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ECG Manifestations: The Poisoned Patient

ECG Manifestations: The Poisoned Patient. Ehsan Bolvardi ,M.D. Introduction. Emergency medicine routinely evaluate and manage poisoned patients. There are numerous drugs that can cause ECG changes and lead to cardiac dysrhythmias. Five main categories : Potassium(K +) efflux blockers,

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ECG Manifestations: The Poisoned Patient

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  1. ECG Manifestations:The Poisoned Patient EhsanBolvardi ,M.D

  2. Introduction • Emergency medicine routinely evaluate and manage poisoned patients. • There are numerous drugs that can cause ECG changes and lead to cardiac dysrhythmias. • Five main categories: Potassium(K+) efflux blockers, Sodium(Na+) channel blockers, Sodium-potassium adenosine triphosphate (Na+/K+ ATPase) blockers, Calcium channel blockers, Beta-adrenergic blockers,

  3. ECG for Etiology?!

  4. Cardiac physiology

  5. Potassium efflux blocker toxicity • Antihistamines • Antipsychotics • Antidysrhythmics • TCAs • Fluoroquinolones • Macrolides ECG: Prolongation of the QT interval

  6. This ECG (taken following a 6g quetiapine overdose):

  7. Diagnosis?

  8. Diagnosis?

  9. Management • Withdrawal of potential cause • Correction of coexisting medical problems(K,Mg,Ca) • Intravenous magnesium sulfate • Electrical overdrive pacing • Unsynchronized electrical defibrillation (AHA guidline)

  10. Sodium channel blocker toxicity • TCAs • Carbamazepine • antidysrhythmics • Citalopram • Cocaine • phenothiazine • Propranolol • Verapamil ECG: Widened QRS , Right axis deviation , bradycardia, VT,VF

  11. ECG after ingestion of 35 mg/kg doxepin

  12. Delayed ECG with worsening TCA toxicity

  13. management • Administration of sodium • Creation of an alkalosis • Hypertonic saline • Hyperventilation • Lidocaine • Avoided:antidysrhythmic (IA,IC)

  14. Na+/K+ ATPase blocking agents and substances • Digoxin • Foxglove • Lily of the valley • Oleander ECG: Increased automaticity accompanied by slowed conduction through the AV node. Acute poisoning most closely correlates with hyperkalemia.

  15. Diagnosis?

  16. Diagnosis?

  17. Diagnosis?

  18. management • Digoxine -specific antibody(Fab) fragments • Atropine sulfate • Cardiac pacing • Phenytoin • Avoid Quinidine and procainamide.

  19. Calcium channel blocker toxicity • Amlodipine(higher affinity for the peripheral vascular smooth muscle) • Nicardipine • Nimodipine • Verapamil(strong affinity for cardiac and vascular calcium channel) • Diltiazem ECG: Sinus bradycardia , Decreased AV node conduction ,Intraventricular conduction defect.

  20. Diagnosis?

  21. management • Atropine • Calcium • Glucagon • Insulin • Sodium bicarbonate

  22. Beta-adrenergic blocker toxicity • Acebutolol • Atenolol • Bisoprolol • Carvedilol • Esmolol • Labetalol • Metoprolol • Propranolol • Sotalol • Timolol ECG: Sinus bradycardia , Decreased AV node conduction

  23. Diagnosis?

  24. Diagnosis?

  25. management • atropine, • glucagon, • calcium, • insulin, • various catecholamines, • Pacemaker insertion, • balloon pump, • bypass

  26. Summary • Order ECG; • Check: rhythm , rate , Axis, QRS widening, PR and QT interval, AV and intraventricular block, Ischemic changes;

  27. This ECG is from a man who presented following a TCA overdose

  28. This is an ECG from a patient of unknown age and presentation

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