EKG Case Presentations Lindsay Saleski, DO

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EKG Case Presentations

Lindsay Saleski DO, MBAFamily Medicine/Emergency Medicine

Midlands Emergency PhysiciansTuomey Hospital

Case #1

• 65 yo female presents to the ED with shortness of breath, palpitations and generalized weakness for the last 3 weeks. Denies associated chest pain.

• Pmhx: CAD

• VS: 110/75, HR 150, Pulseox 98%

• The patients EKG is as follows:

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Case #1: Question #1

• What should you do at this time?

a. Synchronized cardioversion

b. Treat the patient with metoprolol

c. Treat the patient with Digoxin

d. Massage the carotid arteries

e. Treat the patient with IV Adenosine

Case #1: Question #1

• What should you do at this time?

a. Synchronized cardioversion

b. Treat the patient with metoprolol

c. Treat the patient with IV Digoxin

d. Massage his carotid arteries

e. Treat the patient with IV Adenosine

Atrial Fibrillation

• Several characteristic electrocardiogram (ECG) changes define AF: – Presence of low-amplitude fibrillatory waves on ECG without

defined P-waves – “Irregularly irregular” ventricular rhythm – Fibrillatory waves typically have a rate of > 300 beats per minute – Ventricular rate is typically between 100 and 160 beats per

minute

• Treatment– Unstable – synchronized cardioversion– Stable – Assess for anticoagulation, rate control

• B-blockers or Calcium channel blockers• Resting rate goal ≤ 110bpm

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Case #1: Question #2

• Patients with chronic atrial fibrillation are at increased risk for which of the following conditions?

a. Acute MI

b. Ventricular tachycardia

c. Sudden cardiac death

d. Cerebrovascular accident

e. Ventricular fibrillation

Case #1: Question #2

• Patients with chronic atrial fibrillation are at increased risk for which of the following conditions?

a. Acute MI

b. Ventricular tachycardia

c. Sudden cardiac death

d. Cerebrovascular accident

e. Ventricular fibrillation

AFIB Anticoagulation

• Ischemic CVA is most frequent SE

– 5% risk per year

• CHADS2 score - stroke risk assessment

– Warfarin for score of ≥ 2

• Warfarin is superior to ASA/Plavix combo

• If risk of embolization exceeds the risk of bleeding, patient is candidate for long-term antithrombotic therapy

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Case #2

• 68 yo female presents to the ED with intermittent palpitations, lightheadedness and shortness of breath. Symptoms worsened at church this morning. Patient did not feel well, walked to the bathroom and syncopized.

• Pmhx: DM, HTN, CAD with stent placement• VS: HR 200, BP 135/100, RR 20, Pox 100%, T 98.6 • Current: Patient is awake, alert and providing

history. • The patients EKG is as follows:

Case #2: Question #1

• What is the antiarrhythmic of choice in management of stable ventricular tachycardia?

a. Adenosine 6mg IV push

b. B-blockers for rate control

c. Digoxin load the patient

d. Amiodarone 150mg IV

e. Calcium channel blockers for rate control

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Case #2: Question # 1

• What is the antiarrhythmic of choice in management of stable ventricular tachycardia?

a. Adenosine 6mg IV push

b. B-blockers for rate control

c. Digoxin load the patient

d. Amiodarone 150mg IV

e. Calcium channel blockers for rate control

Tachycardia Algorithm.

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

Case #2: Question #2• Just prior to floor transfer to the patient arrests.

The rhythm strip reveals (see below). CPR is initiated. What is the next step in treatment according to ACLS?

a. Administer epinephrine 1mg IV

b. Administer calcium chloride

c. Administer sodium bicarbonate

d. Defibrillation

e. Continue CPR – do not administer medications

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Case #2: Question #2

• Just prior to floor transfer to the patient arrests. The rhythm strip reveals (see below). CPR is initiated. What is the next step in treatment according to ACLS?

a. Administer epinephrine 1mg IV

b. Administer calcium chloride

c. Administer sodium bicarbonate

d. Defibrillation

e. Continue CPR – do not administer medications

ACLS Cardiac Arrest Algorithm.

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

Ventricular Tachycardia

• >3 consecutive ectopic ventricular beats• Widened QRS (>120msec)• Regular rhythm• Rate >100 bpm

• MC sign causes are ischemic heart disease and AMI• ALL wide complex ventricular rhythms treated as Vtach

until proven otherwise• Stable – no evidence of hemodynamic compromise

despite a sustained rapid heart rate• Unstable – evidence of hemodynamic compromise,

but who remains awake with a pulse

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VT Treatment• STABLE with pulse

– Amiodarone 150mg IV over 10 minutes, repeat as needed to max dose of 2.2g/24 hours

– Prepare for elective synchronized cardioversion• UNSTABLE with pulse

– Immediate synchronized cardioversion– IV access and sedation, but don’t delay tx

• Pulseless arrest– IV, O2, monitor, CPR– Biphasic 200J/Monophasic 360J/AED devise specific– CPR 5 cycles– Check pulse and rhythm– Epinephrine 1mg IV/IO whenever initially available and redose

every 3-5 minutes

Case # 3

• 55 yo male presents to the ED became suddenly unresponsive at home. Wife is a nurse and CPR was started immediately. On ED arrival the cardiac monitor has the following rhythm:

Case #3: Question # 1

What is the first line medical therapy?

a. Magnesium 2 gram IV bolus

b. Cardioversion

c. Lidocaine 1mg/kg IV

d. IV fluids 1000ml bolus

e. Epinephrine 1 mg IVP

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Case #3: Question # 1

What is the first line medical therapy?

a. Magnesium 2 gram IV bolus

b. Cardioversion

c. Lidocaine 1mg/kg IV

d. IV fluids 1000ml bolus

e. Epinephrine 1 mg IVP

Torsades de Pointes

• “Twisting of the points”

• Clinical Criteria– Ventricular rate >200bpm

– QRS structure with undulating axis, polarity of complexes appearing to shift about the baseline

• Causes:– Acquired

• Medications, electrolyte disturbances (↓K, Ca & Mag), MI, CVA

– Congenital

Torsades Treatment

• Stable Patient

– IV Magnesium

– IV Isoproterenol: B1 & B2 agonist

– Overdrive pacing to ventricular rate of 100-120bpm

• Unstable

– Unsynchronized cardioversion

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Case # 4

• 41 yo female presents to the FP office as a new patient with acute onset substernal, non-radiating chest pain that started while she was out working in the yard 15 minutes prior to arrival. She states the pain is currently 10/10. She has associated SOB and nausea. No pmhxbut has not seen a PCP in 5 years.

• VS: 160/100, HR: 92, RR: 22, Pox: 98%, T98.9

• The patients EKG is as follows

Case #4: Question#1

• Which of the following time dependent interventions will most likely benefit this patient?a. CK-MB levelb. Stress testc. Angioplastyd. Metoprolol IVe. Atorvastatin PO

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Case #4: Question #1

• Which of the following time dependent interventions will most likely benefit this patient?

a. CK-MB level

b. Stress test

c. Angioplasty

d. Metoprolol IV

e. Atorvastatin PO

STEMI

• EKG evolves through a typical sequence– Hyperacute or peaked T wave– Elevation of the J point and the ST segment retains its concavity– ST segment elevation becomes more pronounced and convex– ST segment may be indistinguishable from the T wave

• The joint ESC/ACCF/AHA/WHF committee: definition of MI established specific ECG criteria for the diagnosis of STEMI:– 2 mm of ST segment elevation in precordial leads V2-V3 for men

and 1.5 mm for women– greater than 1 mm in 2 contiguous leads in other leads

• ACS also = STEMI if:– new left bundle branch block– posterior MI

STEMI Treatment

• Continuous cardiac monitoring, IV access, O2

• Reperfusion Therapy– Percutaneous coronary Intervention (PCI)

• 90 minutes or less for patients transported to PCI-capable hospital

– Fibrinolytic agents• If within 12 hours of onset and no PCI available

• Aspirin

• Nitrates

• β-Blockers

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Case # 5

• 51 yo female presents with palpitations, nausea, and chest pain. The CP is substernal and non-radiating. She states she was having a nightmare and woke up with palpitations. She has had multiple prior episodes for which she has been seen in the ED. She has not obtained outpatient follow up.

• PMHx: CAD, CHF, HTN, drug abuse • BP: 200/148, HR: 177, RR: 36, T: 98.9, Pox: 96%

on RA• The patients EKG is as follows:

Case #5: Question #1

• In this patient ACLS Protocol states that you should immediately:

a. Administer Amiodarone 150mg IV

b. Administer Adenosine 6mg IV

c. Initiate CPR

d. Synchronized cardioversion

e. Administer Sotolol 100mg IV

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Case #5: Question #1

• In this patient ACLS Protocol states that you should immediately:

a. Administer Amiodarone 150mg IV

b. Administer Adenosine 6mg IV

c. Initiate CPR

d. Synchronized cardioversion

e. Administer Sotolol 100mg IV

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

SVT

• Narrow complex tachycardia– QRS complex duration < 0.12 sec

– Ventricular rate >100bpm

– MC type is AvnRT

• Tx: SVT that is not associated with severe symptoms or hemodynamic collapse– Vagal maneuvers

– IV adenosine

– IV non-dihydropyridine calcium channel blocker or an IV beta blocker

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Case # 6

• 66 yo female with pmhx DMII presents to the PCP office for CC of intermittent dizzy spells and two episodes of near syncope over the last week. An EKG is done and she is found to have a heart block. She is sent to the ED for further evaluation. She denies any other complaints at time of ED evaluation.

• VS: 146/78, 40, 20, 98.6, 100% on RA

• The patients EKG is as follows:

Case #6: Question # 1

• What are indications for permanent pacemaker placement in patients with 3rd degree heart block?

a. Symptom free patients with asystole > 3 seconds

b. Dizziness and near-syncope

c. Heart block during exercise in the absence of myocardial ischemia

d. Asymptomatic patients with asystole of 5 seconds or longer

e. Escape rate < 40bpm

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Case #6: Question # 1

• What are indications for permanent pacemaker placement in patients with 3rd degree heart block?

a. Symptom free patients with asystole > 3 seconds

b. Dizziness and near-syncope

c. Heart block during exercise in the absence of myocardial ischemia

d. Asymptomatic patients with asystole of 5 seconds or longer

e. Escape rate < 40bpm

• Correct answer: All of the above

http://content.onlinejacc.org/article.aspx?articleid=1138927

Third Degree Heart Block

• Absent conduction of ALL atrial impulses resulting in complete electromechanical AV dissociation

• P waves and QRS complexes are present but unrelated and occur at different rates

• Treatment:– Pacemaker for those with associated symptoms,

ventricular pauses ≥3 seconds, or a resting heart rate <40 beats/min while awake

– Atropine reverses decrease in AV nodal conduction from vagal tone

EKG Extras

• To review on your own…

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I. Cardiac Anatomy

www.edoctoronline.com

I. EKG Regions

Coronary Anatomy:

V1, V2: posterior wall

V1, V2, V3: anterior septum

V4: apex

V5, V6: low lateral wall

I, avL: high lateral wall

II, III, avF: inferior wall (possible RV)

http://www.nottingham.ac.uk/nursing/practice/resources/cardiology/images/ecg_regions_old.gif

II. Lead Placement: Normal

www.usfca.edu

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III. Rate• Rule of 300- Divide 300 by the number of

boxes between each QRS = rateRate 60 – 100 NormalRate < 60 BradycardiaRate >100 Tachycardia

Left Bundle Branch Block

• The heart rhythm must be supraventricular in origin• The QRS duration must be ≥ 120 ms• There should be a QS or rS complex in lead V1• There should be a RsR' wave in lead V6• The T wave should be deflected opposite the terminal

deflection of the QRS complex. This is known as appropriate T wave discordance with bundle branch block. A concordant T wave may suggest ischemia or myocardial infarction.

• New onset LBBB in setting of chest pain considered a STEMI

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Early Repolarization

• Concave ST elevation in multiple leads

– Not AVR or V1

• J-point elevation with slurring or notching

• Absence of reciprocal changes

• Usually considered benign however some studies showing possible association with Vfib, sudden death, cardiac arrest. Must correlate clinically.

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Pericarditis

• Inflammation of pericardium – Causes: Virus, bacteria, cancer, MI, fungal,

autoimmune

• Symtpoms: Pleuritic CP, improves when leaning forward, shortness of breath

• EKG:– Diffuse ST elevation, concave ST segment

– Absence of reciprocal changes

– PR- segment depression

Rhythm, “Buzzwords,” & ACLS

• Normal Sinus Rhythm: Originating from SA node, P wave before every QRS, P wave in same direction as QRS

• Sinus Bradycardia: stable vs unstable, atropine, prepare for transcutaneous pacing, consider epinephrine or dopamine

• Sinus Tachycardia: determine etiology• Atrial Fibrillation, “irregularly irregular”: stable vs unstable, control rate vs

cardioversion, diltiazem or beta-blockers, avoid AV nodal blocking agents (adenosine, digoxin, diltiazem, verapamil) in setting of AF + WPW

• Atrial Flutter, “sawtooth pattern”: stable vs unstable, control rate vs cardioversion, diltiazem or beta-blockers

• Supraventricular Tachycardia (SVT), “narrow complex tachycardia”: stable vs unstable, control rate vs cardioversion, vagal maneuvers, adenosine

• Torsades de Pointes, “twisting of the points,”: magnesium• Ventricular Tachycardia, “wide complex tachycardia,”: with or without a pulse,

without = defibrillation, with = amiodarone, synchronized cardioversion• Ventricular Fibrillation, “erratic tracing”: defibrillation

http://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/AdvancedCardiovascularLifeSupportACLS/Advanced-Cardiovascular-Life-Support-ACLS_UCM_001280_SubHomePage.jsp

References

• Atrial Fibrillation:– Atrial Fibrillation Management Strategies in the Emergency Department. Emergency Medicine

Practice. February 2013. Volume 15, No 2. – Antithrombotic Therapy in Atrial Fibrillation to Prevent Embolization. UTD. Accessed

6/2/2014.– Atrial Fibrillation: Diagnosis and Treatment. Am Fam Physician. 2011 Jan 1;83(1):61-68.

• Ventricular Tachycardia & Torsades– Polymorphic Ventricular Tachycardia and Torsades de Pointes. Rosen’s Emergency Medicine.

Sixth Edition, Volume 2. pp1243-1244– Piktel JS. Piktel J.S. Chapter 22. Cardiac Rhythm Disturbances. In: Tintinalli JE, Stapczynski J, Ma

O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., CydulkaR.K., Meckler G.D., T eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381483. Accessed August 15, 2014.

– Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729 –S767.

– Aquired Long QT Syndrome. UTD. Accessed 7/24/2014

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References Continued

• STEMI– Hollander JE, Diercks DB. Hollander J.E., Diercks D.B. Chapter 53. Acute Coronary Syndromes: Acute Myocardial Infarction and

Unstable Angina. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381518. Accessed August 15, 2014.

– O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019

– Circulation. 2013; 127: 529-555 Published online before print December 2012, doi: 10.1161/CIR.0b013e3182742c84– ACC/AHA Guideline Update for the Management of ST-Segment Elevation Myocardial Infarction. American Family Physician.

2009; 79 (12):1080-1086

• SVT– An Evidence-Based Approach to Supraventricular Tachydysrhythmias. Emergency Medicine Practice. EBMedicine.net. April 2008.

Volume 10 Number 4. Accessed Online 8/19/2014.

• Heart Block– `Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm

Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):e1-e62. doi:10.1016/j.jacc.2008.02.032. Accessed online 7/13/2015.

– Am Fam Physician. 2014 Feb 15;89(4):279-82. Common questions about pacemakers. Denay KL1, Johansen M2. http://www.aafp.org/afp/2014/0215/p279.html. Accessed online 7/13/2015.

• Definition of Early Repolarization: A Tug of War. Circulation. 2011; 124: 2185-2186 doi: 10.1161/CIRCULATIONAHA.111.064063

• What is Pericarditis? AHA. http://www.heart.org/HEARTORG/Conditions/More/What-is-Pericarditis_UCM_444931_Article.jsp. Accessed 7/13/2015

• Mattu, Amal and Brady, William. ECGs for the Emergency Physician 1. BMJ Publishing Group 2003.