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Dangerous ECG Findings: And what to do about them!

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

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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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