1 / 84

Top Ten (or 11) EKG Killers

Top Ten (or 11) EKG Killers. Micelle Haydel, MD LSUHSC New Orleans. Credit to Amal Mattu, MD. Lectures: ACEP EmedHome Podcasts Visiting Lectures Books: ECG's for the Emergency Physician 1 by Mattu & Brady ECGs for the Emergency Physician 2 by Mattu & Brady

kyra-wilson
Download Presentation

Top Ten (or 11) EKG Killers

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Top Ten (or 11) EKG Killers Micelle Haydel, MD LSUHSC New Orleans

  2. Credit to Amal Mattu, MD • Lectures: • ACEP • EmedHome Podcasts • Visiting Lectures • Books: • ECG's for the Emergency Physician 1 by Mattu & Brady • ECGs for the Emergency Physician 2 by Mattu & Brady • Electrocardiography in Emergency Medicine by Amal Mattu

  3. The EKG must be interpreted in the clinical context. • Don’t order a test unless you know what to do with the results…

  4. Majority QRS complexes are positive (have tall R waves) Except AVR & V1-2; r-wave progression across the precordium T wave in V1 should be small, flat or flipped The Normal Adult EKG

  5. Differential Dx of Tall R waves in V1 • Posterior MI • RBBB • Right Strain • PE • COPD • Cor Pulmonale • RBBB mimics • PE • Brugada • ARVD • WPW • Pediatric EKG (tall R-wave and flipped t-wave V1-3)

  6. Specific causes of non-specificflipped T-Waves • CAD/ischemia • Cardiomyopathies • Myocarditis, pericarditis • PE • Valvular disorders • CNS bleed • LVH, BBB, paced

  7. Differential Diagnosis: Tall t-waves • Hyperacute T-waves/ischemia • HyperKalemia • BER • LVH, BBB, Paced

  8. Low voltage: qrs <10mm precordial • Obese patient The New Orleans’ Special • Restrictive cardiomyopathy • Pericardial effusion • Hypothyroid • Hypothermia • Myocarditis

  9. The EKG must be interpreted in the clinical context. • Don’t order a test unless you know what to do with the results…

  10. EKG in Syncope, PreSyncope, Palpitations

  11. Cardiomyopathies Dilated Hypertrophic Restrictive ARVD/C Arrhythmogenic Right Ventricular Dyplasia/Cardiomyopathy Primary arrhythmic syndromes WPW QT intervalopathies Brugada ARVD CPVT Catecholaminergic Polymorphic Ventricular Tachycardia Not-so BER Other Biggies MI Pulmonary Embolism Is it Syncope-- or is it a sentinel death event??

  12. ~300,000/yr in US Over 35 years ~80% due to CAD ~15% Cardiomyopathy NEJM Huikuri et al. 345 (20): 1473,  November 15, 2001 Sudden Cardiac Death: unexpected death within 1 hour of symptomsFinal, common pathway: Vtach/fib 90%

  13. Sudden Cardiac Death: 1-35 yrsFinal, common pathway: Vtach/fib 90% ~3,000/yr U.S. • ~70% have a structural abnormality • Cardiomyopathies • Coronary Anomalies • Myocarditis • Valvular Disorders • Primary arrhythmic syndromes • Accessory pathways • QT intervalopathies • Ion channelopathies

  14. EKG findings in Sentinel Death Events • Cardiomyopathies: (flipped T waves plus…) • Hypertrophic Cardiomyopathy (LVH) • Dilated (LVH) • Restrictive cardiomyopathy (low voltage,a-fib, conduction disturbances) • Arrhythmogenic Right Ventricular Dysplasia /Cardiomyopathy (Epsilon waves, RBBB pattern)

  15. Primary arrhythmic syndromes Brugada coved/saddle deformity ST V1 &V2 WPW Delta waves, short PR interval, RBBB pattern Prolonged/shortened QT Not so-BER inferior-lateral j-point elevation Catecholaminergic Polymorphic Ventricular Tachycardia:Normal RESTING EKG/ECHO with recurrent syncope starting in childhood related to exertion/emotions. EKG findings in Sentinel Death Events

  16. EKG findings in Sentinel Death Events • Myocarditis (diffuse flipped T waves) • Congenital coronary-artery anomalies (large p waves) • Coronary artery disease: (Wellen’s Sign, Hyperacute T waves, Too tall T-waves) • Valvular disorders (AS: LVH; MVP: normal or flipped T waves inferiorly)

  17. Heart racing, I feel ok now…

  18. WPW • Delta waves, short PR interval • tall R-waves in V1, RBBB pattern • Pseudoinfarction pattern inferiorly

  19. Fainted…

  20. Prolonged qt interval

  21. Prolonged QT

  22. QT interval • Depending on the rate, ~normally about the size of two big blocks

  23. Woozy, I feel ok now…

  24. Congenital SHORT QT syndrome (<320ms) --- vtach, syncope, SCD

  25. Weekend warrior, passed out

  26. Hypertrophic CardioMyopathy • The most common ECG abnormalities • left ventricular hypertrophy • abnormal ST-segments • Deeply flipped T-wave, tall R apical leads, deep Q waves laterally

  27. Hypertrophic CardioMyopathy • Asymmetrical thickening of the ventricular septum • Patients may experience syncope, angina, palpitations, dyspnea

  28. Chief Complaint: Palpitations

  29. Restrictive cardiomyopathy: Low Voltage with flipped anterior Twaves

  30. Restrictive cardiomyopathy: • Amyloidosis, sarcoidosis, hemochromatosis, etc • Ventricles become rigid and lack the flexibility to expand during diastole. • SOB, fatigue, palpitations & syncope other common findings : atrial fib, conduction delays

  31. Specific causes of non-specificflipped T-Waves • CAD/ischemia • Cardiomyopathies • Myocarditis, pericarditis • PE • Valvular disorders • CNS bleed • LVH, BBB, paced

  32. The eye does not see what the mind does not know...

  33. Seizure vs. syncope…

  34. Brugada Na ion channelopathy that predisposes to v-tach/fib Coved or Saddle types

  35. Almost passed out, I feel ok now…

  36. Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy • Replacement of RV muscle by fibro-fatty tissue • Associated with VT and ventricular fibrillation

  37. Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy AVRD/C • May have Epsilon waves: sharp discrete deflections at the terminal portion of the QRS complex in V1-2 • Inverted T waves in the anterior leads • Incomplete or complete RBBB Blips or wiggles in the terminal part of the QRS

  38. Passed out, I feel better now…

  39. Classically BER is found in the mid- precordial leads Notching, smiley face upward deflection Not-so BER: NEJM 358:2016-2023 Haïssaguerre et al, showed that inferior-lateral ST elevation was associated with v tach/fib. BER vs Not-so-Benign Early Repolarization

  40. BER, with inferior-lateral J point elevation • Similar j point elevation & notching has been noted in ARVD, WPW & Brugada. • The jury is still out: BER in the inferior-lateral leads can be considered benign, unless the patient presents with syncope, palpitations, family hx sudden death.

  41. Cardiomyopathies Dilated Hypertrophic Restrictive ARVD/C Arrhythmogenic Right Ventricular Dyplasia/Cardiomyopathy Primary arrhythmic syndromes WPW QT intervalopathies Brugada ARVD CPVT Catecholaminergic Polymorphic Ventricular Tachycardia Not-so BER Other Biggies MI Pulmonary Embolism Is it Syncope-- or is it a sentinel death event??

  42. EKG in Chest Pain and/or SOB • Ischemia • Pericarditis/Myocarditis • PE • Tamponade

  43. Passed out, I feel ok now…

  44. PE • S1,Q3,T3 • Rt strain (RBBB pattern) • Flipped anterior t-waves

  45. Dogma: The most common ECG abnormalities in PE are tachycardia and nonspecific T wave abnormalities. • Recent studies: The most common ECG finding in PE is anterior T-wave inversion. • Mattu: the combination of flipped t-waves anteriorly and inferiorly is very specific for PE.

  46. Number of Leads with T Wave inversion correlating with RV dysfunction on Echo: ≤ 3 = 47% 4-6 = 92% ≥ 7 = 100% Kosuge et al. Circ J 2006 Flipped T waves in Pulmonary Embolism

  47. Severe Shortness of breath

  48. Tamponade

  49. Low voltage: qrs <10mm precordial • Obese patient The New Orleans’ Special • Restrictive cardiomyopathy • Pericardial effusion • Hypothyroid • Hypothermia • Myocarditis

  50. I had chest pain, but I am ok now…

More Related