Dangerous ECG Findings: And what to do about them!

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Dangerous ECG FindingsAnd what to do about them!

• Scott Morsberger, PA-C, MPAS

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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

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Initial ECG
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QT Prolongation

• QTc QT/sq root R-R
• Predisposes to PMVT (TdP)
• Normal QTc Males lt 0.44 s
• Normal QTc Females lt0.46 s
• Greatest risk when QTc gt0.50 s
• Genetic vs. Acquired

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Genetic LQTS

• 7 Gene Mutations
• LQTS 1 7
• Romano Ward
• Lange-Nielson

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Acquired LQTS

• Elytes
• Hypothyroid
• Coronary ischemia/infarct
• CNS disease
• Hypothermia
• Drugs arizonacert.org
• Macrolides, FQs, Haloperidol, TCAs, Methadone,
  Sotalol, etc.

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Treatment

• Non-synchronized Cardioversion (Extremis)
• IV MagSO4
• Pace/Isoproterenol
• Replace Elytes
• STOP OFFENDING DRUGS!!!!
• /- BB, AICD, PPM

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ECG after K Corrected
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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.

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WCT
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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.

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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.

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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, HR72, RR14

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Scenario 2
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Scenario 2

• Labs BUN/CR 78/2.6 (previously 24/1.2).
• CT Chest PE Protocol 2 wks ago. Neg for
  PE/dissection.
• K6.6
• Whats your next step?

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Hyperkalemia

• Symptoms muscle weakness, paralysis.
• Etiology ARF, CKD, DKA, Lactic Acidosis,
  hypoaldosteronism, ureterojejunostomy, rhabdo,
  crush injury, TLS.
• Drugs ACEI, ARB, Aldosterone blockers, Nsaids.

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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 gt7 but
  frequently occur when lt7 if acute.

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Hyperkalemic ECG Changes

• Earliest Peaked Ts with short QT.
• Progressive lengthening of PR/QRS intervals.
• P waves disappear/QRS widens to a sine wave
  ultimately.
• Ventricular standstill.

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Hyperkalemic ECG Changes

• ECG correlates poorly with K level.
• Can be used as a clue but not to diagnose
  hyperkalemia.
• Other entities cause peaked Ts (acute MI, early
  repol, LVH.

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Treatment of Hyperkalemia

• Stabilize Calcium
• Shift- Insulin, D50, Albuterol, Sodium Bicarb.
• Remove Loop/Thiazide diuretics, Kayexalate, HD.
• Prevent

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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.

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Initial ECG
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Scenario 3

• Adenosine 6mg IV. No effect.
• ED SVT continues.
• Vitals stable except for heart rate.
• Patient moderately symptomatic.

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SVT ECG2
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SVT Algorithm

• Assess patient stability.
• Is it Sinus Rhythm?
• If SR, treat the underlying disorder.
• If not SR, and unstable CV.

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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.

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Tachycardia Algorithm
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SVT ECG2
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SVT ECG3 Old for Comparison
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SVT Rhythm Strip
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Scenario 3

• TSH WNL.
• Mg2 2.0
• K 4.2
• Steroids for bronchitis.
• AVNRT.
• Long acting Diltiazem as bridge to ablation.

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Wide Complex Tachycardia
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Wide Complex Tachycardia
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Wide Complex
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?Wide Complex Tachycardia