syncope ekg’s “blues clues” to the deadly misses...8/13/2018 1 syncope ekg’s “blues...
TRANSCRIPT
8/13/2018
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Syncope EKG’s“Blues Clues” to the Deadly
MissesTodd Haber MD. NE FACEP
LRH ED
This is an EKG lectureYou wanted this….
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But ended up with this…
Disclosures
• I get NOTHIN….FROM EVERYBODY….
• I stink at Power Point…
But FCEP waived my fee….
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Props and Kudos
• Dr. Amal Mattu
Mentorship and guidance
• www.ecgweekly.com
The little website that could…
• www.lifeinthefastlane.comGazillions of images
Objectives
• EKG in the ED‐‐‐ A BRIEF overview
• Syncope – a BRIEF Overview
• EKG findings in the patient w/Syncope• The obvious• The mimics
• Pearls and Pitfalls• Hidden Subtle clues to BADNESS
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Ground Rules…
• This is an ECG talk…
• No Deep Dives
• No MEMORIZATION
• Play Along and be interactive…
• Relax and Enjoy the show…
EKG’s in the ED…
What is the Clinical Question
• ACS???
• Rhythm???
• Miscellaneous• Syncope• Toxicology• Electrolytes
Predictive value of test
• Pre‐test Probability
• Sensitivity
• Specificity
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Systematic ApproachEvery Patient, Every time…
• Rate
• Rhythm
• Axis
• Intervals
• Voltage/Hypertrophy
• Ischemia
Syncope
• Loss of Consciousness
• Loss of postural tone
• Recovery +/‐ symptoms
• Common‐Usually Benign/Can be Lethal
• Low Yield‐High Risk
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Causes
• CardiacPump/StructuralRhythm/Electrical
• Reflex Mediated
• Postural/Volume
• NeurologicSz , SAH
Cardiovascular
Structural
• Ischemia
• Myo/pericarditis
• Congenital• Valves
• CardiomyopathyHypertrophic/dilated
• RV dysplasia• PE/TAD
Electrical
• Long‐Short QT
• Pre‐excitation
• Idiopathic VT
• Brugada
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Step #1Focused History and Physical
Diagnosis clear
• Benign non‐cardiac
• Serious‐ non‐cardiac
• Serious‐ cardiac
Diagnosis unclear
• Low Risk
• High Risk• Abnormal EKG• Evidence of CV disease• Absence of prodrome• Low BP• Age• Family Hx
Step #2 EKGWhat to look for???
• Obvious
Rate/Rhythm
Ischemia
• Subtle
Structural
Electrical
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65 y.o. w/ syncope
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Pearls….
• Do not depend on the computer
False Negatives, False Positives
• Beware of Hidden P’sV1, QRS, T waves (pokey)
• Are P’s and QRS married?Every P followed by QRS?
Every QRS preceded by P?
92 y.o. w/ Syncope
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Hyperkalemia
• Peaked T waves
• Widened QRS (rare in STEMI)
• Prolonged PR
• Flat/Loss of P waves
• AV Blocks
• BBB’s
• Psuedo ACS
• RAD (rare in STEMI)
Hyper K‐Again!!!
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Hyper K Pearls
• Hyper K causes “blocks” without other changes
• Consider Hyper‐K AND Empiric Rx
• Consider Hyper K when ACLS fails !!!!
57 y.o. Syncope CP and BP 70
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Pearls
• Consider TAD w/ Syncope AND Chest Pain
• ACS‐not a common cause of Syncope
• Diffuse STD’s w/STE AvrL main/triple vessel ACS
Consider Global ischemia
PE, TAD , GI Bleed, Hypoxia
70 y.o CP/SOB syncope‐‐‐‐ cardiac arrest
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Pulmonary Embolism
• Sinus tachycardia
• S1Q3T3 (not sensitive/not specific)
• RAD (rare in STEMI)
• New RBBB or iRBBB (widened QRS) rare in STEMI
• STE/STD’s INF/Septal leads
• NEW TWI’S Anteroseptal +/‐ Inf leads
Pearls
• Syncope + STE AND R axisPE
Na Channel Blocker
Hyper K
• ACS usually Vfib arrest / blocksNot asystole
• ACS uncommon cause of syncopeBeware of mimics
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StructuralThe Hunt for Hidden Badness
• P wavesAmplitude/width
• QRSAxis, amplitude, notches
High Voltage, Low Voltage
• T wavesAmplitude, polarity, shape
The “Normal ECG”
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The Normal EKG
• P waves upright (except avr)Biphasic in V1
• Normal max QRS V4 (transition)
• T waves concordantFlipped in Avr /V1/III
• Increased QRS (width or amplitude) ‐‐disconcordance
Normal P wave
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LAE/RAE/Bi‐Atrial
RVH
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LVH
Low Voltage
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Axis
LAD
• LBBB
• LAFB
• INF MI
• Pacer
• WPW
• LVH
RAD
• Na channel blockade• RV Strain
Acute‐ PEChronic‐ Pulm Htn
• Hyper K• ASD• RVH• Leads
Crochetage‐ASD
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23 y.o w/ syncope
ARVD/RVCMEKG Findings• Epsilon Waves
Highly specific (30% sensitive)
• Flipped T waves V1‐V3Sensitive ‐Non specific
• Prolonged S upstroke V1‐V3Widened QRS
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14 y.o syncope during basketball game
HCMEKG Features
• HLVV w/ ST‐T changes
• LAE
• Deep Narrow Dagger Q’sInferior/Lateral
• Giant Precordial Flipped T waves (Apical HCM
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34 y.o. episodoic palpitations
WPW
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EKG Findings in WPW
• PR < 120 msec
• Delta Wave (slurred QRS upstroke)
• QRS >110 msec
• Disconcordance (ST‐T)
• Psuedo‐Infarct pattern
WPW w/SVT
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WPW‐ Afib RVR
WPW Tachycardia Pearls
• WPW –Regular Narrow TachycardiaTreat as PSVT
• WPW‐Regular Wide TachycardiaTreat as V‐Tach
• WPW‐Irregular Wide TachycardiaElectricity
Procainamide
AVOID AV Blockers
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65 y.o w/ severe malaise/ syncope
Prolonged QTc Pearls
• Hypo’sK+/Ca 2+/Mg 2+
• Congenital
• Meds
• Hypothermia
• Polymorphic Vtach‐‐‐Rx Mg 2+
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Brugada Pattern
• iRBBB V1‐V2
• STE v1‐V2
• 3 Types
• PrecipitantsFever/meds/cocaine
• Transient
• 50% genetic
• 0.4%‐0.9% general population
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Brugada
Brugada Syndrome
• Brugada Pattern+ Symptoms
• Na Channelopathy
• 20% sudden death‐normal hearts
• 4%‐5% all Sudden Deaths
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Symptoms
• Polymorphic VtachSustained‐Cardiac arrest
Resolves‐Syncope
• Afib‐rare
• Usually Nocturnal
• Usually Non‐exertional
• Palpitations rare
Take Home Points
• SyncopeCommon
Low Yield/High Risk
• Work‐upHistory/History/History
EKGLabs as directed
• Blues Clues to “badness” in ECGObvious—beware traps/mimicsSubtle‐ you really need to look!!!
• NEVER USE COMPUTER “READ”
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EKG Clues will return…Thank you for your time and…