1 / 35

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.

morey
Télécharger la présentation

Dangerous ECG Findings: And what to do about them!

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related