpitations and syncope

35. inherited disorder associated with paroxysmal ventricular arrhythmias and sudden cardiac death. Epsilon wave (most specific finding, seen in 30% of patients) T wave inversions in V1-3 (85% of patients) Slurred S wave (V1-3): 95% of patients Localised QRS widening of 110ms in V1-3 Paroxysmal episodes of ventricular tachycardia

36. 1 st degree: 2 nd degree Mobitz 1 Mobitz 2 3 rd Degree

37. 60 year old male presents to ED after syncope. History of CKD.

38. Increased extracellular potassium reduces myocardial excitability. leads to suppression of impulse generation by the SA node and reduced conduction system, resulting in bradycardia, conduction blocks and ultimately cardiac arrest.

39. Serum potassium > 5.5 mEq/L is associated with repolarization abnormalities: Peaked T waves Serum potassium > 6.5 mEq/L is associated with progressive paralysis of the atria: Lengthen PR, P wave widens and flattens Serum potassium > 7.0 mEq/L is associated with conduction abnormalities and bradycardia: Prolonged QRS interval with bizarre QRS morphology High-grade AV block with slow junctional and ventricular escape rhythms Sinus bradycardia or slow AF Development of a sine wave appearance (a pre-terminal rhythm) Serum potassium level of > 9.0 mEq/L causes cardiac arrest due to: Asystole Ventricular fibrillation PEA with bizarre, wide complex rhythm

40. An 18 year old lady is found collapsed at home. When you see her she has a GCS of 10 and you notice that her pupils are dilated.

41. A,B,C,D,E (ventilation may be required) Bloods including paracetamol level; Activated charcoal if within 8hrs of ingestion Sodium bicarbonate (50ml of 8.4%) Give if any arrhythmia or QRS widening Further options: If seizures: benzodiazepines

42. 55 year old male with hx of PCKD presents with GCS 3

43. 82 year old male presents with syncope

44. 84 year old male with hx of CCF plus IHD presents post syncope

45. Important ECG findings in Syncope: Q waves in II, III, aVF, V5, and V6 Paroxysmal or sustained dysrhythmia on monitoring in clinic Non-sinus rhythm of any sort Nonspecific intraventricular conduction delay (QRS > 100 ms without left or right bundle branch pattern) Left bundle branch block or left anterior or posterior hemiblock ECG signs of coronary ischemia Long QT syndrome - QTc > 440-450 msec in men or > 460 msec in women Brugada sign - right bundle branch block and anterior ST elevation Left ventricular hypertrophy in someone with no reason to have it and/or ◦ Pre-excitation syndromes (PR interval < 120 msec) with or without delta wave Can Quick BRAD Walk Home

46. 1. OME – Oxford Medical Education: ECGs and knowledge 2. Life in the fast lane – ECG diagnoses A-Z 3. Prospective validation of the San Francisco Syncope Rule to predict patients with serious outcomes. AAEM 2013. Image from ref 1