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EKG Rounds

EKG Rounds. Elizabeth Haney 19 October 2006. Case. 32 y.o. Caucasian male presents w/ 4 hours sharp RSCP Radiation to Lt shoulder and arm Worse with deep inspiration, no exertional change PMHx: healthy, URTI Sx x 5/7 Meds: occasional tylenol NKDA. Case (cont’d).

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EKG Rounds

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  1. EKG Rounds Elizabeth Haney 19 October 2006

  2. Case • 32 y.o. Caucasian male presents w/ 4 hours sharp RSCP • Radiation to Lt shoulder and arm • Worse with deep inspiration, no exertional change • PMHx: healthy, URTI Sx x 5/7 • Meds: occasional tylenol • NKDA

  3. Case (cont’d) • Vitals: HR 120 reg, RR 24, BP 124/82 bilat, T 37.1, O2 sat 99% • O/E: sitting up in bed, moderate distress, otherwise exam normal

  4. EKG

  5. Pericarditis • Overview of the pericardium and pericarditis • 4 EKG stages • Differentiating between pericarditis and early repolarization

  6. Pericardium • Back to basics: • Pericardium: fibroelastic sac, composed of parietal and visceral layers with narrow potential space between • Normally contains 15-60ml plasma ultrafiltrate. • Drainage via thoracic duct and right lymphatic duct into Rt pleural space

  7. Pericarditis • Inflammation of pericardium • Etiology: Most cases idiopathic, with specific etiology in only 22%

  8. Pericarditis • Classical features: RSCP (varies w/ respiration, sharp, worse w/ lying down, relieved w/ sitting up, may radiate to trapezius), EKG abnormalities, +/- pericardial friction rub (~25% of cases)

  9. EKG Findings • Changes reflect superficial inflammation of the epicardium • ~90% will show STE, most commonly in leads I,II,V5-6 (70% of patients) • PR depression in all leads except aVR (elevation) may be 1st sign, reflecting repolarization abnormality of atria • Changes follow typical 4 stage evolution over weeks to months Demangone,D., ECG Manifestations: Noncoronary Heart Disease., Emerg Med Clin N Am 24 (2006) 113-115

  10. 4 Stages of EKG changes • Stage I:  Typically occurs during the first hours – days. Diffuse concave-upward ST segment elevation with concordance of T waves; ST-segment depression in aVR or V1; PR segment depression • Stage II: Normalization of ST and PR segments; T wave flattening. Days – weeks. • Stage III: Symmetric T wave inversion. ~ 3 weeks -2 months • Stage IV: Gradual resolution of T-wave inversion (may remain inverted). May last 3 months

  11. What causes STE in the Emerg? • LVH with Strain (25%) • Undefined STE (17%) • Acute MI (15%) • LBBB (15%) • Benign Early repolarization (12%) • RBBB (5%) • Non-specific BBB (5%) • LV aneurysm (3%) • Pericarditis (1%) • Retrospective review of 202 patients with chest pain and STE >1mm in limb leads, >2mm precordial leads, 2 or more contiguous leads Brady WJ et al. Cause of ST Segment Abnormality in ED Chest Pain Patients. Am J Emerg Med 2001; 19: 25-28.

  12. Benign Early Repolarization • Normal EKG variant • May be related to enhanced vagal tone • Prevalent in patients with high (T5 or higher) spinal cord injuries where sympathetic flow interrupted • Males > Females • Predominantly age <50 • Incidence 1-2% Rosen’s, Mehta, et al. Early Repolarization. Clin.Cardiol. 1999; 22, 59-65

  13. Early Repolarization Characterized by: • Diffuse ST segment elevation on EKG • Upward concavity of the initial portion of the ST segment • Notching of the terminal portion of the QRS complex at the J point (jcn of QRS with ST) • Symmetrical, concordant T waves of large amplitude • Relative temporal stability over time • Maximal STE typically in precordial leads V2-V5 Rosen’s

  14. How can we distinguish between Early Repolarization and Pericarditis?

  15. ST/T Ratio Tool

  16. ER vs. Pericarditis

  17. Summary • 4 stages of Pericaritis EKG changes • Ddx of STE • Early Repolarization • Use of the ST/T wave ratio to help differentiate pericarditis from early repolarization

  18. References • www.uptodate.com • Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed., 2006; Ch. 81: 1280-88 • Demangone,D., ECG Manifestations: Noncoronary Heart Disease., Emerg Med Clin N Am 24 (2006) 113-115 • Brady WJ et al. Cause of ST Segment Abnormality in ED Chest Pain Patients. Am J Emerg Med 2001; 19: 25-28. • Mehta, et al. Early Repolarization. Clin.Cardiol. 1999; 22, 59-65

  19. Pericarditis vs. AMI

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