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Top Ten (or 11) EKG Killers

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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 ... – PowerPoint PPT presentation

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Title: Top Ten (or 11) EKG Killers


1
Top Ten (or 11) EKG Killers
  • Micelle Haydel, MD
  • LSUHSC New Orleans

2
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

3
The EKG must be interpreted in the clinical
context.
  • Dont order a test unless you know what to do
    with the results

4
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

5
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)

6
Specific causes of non-specific flipped T-Waves
  • CAD/ischemia
  • Cardiomyopathies
  • Myocarditis, pericarditis
  • PE
  • Valvular disorders
  • CNS bleed
  • LVH, BBB, paced

7
Differential Diagnosis Tall t-waves
  • Hyperacute T-waves/ischemia
  • HyperKalemia
  • BER
  • LVH, BBB,
  • Paced

8
Low voltage qrs lt10mm precordial
  • Obese patient The New Orleans Special
  • Restrictive cardiomyopathy
  • Pericardial effusion
  • Hypothyroid
  • Hypothermia
  • Myocarditis

9
The EKG must be interpreted in the clinical
context.
  • Dont order a test unless you know what to do
    with the results

10
EKG in Syncope, PreSyncope, Palpitations
11
Is it Syncope--
or is it a sentinel death event??
  • Cardiomyopathies
  • Dilated
  • Hypertrophic
  • Restrictive
  • ARVD/C Arrhythmogenic Right Ventricular
    Dyplasia/Cardiomyopathy
  • Primary arrhythmic syndromes
  • WPW
  • QT intervalopathies
  • Brugada
  • ARVD
  • CPVT Catecholaminergic Polymorphic Ventricular
    Tachycardia
  • Not-so BER
  • Other Biggies
  • MI
  • Pulmonary Embolism

12
Sudden Cardiac Death unexpected death within 1
hour of symptomsFinal, 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

13
Sudden Cardiac Death 1-35 yrsFinal, common
pathway Vtach/fib 90
  • 3,000/yr U.S.
  • 70 have a structural abnormality
  • Cardiomyopathies
  • Coronary Anomalies
  • Myocarditis
  • Valvular Disorders
  • Primary arrhythmic syndromes
  • Accessory pathways
  • QT intervalopathies
  • Ion channelopathies

14
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)

15
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.

16
EKG findings in Sentinel Death Events
  • Myocarditis (diffuse flipped T waves)
  • Congenital coronary-artery anomalies (large p
    waves)
  • Coronary artery disease (Wellens Sign,
    Hyperacute T waves, Too tall T-waves)
  • Valvular disorders (AS LVH MVP normal or
    flipped T waves inferiorly)

17
Heart racing, I feel ok now
18
WPW
  • Delta waves, short PR interval
  • tall R-waves in V1, RBBB pattern
  • Pseudoinfarction pattern inferiorly

19
Fainted
20
Prolonged qt interval
21
Prolonged QT
22
QT interval
  • Depending on the rate, normally about the size
    of two big blocks

23
Woozy, I feel ok now
24
Congenital SHORT QT syndrome (lt320ms) --- vtach,
syncope, SCD
25
Weekend warrior, passed out
26
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

27
Hypertrophic CardioMyopathy
  • Asymmetrical thickening of the ventricular septum
  • Patients may experience syncope, angina,
    palpitations, dyspnea

28
Chief Complaint Palpitations
29
Restrictive cardiomyopathy Low Voltage with
flipped anterior Twaves
30
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

31
Specific causes of non-specific flipped T-Waves
  • CAD/ischemia
  • Cardiomyopathies
  • Myocarditis, pericarditis
  • PE
  • Valvular disorders
  • CNS bleed
  • LVH, BBB, paced

32
The eye does not see what the mind does not
know...
33
Seizure vs. syncope
34
Brugada
Na ion channelopathy that predisposes to
v-tach/fib
Coved or Saddle types
35
Almost passed out, I feel ok now
36
  • Arrhythmogenic Right Ventricular Dysplasia/
    Cardiomyopathy
  • Replacement of RV muscle by fibro-fatty tissue
  • Associated with VT and ventricular fibrillation

37
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
38
Passed out, I feel better now
39
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 3582016-2023 Haïssaguerre et
    al, showed that inferior-lateral ST elevation was
    associated with v tach/fib.

40
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.

41
Is it Syncope--
or is it a sentinel death event??
  • Cardiomyopathies
  • Dilated
  • Hypertrophic
  • Restrictive
  • ARVD/C Arrhythmogenic Right Ventricular
    Dyplasia/Cardiomyopathy
  • Primary arrhythmic syndromes
  • WPW
  • QT intervalopathies
  • Brugada
  • ARVD
  • CPVT Catecholaminergic Polymorphic Ventricular
    Tachycardia
  • Not-so BER
  • Other Biggies
  • MI
  • Pulmonary Embolism

42
EKG in Chest Pain and/or SOB
  • Ischemia
  • Pericarditis/Myocarditis
  • PE
  • Tamponade

43
Passed out, I feel ok now
44
PE
  • S1,Q3,T3
  • Rt strain (RBBB pattern)
  • Flipped anterior t-waves

45
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.

46
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

47
Severe Shortness of breath
48
Tamponade
49
Low voltage qrs lt10mm precordial
  • Obese patient The New Orleans Special
  • Restrictive cardiomyopathy
  • Pericardial effusion
  • Hypothyroid
  • Hypothermia
  • Myocarditis

50
I had chest pain, but I am ok now
51
Wellens Sign
  • Associated with a critical, proximal LAD lesion
  • Classically, occurs during a pain-free period

52
Chest Pain
53
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

54
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)

55
I had chest pain, but I am ok now
Today
One week ago
56
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 dont belong in V1 except
  • LBBB
  • LVH

57
Chest Pain
58
ST elevation in V1, plus ST elevation AVR
59
AVR Left Main lesionsis 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.
60
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.                    
61
I had chest pain, but I am ok now
62
Pericarditis
63
CP, SOB
25yo, low grade fever, dyspnea, uri symptoms,
chest pain
64
Myocarditis SOB, CP, fever
  • Diffuse T-wave inversions with or without ST
    segment abnormality
  • Incomplete atrioventricular conduction blocks or
    Intraventricular conduction blocks (usually
    transient)

65
EKG in Chest Pain and/or SOB
  • Ischemia
  • Pericarditis/Myocarditis
  • PE
  • Tamponade

66
EKG in Weak Dizzy
  • Electrolytes

67
I feel weak
68
Hyperkalemia
69
SLOW Vtach?
  • It aint tach, if it aint tachy
  • V-tach gt120bpm.
  • Severe hyperkalemia
  • Idioventricular/reperfusion dysrhythmias
  • Type IA medication toxicity
  •         TCA toxicity
  •         Cocaine toxicity

70
I feel weak
71
Hypocalcemia prolonged QT
72
EKG in Weak Dizzy
  • Electrolytes

73
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

74
Depressed, AMS
75
TCA overdose
Sodium channel blockade TCA, Cocaine, Benadryl,
anticholinergic, dilantin SALT shock, AMS, Long
QT Terminal slurring R in AVR
76
Sympathetomimetics/Cocaine
Typically more tachy than TCA OD b/c less
potassium efflux blockade
77
Depressed, took something.
78
Potassium efflux blockers Medication induced
long qt
79
Medication induced long qt
80
Depressed, AMS
81
B-blocker/Ca-Channel blocker
82
Digitalis
  • Acute AV block
  • Chronic Increased automaticity

83
EKG in Overdose
  • TCA
  • Sympathetomimetics/Cocaine
  • B-blocker/Ca-Channel blocker
  • Digitalis

84
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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