ekg rounds mark bromley pgy3. objectives identify classic ecg findings of pe understand the...
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EKG RoundsMark Bromley PGY3
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Objectives Identify classic ECG findings of PE
Understand the pathophysiologic basis
Discuss clinical utility
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What are the Classic Findings of PE on ECG?
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Case 1A 54 year-old man
Presents with sudden dyspnea
Hx of recent orthopedic surgery
OE: moderate distress dyspnea HR115 RR 36 O2 sats: 92% BP 165/90 His exam was unremarkable except for a casted L leg
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Case 1
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FindingsTachycardia
Rightward axis
S1Q3T3
Simultanoeus T-wave inversion in inferior & anteroseptal leads
Incomplete RBBB
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What are the Classic Findings of PE on ECG?
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“Classic” ECG AbnormalitiesSinus Tachycardia
RV strain pattern T wave inversions in V1-V4
Rightward axis deviation
Incomplete RBBB
P pulmonalae
S1Q3 or S1Q3T3 pattern
Acute cor pulomnale: S1Q3T3 pattern, right axis deviation, and RBBB.
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These changes, particularly in combination, are suggestive but not diagnostic of PE
Even pts with massive PE may have only mild, nonspecific ECG changes
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In pulmonary embolus,…what is the most common ECG pattern?
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Normal ECGCompletely normal
Sinus rhythm between 60-100 bpm
Normal conduction
Normal axis
Normal P wave, QRS complex, and ST segment/T wave morphologies
An entirely normal ECG is found in10% to 25%*
*(Panos, 1988; Hubloue, 1996)
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What is the most common ECG abnormality?
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Sinus Tachycardia
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comment on the conduction
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Right Sided StrainIncomplete RBBB
right-sided heart pressures leads to ventricular afterload
Results in right-sided myocardial wall tension
The RV is not able to withstand such pressures
…it rapidly dilates
chamber size and eventual contractile dysfunction
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Case 229-year-old woman
Presents with shortness of breath
History: 8 weeks pregnant
On exam: Visibly distressed HR 110 RR 32 O2 Sat 91% on 5 L BP 80/40
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Case 2
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FindingsRate 120
Incomplete RBBB
T wave abnormality
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29 F 19 weeks gestation. Presents SOB.
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2 hours later
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P pulmonalaeAssociated with RA enlargement
Incidence: 2% - 30%
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Case 369-year-old man
Presents with shortness of breath
History of diabetes and hypertension
On exam: Comfortable and alert. HR 110 RR 32 O2 Sat 97% on 5 L BP 163/107 Exam was otherwise unremarkable
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Case 3
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Case 3 - findingsTachycardia
R axis deviation
Incomplete RBBB
S1Q3T3
Simultaneous inversion of T waves in Inferior and anteroseptal leads
p pulmonalae
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Ischemia and InfarctionCO compromises both systemic and coronary
perfusion
wall tension
Systemic hypotension Ischemia and infarction
As right-sided ventricular dysfunction worsens, RV infarction and circulatory collapse may occur
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Right Axis DeviationRV enlargement
Negative deflection of lead I
Positive deflection of V6
Left axis deviation – more common (related to underlying dz)
When control for underlying disease – equal incidence
(Nielsen, 1989)
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McGinn-White Pattern S1Q3T3
First described in 1935 – 7 pts with massive PE
Since numerous authors have refuted the usefulness
Still classically linked to PE
Q: Give a differential diagnosis for S1Q3T3. PTx Embolism
AIR, FAT, PE Cor pulmonalea
Severe Pneumonia Neoplastic disease
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Diagnostic value of ECGMany studies have been done in patients with confirmed PE
Diagnostic value of ECG can only be determined by applying it to patients with suspected PE
…then determine if the test is predictive of PE
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Pts presenting to ED – R/O PE
ECGs were obtained on 189/212 patients
analyzed for 28 features thought to be associated with PE
Only tachycardia and incomplete RBBB were significantly more frequent in patients with PE than those without PE
S1Q3T3 not predictive
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PrognosisWhat findings were more frequent in pts with fatal outcome?
Atrial arrhythmias Complete right bundle branch block Peripheral low voltage Pseudoinfarction pattern (Q waves) in leads III and aVF STΔ’s (or ) in left precordial leads
29% of pts who exhibited ≥ 1 of these abnormalities did not survive to hospital discharge
11% of the patients without a pathological ECG
(Giebel et al., 2005)
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Take Home PointsECG is not a sensitive or specific test for PE
ECG changes are transient
Most common ECG finding – normal
Most common ECG abnormality – sinus tach
Value of ECG in PE Assessing other etiologies Prognostic value
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References Panos R J, Barish RA, Whye DW, et al: The electrocardio-
graphic manifestations of pulmonary embolism. J Emerg Med 1988; 6:301-7
Hubloue I, Schoors D, Diltoer M, et al: Early electrocardio- graphic signs in acute massive pulmonary embolism. Eur J Emerg Med 1996; 3:199-204
Akula et al. Right-sided EKG in pulmonary embolism. Journal of the National Medical Association (2003).
Nielsen F, Lund O, Ronne K, et al: Changing electrocardio- graphic findings in pulmonary embolism in relation to vascular ob- struction. Cardiol 1989;76:274-284
Geibel et al. Prognostic value of the ECG on admission in patients with acute major pulmonary embolism. European Respiratory Journal (2005)
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Right Sided Chest Leads Increase the sensitivity of ECG
Very small study looked prospectively at 100 pts
Results: PE present in 20pts Standard ECG - findings present in 80% Right-sided ECG – findings present in 100% qr or qs in V4R, V5R, V6R, increased sensitivity
(Akula, 2003)
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Case 418 year female
Presents with syncope
History: OCP
OE: looks well HR 102 RR 17 BP 120/76 O2 sats 94% Otherwise unremarkable
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Case 4