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Dangerous ECG Findings: And what to do about them

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Dangerous ECG Findings: And what to do about them

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    1. Dangerous ECG Findings: And what to do about them! Scott Morsberger, PA-C, MPAS

    2. Scenario #1 45 Year Old Female. Hx of vagal sounding syncope. PMHx: HTN, Anxiety, OSAS. Lower abd pain/syncope without usual prodrome. Wakes up SOB. Meds: Lisinopril/HCT, Fluoxetine. ED: K+= 2.8

    3. Initial ECG

    4. QT Prolongation QTc= QT/sq root R-R Predisposes to PMVT (TdP) Normal QTc Males < 0.44 s Normal QTc Females <0.46 s Greatest risk when QTc >0.50 s Genetic vs. Acquired

    5. Genetic LQTS 7 Gene Mutations LQTS 1 – 7 Romano Ward Lange-Nielson

    6. Acquired LQTS Elytes Hypothyroid Coronary ischemia/infarct CNS disease Hypothermia Drugs: arizonacert.org Macrolides, FQ’s, Haloperidol, TCA’s, Methadone, Sotalol, etc.

    7. Treatment Non-synchronized Cardioversion (Extremis) IV MagSO4 Pace/Isoproterenol Replace Elytes STOP OFFENDING DRUGS!!!! +/- BB, AICD, PPM

    8. ECG after K+ Corrected

    9. EP Consult Presumptive LQTS2 HERG Gene (potassium channel) Paroxysmal QT prolongation when potassium low or with dehydration. D/C HCTZ Add BB Get labs when vomiting etc.

    10. WCT

    11. PMVT vs. Torsades PMVT frequently ischemic (If QTc WNL). PMVT in setting of prolonged QTc= TdP. Very important distinction: PMVT= BB, Amio, cath etc. TdP= look for etiology to long QTc.

    12. Torsades de Pointes Triggered by a PVC falling during the repolarization period. Increased frequency while bradycardic. Thus, pacing/isoproterenol make sense as treatments. Fix lytes. If hemodynamic compromise, CV then look for etiology of QT prolongation. BB (?) to avoid catecholamine surge.

    13. Scenario #2 64 YO Male. To ED for profound weakness/nausea. Hospitalized two weeks ago for newly diagnosed CHF (NICM). Meds: ASA, Carvedilol 12.5mg bid, Lisinopril 40mg qd, Furosemide 20mg qd, KCl 20mEq qd, Spironolactone 25mg qd, Simvastatin 10mg qd. Afebrile, 96/52, HR=72, RR=14

    14. Scenario #2

    15. Scenario #2 Labs: BUN/CR= 78/2.6 (previously 24/1.2). CT Chest PE Protocol 2 wks ago. Neg for PE/dissection. K+=6.6 What’s your next step?

    16. Hyperkalemia Symptoms: muscle weakness, paralysis. Etiology: ARF, CKD, DKA, Lactic Acidosis, hypoaldosteronism, ureterojejunostomy, rhabdo, crush injury, TLS. Drugs: ACEI, ARB, Aldosterone blockers, Nsaids.

    17. Hyperkalemia Causes a host of cardiac dysrhythmias: sinus brady, sinus arrest, idioventricular rhythms, VT, VF, asystole. Can cause all types of blocks. Dysrhythmias tend to occur when K+ is >7 but frequently occur when <7 if acute.

    18. Hyperkalemic ECG Changes Earliest: Peaked T’s with short QT. Progressive lengthening of PR/QRS intervals. P waves disappear/QRS widens to a sine wave ultimately. Ventricular standstill.

    19. Hyperkalemic ECG Changes ECG correlates poorly with K+ level. Can be used as a clue but not to diagnose hyperkalemia. Other entities cause peaked T’s (acute MI, early repol, LVH.

    20. Treatment of Hyperkalemia Stabilize – Calcium Shift- Insulin, D50, Albuterol, Sodium Bicarb. Remove – Loop/Thiazide diuretics, Kayexalate, HD. Prevent

    21. Scenario #3 60 Year Old Female. PMHx: SVT, HTN, dyslipidemia, hypothyroid. Meds: Ramipril, atorvastatin, levothyroxine. Sx of acute exac. asthmatic bronchitis. Palps lead to EMS call.

    22. Initial ECG

    23. Scenario #3 Adenosine 6mg IV. No effect. ED – SVT continues. Vitals stable except for heart rate. Patient moderately symptomatic.

    24. SVT ECG#2

    25. SVT Algorithm Assess patient stability. Is it Sinus Rhythm? If SR, treat the underlying disorder. If not SR, and unstable = CV.

    26. Stable SVT Algorithm 12 Lead, Regular or Irregular? Look for p waves. If no p waves and irregular- Consider A-fib. If multiple p wave morphologies – MAT. If no p waves, consider CSM or Adenosine. Adenosine is diagnostic and therapeutic.

    27. Tachycardia Algorithm

    28. SVT ECG#2

    29. SVT ECG#3 Old for Comparison

    30. SVT Rhythm Strip

    31. Scenario #3 TSH WNL. Mg2+= 2.0 K+= 4.2 Steroids for bronchitis. AVNRT. Long acting Diltiazem as bridge to ablation.

    32. Wide Complex Tachycardia

    33. Wide Complex Tachycardia

    34. Wide Complex

    35. ?Wide Complex Tachycardia

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