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    Top Ten (Or 11) EKG Killers

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    phausknecht
    This document provides a summary of important EKG findings related to various cardiac conditions that can present with symptoms like syncope, presyncope, palpitations, or chest pain. It discusses normal EKG patterns and various abnormalities that should be considered in the differential diagnosis for these symptoms. These include cardiomyopathies, arrhythmias, pulmonary embolism, myocardial infarction, pericarditis, and other conditions. Specific EKG patterns are presented that may help identify these underlying problems. The importance of interpreting EKGs in the clinical context is emphasized.

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    Top Ten (Or 11) EKG Killers

    Uploaded by

    phausknecht
    91 views84 pages
    This document provides a summary of important EKG findings related to various cardiac conditions that can present with symptoms like syncope, presyncope, palpitations, or chest pain. It discusses normal EKG patterns and various abnormalities that should be considered in the differential diagnosis for these symptoms. These include cardiomyopathies, arrhythmias, pulmonary embolism, myocardial infarction, pericarditis, and other conditions. Specific EKG patterns are presented that may help identify these underlying problems. The importance of interpreting EKGs in the clinical context is emphasized.

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    Master your EKGs

    Original Title

    Top Ten (or 11) EKG Killers

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    This document provides a summary of important EKG findings related to various cardiac conditions that can present with symptoms like syncope, presyncope, palpitations, or chest pain. It discusses normal EKG patterns and various abnormalities that should be considered in the differential diagnosis for these symptoms. These include cardiomyopathies, arrhythmias, pulmonary embolism, myocardial infarction, pericarditis, and other conditions. Specific EKG patterns are presented that may help identify these underlying problems. The importance of interpreting EKGs in the clinical context is emphasized.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    91 views84 pages

    Top Ten (Or 11) EKG Killers

    Uploaded by

    phausknecht
    This document provides a summary of important EKG findings related to various cardiac conditions that can present with symptoms like syncope, presyncope, palpitations, or chest pain. It discusses normal EKG patterns and various abnormalities that should be considered in the differential diagnosis for these symptoms. These include cardiomyopathies, arrhythmias, pulmonary embolism, myocardial infarction, pericarditis, and other conditions. Specific EKG patterns are presented that may help identify these underlying problems. The importance of interpreting EKGs in the clinical context is emphasized.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 84

    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
     Electrocardiography in Emergency Medicine by Amal Mattu
    The EKG must be interpreted in the
    clinical context.

     Don’t order a test unless you


    know what to do with the
    results…
    The Normal Adult EKG

     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
    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)
    Specific causes of non-specific flipped T-Waves

     CAD/ischemia
     Cardiomyopathies
     Myocarditis, pericarditis
     PE
     Valvular disorders
     CNS bleed

     LVH, BBB, paced


    Differential Diagnosis: Tall t-waves
     HyperacuteT-waves/ischemia
     HyperKalemia

     BER
     LVH, BBB,

    Paced
    Low voltage: qrs <10mm precordial
     Obese patient The New Orleans’ Special
     Restrictive cardiomyopathy
     Pericardial effusion
     Hypothyroid
     Hypothermia
     Myocarditis
    The EKG must be interpreted in the
    clinical context.

     Don’t order a test unless you


    know what to do with the
    results…
    EKG in Syncope, PreSyncope,
    Palpitations
    Is it Syncope--
    or is it a sentinel death event??
     Cardiomyopathies  Other Biggies
     Dilated  MI
     Hypertrophic  Pulmonary
     Restrictive Embolism
     ARVD/C Arrhythmogenic Right
    Ventricular Dyplasia/Cardiomyopathy
     Primary arrhythmic syndromes
     WPW
     QT intervalopathies
     Brugada
     ARVD
     CPVT Catecholaminergic Polymorphic
    Ventricular Tachycardia
     Not-so BER
    Sudden Cardiac Death: unexpected death within 1 hour
    of symptoms
    Final, common pathway: Vtach/fib 90%

    ~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: 1-35 yrs
    Final, common pathway: Vtach/fib 90%
    ~3,000/yr U.S.
     ~70% have a structural abnormality
     Cardiomyopathies

     Coronary Anomalies Identified Causes SCD 1-35 years


     Myocarditis

     Valvular Disorders 30% HCM

     Primary arrhythmic syndromes 25% Coronary


     Accessory pathways Anomalies
    20%
    Myocarditis
     QT intervalopathies
    15%
     Ion channelopathies Valvulopathies
    10%
    Primary arrhythmic
    5% syndromes
    ARVD
    0%
    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)
    EKG findings in Sentinel Death Events

     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
     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)
    Heart racing, I feel ok now…
     Delta waves, short PR interval
    tall R-waves in V1, RBBB pattern
    WPW 
     Pseudoinfarction pattern inferiorly
    Fainted…
    Prolonged qt interval
    Prolonged QT
    QT interval

     Depending on the
    rate, ~normally
    about the size of
    two big blocks
    Woozy, I feel ok now…
    Congenital SHORT QT syndrome
    (<320ms) --- vtach, syncope, SCD
    Weekend warrior, passed out
    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
    Hypertrophic CardioMyopathy
     Asymmetrical thickening of the ventricular septum
     Patients may experience syncope, angina,
    palpitations, dyspnea
    Chief Complaint: Palpitations
    Restrictive cardiomyopathy:
    Low Voltage with flipped anterior Twaves
    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


    Specific causes of non-specific flipped T-Waves

     CAD/ischemia
     Cardiomyopathies
     Myocarditis, pericarditis
     PE
     Valvular disorders
     CNS bleed

     LVH, BBB, paced


    The eye does not see what the mind
    does not know...
    Seizure vs. syncope…
    Brugada

    Na ion channelopathy that


    predisposes to v-tach/fib

    Coved or Saddle types


    Almost passed out, I feel ok now…
    Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy
    • Replacement of RV muscle by fibro-fatty tissue
    • Associated with VT and ventricular fibrillation
    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
    Passed out, I feel better now…
    BER vs Not-so-Benign Early Repolarization
     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, 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.
    Is it Syncope--
    or is it a sentinel death event??
     Cardiomyopathies  Other Biggies
     Dilated  MI
     Hypertrophic  Pulmonary
     Restrictive Embolism
     ARVD/C Arrhythmogenic Right
    Ventricular Dyplasia/Cardiomyopathy
     Primary arrhythmic syndromes
     WPW
     QT intervalopathies
     Brugada
     ARVD
     CPVT Catecholaminergic Polymorphic
    Ventricular Tachycardia
     Not-so BER
    EKG in Chest Pain and/or SOB

    • Ischemia
    • Pericarditis/Myocarditis
    • PE
    • Tamponade
    Passed out, I feel ok now…
    PE
     S1,Q3,T3
     Rt strain (RBBB pattern)
     Flipped anterior t-waves
    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.
    Flipped T waves in Pulmonary Embolism

     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


    Severe Shortness of breath
    Tamponade
    Low voltage: qrs <10mm precordial
     Obese patient The New Orleans’ Special
     Restrictive cardiomyopathy
     Pericardial effusion
     Hypothyroid
     Hypothermia
     Myocarditis
    I had chest pain, but I am ok now…
    Wellen’s Sign
    • Associated with a critical, proximal LAD lesion
    • Classically, occurs during a pain-free period
    Chest Pain
    HyperAcute T-waves
     HyperAcute T-waves in the anterior leads
     Poor R- wave progression
     T-waves are asymmetrical and broad-based
     Follows a pattern of injury
    Differential Diagnosis: Tall t-waves
     Hyperacute T-waves (broad, asym)
     HyperKalemia (narrow, pointy)
     BER (usually associated with tall r-waves)
     LVH (usually assoc with prwp)
     LBBB (prwp, wide)
    I had chest pain, but I am ok now…

    Today

    One week
    ago
    HyperAcute T-wave in V1
    The normal ECG has a small, flat or inverted T-wave in lead V1 and if
    upright or larger in V1 than V6 in the setting of ACS:
     Suggests significant underlying CAD or acute ischemia if new
     may precede other expected ECG changes
     Tall t-waves don’t belong in V1 except:
     LBBB
     LVH
    Chest Pain
    ST elevation in V1,
    plus ST elevation AVR
    AVR & Left Main lesions:
    is it magic or is it simply reversal of V6?

    Fu, et al, The American Journal of Cardiology, Volume 99, Issue 7 reported
    higher mortality risk in patients with flipped T & ST depression in the V5-6.
    Mattu: aVR

    A. ST-segment elevation in lead aVR suggestive of LMCA occlusion: in NonSTEACS pts,


    increased 30 day mortality: Yan, American Heart Journal - Volume 154, Issue 1
    B. PR-segment elevation suggestive of acute pericarditis.
    C. Prominent R′ wave suggestive of TCA poisoning.
    D. Rapid, regular, narrow QRS complex tachycardia with ST-segment elevation suggestive
    of WPW-related tachycardia.
    I had chest pain, but I am ok now…
    Pericarditis
    CP, SOB…

    25yo, low grade fever, dyspnea, uri symptoms, chest pain…


    Myocarditis: SOB, CP, fever
     Diffuse T-wave inversions with or without ST segment abnormality

     Incomplete atrioventricular conduction blocks or Intraventricular


    conduction blocks (usually transient)
    EKG in Chest Pain and/or SOB

    • Ischemia
    • Pericarditis/Myocarditis
    • PE
    •Tamponade
    EKG in Weak & Dizzy
    Electrolytes
    I feel weak…
    Hyperkalemia
    “SLOW Vtach”? It ain’t tach, if it ain’t tachy
    V-tach >120bpm….
    • Severe hyperkalemia
    • Idioventricular/reperfusion dysrhythmias
    • Type IA medication toxicity
    TCA toxicity
    Cocaine toxicity
    I feel weak…
    Hypocalcemia– prolonged QT
    EKG in Weak & Dizzy
     Electrolytes
    EKG in Overdose
     Na Channel Blockade
     Widen QRS
     K+ efflux blocker
     Prolongs qt interval
     AV nodal blocker
     Depresses inotropy
     Depresses chronotropy
     Digitalis: Na/K pump
     AV nodal blockage
     Increased automaticity
    Depressed, AMS…
    TCA overdose

    Sodium channel blockade: TCA, Cocaine, Benadryl, anticholinergic, dilantin


    SALT: shock, AMS, Long QT & Terminal slurring R in AVR
    Sympathetomimetics/Cocaine

    Typically more tachy than TCA OD b/c less potassium efflux blockade
    Depressed, took something….
    Potassium efflux blockers: Medication
    induced long qt
    Medication induced long qt
    Depressed, AMS…
    B-blocker/Ca-Channel blocker
    Digitalis
    Acute: AV block

    Chronic: Increased
    automaticity
    EKG in Overdose
     TCA
     Sympathetomimetics/Cocaine
     B-blocker/Ca-Channel blocker
     Digitalis
    EKG Stat!!

    ECG, Willem Einthoven, assigning P, Q, R, S and T to the various


    deflections and awarded the 1924 Nobel Prize

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