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EKG - Dysrhythmia Workshop

EKG - Dysrhythmia Workshop. Wayne E. Ellis, Ph.D., CRNA . Overview. Anatomy Fundamental Concepts Myocardial Injury Modified Chest Leads Dysrhythmias S inus Atrial AV node Junctional Ventricular Practice Strips. Preop Predictors Periop Cardiac Morbidity “high risk patients”.

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EKG - Dysrhythmia Workshop

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  1. EKG - Dysrhythmia Workshop Wayne E. Ellis, Ph.D., CRNA

  2. Overview AnatomyFundamental ConceptsMyocardial InjuryModified Chest LeadsDysrhythmias Sinus Atrial AV node Junctional VentricularPractice Strips

  3. Preop Predictors Periop Cardiac Morbidity “high risk patients” Recent MI Current CHF

  4. Let’s consider the following uninterpreted EKG : Lap-chole on 55 yo black male Hx HTN ( Rx “BP pill” ) Per family member Poor historian Lab “normal” 160 / 96 , 92 , 12

  5. Your diagnosis ? a. “ I think it’s OK ” b. Wait for cardiology to confirm ? How should it / might it affect your anesthetic plan? a. Delay case ? b. Cancel case ? c. Proceed based upon surgeon’s request ? d. Consult with other anesthesia team member (MDA) & proceed accordingly ? Where do you stand medico-legally ?

  6. Cardiac Anatomy

  7. Left Coronary Artery Sinus Artery Right Coronary Artery Circumflex Left Anterior Descending

  8. Circumflex Right Coronary Artery Posterior Descending Coronary Artery

  9. Circumflex Right Coronary Artery Posterior Descending Right Dominant Coronary Circulation

  10. Circumflex Lateral MI

  11. Right Coronary Artery Posterior MI

  12. Posterior Descending Inferior MI

  13. Left Anterior Descending Anterior MI

  14. Conduction System

  15. Bundle of His S-A Node Left Bundle Branch Posterior Fascicle Anterior Fascicle A-V Node Purkinje Fibers Right Bundle Branch

  16. Coronary Circulation Distribution to the Conduction System

  17. Bundle of His S-A Node A-V Node RCA / Cx

  18. Posterior Fascicle Anterior Fascicle LAD Purkinje Fibers Right Bundle Branch

  19. CHB 10% (11%) 5% Inferior MI Anterior MI

  20. CHB Asystole Death (CHB after ea MI) 10% (11%) 15% (13%) 35% (36%) 5% 80% (78%) 80% (81%) Inferior MI Anterior MI

  21. Arrhythmias & Type of MI Inferior - narrow complex dysrhythmias Sinus dysrhythmias Junctional dysrhythmias 3rd degree A-V block with a junctional escape rhythm Anterior - wide complex dysrhythmias Mobitz II 3rd degree A-V block with a ventricular escape rhythm

  22. Fundamentals of Electrocardiographic Monitoring

  23. ventricular depolarization QRS = P = atrial depolarization ventricular repolarization T =

  24. a v c CVP Tracing P QRS

  25. 1 2 0.16 0.08 0.04 0.12 0.20 3 4 5 3 1 2 4 calibration pulse 1 mV = 10 mm sweep speed 25 mm / sec vertical axis 1 mm = 0.1 mV each mm = 0.04 sec each square = 1 mm

  26. Waveform, Interval, and Segment Identification

  27. Waveform, Interval, and Segment Identification Isoelectric Line

  28. Waveform, Interval, and Segment Identification Isoelectric Line Positive Waveform Negative Waveform

  29. Waveform, Interval, and Segment Identification Isoelectric Line P Positive Waveform Negative Waveform

  30. Waveform, Interval, and Segment Identification Isoelectric Line P Positive Waveform Negative Waveform Q

  31. Waveform, Interval, and Segment Identification R Isoelectric Line P Positive Waveform Negative Waveform Q

  32. Waveform, Interval, and Segment Identification R Isoelectric Line P Positive Waveform Negative Waveform Q S

  33. R Isoelectric Line T P Positive Waveform Negative Waveform Q S Waveform, Interval, and Segment Identification

  34. R Isoelectric Line T P Positive Waveform Negative Waveform U Q S Waveform, Interval, and Segment Identification

  35. U Waveform, Interval, and Segment Identification R Isoelectric Line T P Positive Waveform Negative Waveform ST Q S

  36. U Waveform, Interval, and Segment Identification R Isoelectric Line T P Positive Waveform Negative Waveform ST PR interval Q S

  37. U Waveform, Interval, and Segment Identification R Isoelectric Line T P Positive Waveform Negative Waveform ST PR interval Q S QT interval

  38. QT Interval- Should be < 1/2 preceding R to R interval -

  39. QT Interval- Should be < 1/2 preceding R to R interval - QT interval

  40. QT Interval- Should be < 1/2 preceding R to R interval - QT interval

  41. R R QT Interval- Should be < 1/2 preceding R to R interval - QT interval

  42. R R QT Interval- Should be < 1/2 preceding R to R interval - QT interval

  43. R R QT Interval- Should be < 1/2 preceding R to R interval - QT interval

  44. R R QT Interval- Should be < 1/2 preceding R to R interval - 65 - 90 bpm QT interval

  45. R R QT Interval- Should be < 1/2 preceding R to R interval - 65 - 90 bpm QT interval Normal QTc = 0.46 sec

  46. Practice Waveform Identification

  47. D A C B

  48. D A C B No Q waves RS complex

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