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CRITICAL CARE ECG’S

CRITICAL CARE ECG’S. Preeta John. In the diagram normal range - 30 to +90. Left axis deviation superior and leftward -30 to -90 Right axis deviation inferior and rightward +90 to +150 . PR Interval beginning of P to beginning of QRS  Normal: 0.12 - 0.20s Short PR: < 0.12s

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CRITICAL CARE ECG’S

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  1. CRITICAL CARE ECG’S Preeta John

  2. In the diagram normal range - 30 to +90. • Left axis deviation superior and leftward -30 to -90 • Right axis deviation inferior and rightward +90 to +150

  3. PR Interval • beginning of P to beginning of QRS •  Normal: 0.12 - 0.20s • Short PR: < 0.12s • QRS Duration • duration of QRS complex • Normal: 0.06 - 0.12s

  4. QT Interval • beginning of QRS to end of T wave • Normal: heart rate dependent (corrected QT = QTc = measured QT % sq-root RR in seconds; upper limit for QTc = 0.44 sec)

  5. How to read an ECG • Standardisation • Rate • Rhythm • Axis • Chamber enlargement & hypertrophy • Arrythmias & conduction delays • Ischaemia / infarction

  6. Case scenario 1 • 26 year old man • Run over by a truck • Managed in local hospital • Brought to casualty 24 hours later • head injuries and extensive crush injury to lower limbs • GCS 10/15 • BP: 90/60 HR:46/min

  7. Admitted in ICU and stabilised

  8. ECG

  9. S.creat: 4.5 mg% • S. K: 7.1 mEq/l • CPK: 36,000

  10. Course • Pharmacological measures to decrease pottassium • Dialysis • Surgery • Patient did well and was discharged 2 weeks later

  11. ECG

  12. Take home message • Consider potassium derangements in any arrythmia in the ICU • Focus on treating the underlying dyselectrolytemia promptly

  13. Case scenario 2 • 20 year old primigravida from Chittoor • Fever, jaundice and altered sensorium for 5 days • GCS: 12/15 • Blood smear positive for plasmodium falciparum • Parasitic index 10%

  14. Started on Quinine infusion • On day 2, Sudden hypotension • BP:80 sys HR: 200/min

  15. ECG

  16. Polymorphous ventricular tachycardia -Torsade de pointes. • wide QRS complexes with multiple morphologies • changing R - R intervals • the axis twists about the isoelectric line • recognise this pattern - number of reversible causes • heart block • hypokalaemia or hypomagnesaemia • drugs e.g. tricyclic antidepressant overdose • congenital long QT syndromes • other causes of long QT (e.g. IHD

  17. DC cardioversion • Causes • Treatment – hemodynamically stable and unstable • Monitor QT interval while on quinine!

  18. The QT interval duration is greater than 50% of the RR interval, a good indication that it is prolonged in this patient. Although there are many causes for the long QT, patients with this are at risk for malignant ventricular arrhythmias, syncope, and sudden death.

  19. QT • Normal upto 0.45 • Stop quinine if ≥ 0.60

  20. Quinine discontinued, changed to artemether • QT interval normalised • Delivered fresh stillborn • Gradual recovery

  21. Take home message • Monitor QT interval while on quinine! • Consider iatrogenic causes of arrythmias - drugs - inotropes - central lines

  22. Case scenario 3 • 72 year old man • Diabetic with urosepsis • Emphysematous pyelonephritis-post nephrectomy • Being ventilated in ICU • On inotropic support-noradrenaline 5ug/min: BP- 110/60mm Hg

  23. On day 3, sudden hypotension • Cold clammy extremities • BP: 60 sys HR: 140/min • CVP:25cms • Chest: bilateral crackles • CVS: muffled

  24. ECG

  25. Serial ECGs and Cardiac enzymes • Thrombolysis/ UFheparin/ LMWH • Differentials

  26. Trop I :12 • Thrombolysis contraindicated • Progressive hypotension on increasing inotropes • Expired

  27. Take home message • Consider myocardial ischemia in every case of sudden hypotension

  28. Case scenario 4 • 55yr old man • Sudden onset progressive BOE for 2 days. • Sudden worsening of breathlessness today • No chest pain, fever, cough • No DM, HTN, Smoke

  29. Examination • Obese • No pallor, edema • BP: 110/70mmHg HR:110/min • JVP: elevated 3cms • Resp : clear • CVS: S3, sharp S2 • Abd: NAD

  30. Sudden hypoxia and hypotension BP: not recordable

  31. Admitted to MICU • Thrombolysed with STK • Improvement over 24 hours

  32. Case scenario-5 • A 30 year old lady diagnosed to have ruptured empyema gall bladder with peritonitis underwent cholecystectomy. On the first post operative day –high grade fever followed by hypotension started on ionotropes . A day later blood culture –heavy growth of pseudomonas

  33. O/E: • BP: 90/40mmHg. HR- 160/minute • Interpret her ECG

  34. Takotsubo cardiomyopathy

  35. Takotsubo cardiomyopathy • ICU cardiomyopathy • Seen in critically ill patients • Mimics myocardial ischemia • No specific treatment • Reverts as patient improves • No residual complications

  36. Case scenario-6 • 50 year old man known alcoholic presented with a history of acute abdomen • He was diagnosed to have pancreatitis • He had a similar episode 6 months ago and a syncopial attack was admitted in the ICU and discharged a week later

  37. Diagnosis

  38. Brugada syndrome • Congenital channelopathy • Seen in asians • Prone for sudden onset of ventricular tachycardia/cardiac arrest • ICD only treatment • Precipitated by alcohol, prothiadine

  39. Case scenario-7 • 25 year old man with a history of corrosive acid poisoning presented a day later with a history of chest pain and fever • O/E: He was febrile BP100/60 PR 140/minute

  40. Case scenario-8 • 60 year old man with CA stomach underwent a total gastrectomy. Three days later became breathless, was febrile and had multiple ventricular ectopics assosiated with hemodynamic instability. • Subsequently he was intubated. • Common causes ruled out .He was started on an amiodarone infusion and he settled • 24 hours later

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