Post on 25-Jun-2020
transcript
ECG made easyPart 2 – ECG Quiz
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• Presented by:• Dr Randall Hendriks, Interventional Cardiologist – Western Australia
1. Left2. Right3. Indeterminate
? Axis
1. Left2. Right3. Indeterminate
? Axis
1. Left2. Right3. Indeterminate
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? Axis
1. Left2. Right3. Indeterminate
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? Axis
1. Left2. Right3. Indeterminate
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? Axis
1. Left2. Right3. Indeterminate
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? Axis
Standard limb lead reversal!
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial fibrillation2. Atrial flutter3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial flutter2. Atrial fibrillation3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Atrial flutter2. Atrial fibrillation3. SVT4. Sinus tachycardia5. Junctional
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Tachycardia
1. Sinus bradycardia2. First degree AV block3. Mobitz Type I
(Wenckebach)4. Mobitz Type 25. Complete heart block
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Bradycardia
1. Sinus bradycardia2. First degree AV block3. Mobitz Type I
(Wenckebach)4. Mobitz Type 25. Complete heart block
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Bradycardia
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Inferior2. Anterior3. Lateral4. Posterior5. IPL
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ST elevation MI
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – 30 year old Thai man with syncope
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – 30 year old Thai man with syncope
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – young adult patient with pleuritic chest pain
1. VT2. SVT with aberrancy
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Palpitations
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – young adult patient with pleuritic chest pain
1. Anterior MI2. Normal repolarisation3. LV aneurysm4. Pericarditis5. Brugada syndrome
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ST elevation – young adult patient with pleuritic chest pain
1. Absence of RS?2. No – next question
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Palpitations
1. R/S interval > 100msec?2. Yes - VT
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Palpitations
Can’t miss-life threatening ECGs
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Bradycardia and hypotensive in ED
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Bradycardia and hypotensive in ED
Complete heart block
Wolff-Parkinson-White syndrome
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Palpitations: 20 year old female with presyncope
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Palpitations: 20 year old female with presyncope
Pre-excited AF
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Hypokalaemia
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Broad complex tachycardia – diagnosis?
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Broad complex tachycardia – diagnosis?
Torsades de Pointes – QT prolongation
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Hypokalaemia
• Decreased extracellular K – hyperexcitability: re-entrant arrhythmias
• Increase amplitude and width of P wave• Prolonged PR interval• T flattening / inversion• ST depression• Prominent U waves• Apparent long QT (QTU fusion)• SVEs, VPBs• SVT (AF, atrial flutter, atrial tachy)• VT, VF and Torsades de Pointes
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Hyperkalaemia
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Hyperkalaemia
• Increased extracellular K – reduces myocardial excitability• Repolarisation changes:
Peaked T waves• Atrial paralysis:
P wave widens and flattensPR prolongationP wave disappears
• Conduction abnormality and bradycardia:QRS prolongs / bizarreHigh grade AV block, junctional and ventricular escape rhythmsSinus brady or slow AFSine wave (pre terminal)
• Cardiac arrest:AsystoleVFPEA with bizarre wide QRS
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Hyperkalaemia
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Digoxin toxicity – PAT with block and VPBs
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Bidirectional VT – digoxin toxicity
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Digoxin toxicity
• Increased automaticity / decreased AV conduction:SVT with slow ventricular response
• PVC’s, sinus brady, AF• Any type of AV block• Regularised AF (AF with CHB)• VT (polymorphic or bidirectional)
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Intracranial haemorrhage
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Intracranial haemorrhage
• Widespread giant T inversion• QT prolongation• Bradycardia (Cushing reflex – brain stem herniation)• ST elevation or depression• Increased U wave amplitude• ST, junctional, VPBs, AF• (? Hypothalamic stimulation / autonomic dysregulation)
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Massive pulmonary embolism
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Massive pulmonary embolism
• Sinus tachycardia• Complete or incomplete RBBB• RV strain
T inversion V1-4, II,III,aVF• Right axis deviation• Dominant R V1• P pulmonale• SI, QIII, TIII in 20% only• Clockwise rotation• Atrial arrhythmias• Non specific ST/T changes
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Pacemaker malfunction
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70 year old, chest pain and diaphoresis
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70 year old, chest pain and diaphoresis
Extensive anterior MI (‘tombstoning” pattern)
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Ischaemic sounding chest pain
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Ischaemic sounding chest pain
Wellens’ Syndrome – proximal LAD stenosis
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LMCA occlusion
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LMCA occlusion
• Widespread ST depression (leads I, II, V4 – 6)• ST elevation aVR ≥ 1mm• ST elevation aVR ≥ V1
• Can also see in:prox LAD occlusionsevere triple vessel diseasediffuse subendocardial ischaemia (ie. post resuscitation)
• aVR records electrical activity right upper portion of heart, including RVOT and basal IV septum
Anterior STEMI equivalentST depression and peaked T waves in precordial leadsSeen in ~ 2% acute LAD occlusionsYounger / male / hypercholesterolaemia
Code STEMI
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De Winter’s T wave
Middle aged female presents with dyspnoea, prior mastectomy for breast cancer.
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Middle aged female presents with dyspnoea, prior mastectomy for breast cancer.
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QRS alternans – pericardial effusion
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Ventricular flutter
Ventricular flutter
•Continuous monomorphic sine wave•No identifiable P, QRS or T wave•Rate >200•Extreme form of VT•Rapid degeneration into VF
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Bradyarrhythmias (any)Osborn waves (= J waves = positive deflection at J point)Prolonged PR, QRS and QTShivering artefactVPBsCardiac arrest due to VT, VF or asystole
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Hypothermia
BradycardiaLow QRS voltageWidespread T wave inversionQT prolongationFirst degree AV blockIVCDs
Myxoedematous deposits in myocardiumDecreased SNS activityLess thyroxine – decreased inotropy / chronotropy
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Hypothyroidism
The End
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