ecg cases
TRANSCRIPT
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In the diagram normal range - 30 to +90.
Left axis deviation superior and leftward
-30 to -90
Right axis deviation inferior and rightward
+90 to +150
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PR Interval
beginning of P to beginning of QRS
Normal: 0.12 - 0.20s
Short PR: < 0.12s QRS Duration
duration of QRS complex
Normal: 0.06 - 0.12s
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QT Interval
beginning of QRS to end of T wave
Normal: heart rate dependent (correctedQT =QTc = measured QT % sq-root RRin seconds; upper limit for QTc = 0.44 sec)
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How to read an ECG
Standardisation
Rate
RhythmAxis
Chamber enlargement & hypertrophy
Arrythmias & conduction delays Ischaemia / infarction
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Case scenario 1
26 year old man
Run over by a truck
Managed in local hospital
Brought to casualty 24 hours later
head injuries and extensive crush injury tolower limbs
GCS 10/15
BP: 90/60 HR:46/min
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Admitted in ICU and stabilised
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ECG
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S.creat: 4.5 mg%
S. K: 7.1 mEq/l
CPK: 36,000
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Course
Pharmacological measures to decrease
pottassium
Dialysis
Surgery
Patient did well and was discharged 2
weeks later
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ECG
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Take home message
Consider potassium derangements in any
arrythmia in the ICU
Focus on treating the underlying
dyselectrolytemia promptly
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Case scenario 2
20 year old primigravida from Chittoor Fever, jaundice and altered sensorium for
5 days
GCS: 12/15
Blood smear positive for plasmodium
falciparum
Parasitic index 10%
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Started on Quinine infusion
On day 2, Sudden hypotension
BP:80 sys HR: 200/min
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ECG
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Polymorphous ventricular tachycardia -Torsade depointes.
wide QRS complexes with multiple morphologies
changing R - R intervals
the axis twists about the isoelectric line
recognise this pattern - number of reversible causes heart block
hypokalaemia or hypomagnesaemia
drugs e.g. tricyclic antidepressant overdose congenital long QT syndromes
other causes of long QT (e.g. IHD
http://www.ecglibrary.com/l_qt.htmlhttp://www.ecglibrary.com/l_qt.html -
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DC cardioversion
Causes
Treatment
hemodynamically stable andunstable
Monitor QT interval while on quinine!
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The QT interval duration is greater than
50% of the RR interval, a good indication
that it is prolonged in this patient. Although
there are many causes for the long QT,patients with this are at risk for malignant
ventricular arrhythmias, syncope, and
sudden death.
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QT
Normal upto 0.45
Stop quinine if 0.60
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Quinine discontinued, changed to
artemether
QT interval normalised
Delivered fresh stillborn
Gradual recovery
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Take home message
Monitor QT interval while on quinine!
Consider iatrogenic causes of arrythmias
- drugs- inotropes
- central lines
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Case scenario 3
72 year old man
Diabetic with urosepsis
Emphysematous pyelonephritis-postnephrectomy
Being ventilated in ICU
On inotropic support-noradrenaline5ug/min: BP- 110/60mm Hg
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On day 3, sudden hypotension
Cold clammy extremities
BP: 60 sys HR: 140/min CVP:25cms
Chest: bilateral crackles
CVS: muffled
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ECG
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Serial ECGs and Cardiac enzymes
Thrombolysis/ UFheparin/ LMWH
Differentials
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Trop I :12
Thrombolysis contraindicated
Progressive hypotension on increasinginotropes
Expired
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Take home message
Consider myocardial ischemia in every
case of sudden hypotension
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Case scenario 4
55yr old man
Sudden onset progressive BOE for 2
days.
Sudden worsening of breathlessness
today
No chest pain, fever, cough
No DM, HTN, Smoke
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Examination
Obese
No pallor, edema
BP: 110/70mmHg HR:110/min JVP: elevated 3cms
Resp : clear
CVS: S3, sharp S2Abd: NAD
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Sudden hypoxia and
hypotension
BP: not recordable
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Admitted to MICU
Thrombolysed with STK
Improvement over 24 hours
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Case scenario-5
A 30 year old lady diagnosed to have
ruptured empyema gall bladder with
peritonitis underwent cholecystectomy. On
the first post operative dayhigh gradefever followed by hypotension started on
ionotropes . A day later blood culture
heavy growth of pseudomonas
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O/E:
BP: 90/40mmHg. HR- 160/minute
Interpret her ECG
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Takotsubo cardiomyopathy
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Takotsubo cardiomyopathy
ICU cardiomyopathy
Seen in critically ill patients
Mimics myocardial ischemia No specific treatment
Reverts as patient improves
No residual complications
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Case scenario-6
50 year old man known alcoholic
presented with a history of acute abdomen
He was diagnosed to have pancreatitis
He had a similar episode 6 months ago
and a syncopial attack was admitted in the
ICU and discharged a week later
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Diagnosis
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Brugada syndrome
Congenital channelopathy
Seen in asians
Prone for sudden onset of ventricular
tachycardia/cardiac arrest
ICD only treatment
Precipitated by alcohol, prothiadine
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Case scenario-7
25 year old man with a history of corrosive
acid poisoning presented a day later with a
history of chest pain and fever
O/E: He was febrile BP100/60 PR
140/minute
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Case scenario-8
60 year old man with CA stomachunderwent a total gastrectomy. Three dayslater became breathless, was febrile and
had multiple ventricular ectopicsassosiated with hemodynamic instability.
Subsequently he was intubated.
Common causes ruled out .He was startedon an amiodarone infusion and he settled
24 hours later
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Take home message
All anti arrythmics are proarrythmics too
All patients on amiodarone infusion once
stabilised slowly overlap with oral route &
taper infusion
Amiodarone half life -prolonged
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Interesting ECGs
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Thank you