EKG Case Presentations Lindsay Saleski, DO

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EKG Case Presentations

Lindsay Saleski DO, MBA Family Medicine/Emergency Medicine

Midlands Emergency Physicians Tuomey Hospital

Case #1

• 65 yo female presents to the ED with shortness of breath, palpitations and generalized weakness for the last 3 weeks. Denies associated chest pain.

• Pmhx: CAD

• VS: 110/75, HR 180, Pulseox 98%

• The patients EKG is as follows:

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Question #1

• What should you do at this time?

a. Synchronized cardioversion

b. Treat the patient with IV cardiazem

c. Treat the patient with IV procainamide

d. Massage his carotid arteries

e. Treat the patient with IV Adenosine

Atrial Fibrillation

• Several characteristic electrocardiogram (ECG) changes define AF: – Presence of low-amplitude fibrillatory waves on ECG without

defined P-waves – “Irregularly irregular” ventricular rhythm – Fibrillatory waves typically have a rate of > 300 beats per minute – Ventricular rate is typically between 100 and 160 beats per

minute

• Treatment – Unstable – cardioversion vs. fluids/rate control – Stable – Assess for anticoagulation, rate control

• B-blockers • Calcium channel blockers

Question #2

• Patients with chronic atrial fibrillation are at increased risk for which of the following conditions?

a. Acute MI

b. Ventricular tachycardia

c. Sudden cardiac death

d. Cerebrovascular accident

e. Ventricular fibrillation

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AFIB Anticoagulation

• Every patient with AF should be evaluated for the need of antithrombotic therapy to prevent systemic embolization

• Ischemic CVA is most frequent clinical manifestation

• CHADS2 score - the recommended strategy for stroke risk assessment

• If risk of embolization exceeds the risk of bleeding, patient is candidate for long-term antithrombotic therapy

Case #2

• 68 yo female presents to the ED with intermittent palpitations, lightheadedness and shortness of breath. Symptoms worsened at church this morning. Patient did not feel well, walked to the bathroom and syncopized.

• Pmhx: DM, HTN, CAD with stent placement • VS: HR 200, BP 135/100, RR 20, Pox 100%, T 98.6 • Current: Patient is awake, alert and providing

history. • The patients EKG is as follows:

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Question #1

• What is the antiarrhythmic of choice in management of Ventricular tachycardia?

a. Adenosine 6mg IV push

b. B-blockers for rate control

c. Digoxin load the patient

d. Amiodarone 150mg IV

e. Calcium channel blockers for rate control

Tachycardia Algorithm.

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

Question #2 • Just prior to floor transfer to the patient arrests.

The rhythm strip reveals (see below). CPR is initiated. What is the next logical step in treatment?

a. Administer epinephrine 1mg IV

b. Administer calcium chloride

c. Administer sodium bicarbonate

d. Defibrillate the patient

e. Continue CPR – do not administer medications

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ACLS Cardiac Arrest Algorithm.

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

Monomorphic Ventricular Tachycardia

• Widened QRS (>120msec) • electric signal is slow because originates outside of the

normal conduction system

– Regular Rhythm – Rate 150-200 bpm • ALL wide complex ventricular rhythms treated as Vtach

until proven otherwise • Stable – no evidence of hemodynamic compromise

despite a sustained rapid heart rate • Unstable – evidence of hemodynamic compromise, but

who remains awake with a pulse

VT Treatment

• Stable with pulse – Amiodarone 150mg IV over 10 minutes, repeat as needed to max dose

of 2.2g/24 hours – Prepare for elective synchronized cardioversion

• Unstable with pulse – Immediate synchronized cardioversion – IV access and sedation, but don’t delay tx

• Pulseless arrest – IV, O2, monitor, CPR – Biphasic 200J/Monophasic 360J/AED devise specific – CPR 5 cycles – Check pulse and rhythm – Epinephrine 1mg IV/IO whenever initially available and redose every 3-

5 minutes

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Case # 3

• 55 yo male presents to the ED became suddenly unresponsive at home. Wife is a nurse and CPR was started immediately. On ED arrival the cardiac monitor has the following rhythm:

Question # 1

What is the first line therapy?

a. Magnesium 2 gram IV bolus

b. Cardioversion

c. Lidocaine 1mg/kg IV

d. IV fluids 1000ml bolus

e. Epinephrine 1 mg IVP

Torsades de Pointes

• “Twisting of the points”

• Clinical Criteria – Ventricular rate >200bpm

– QRS structure with undulating axis, polarity of complexes appearing to shift about the baseline

• Causes: – Acquired

• Medications, electrolyte disturbances (↓K, Ca & Mag), MI, CVA

– Congenital

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Torsades Treatment

• Stable Patient

– IV Magnesium

– IV Isoproterenol

– Overdrive pacing to ventricular rate of 100-120bpm

• Unstable

– Unsynchronized cardioversion

Case # 4

• 41 yo female presents to the FP office as a new patient with acute onset substernal, non-radiating chest pain that started while she was out working in the yard 15 minutes prior to arrival. She states the pain is currently 10/10. She has associated SOB and nausea. No pmhx but has not seen a PCP in 5 years.

• VS: 160/100, HR: 92, RR: 22, Pox: 98%, T98.9

• The patients EKG is as follows

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STEMI Question

• Which of the following time dependent interventions will most likely benefit this patient?

a. CK-MB level b. Stress test c. Angioplasty d. Metoprolol IV e. Atorvastatin PO

STEMI

• EKG evolves through a typical sequence – hyperacute or peaked T wave – elevation of the J point and the ST segment retains its concavity – ST segment elevation becomes more pronounced and convex – ST segment may be indistinguishable from the T wave

• The joint ESC/ACCF/AHA/WHF committee: definition of MI established specific ECG criteria for the diagnosis of STEMI: – 2 mm of ST segment elevation the precordial leads for men and 1.5 mm for women – greater than 1 mm in other leads – Q wave or abnormal R wave develops over a period of hours to days

• Hours to weeks later: – the ST segment returns to the isoelectric baseline – R wave amplitude becomes markedly reduced – Q wave deepens – T wave becomes inverted

• ACS also = STEMI if: – new left bundle branch block – posterior MI

STEMI

• Continuous cardiac monitoring, IV access, O2

• Reperfusion – Percutaneous coronary Intervention (PCI)

• 90 minutes or less for patients transported to PCI-capable hospital

– Fibrinolytic agents • If within 12 hours of onset and not PCI available

• Aspirin

• Nitrates

• β-Blockers

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Case # 5

• 51 yo female presents with palpitations, nausea, and chest pain. The CP is substernal and non-radiating. She states she was having a nightmare and woke up with palpitations. She has had multiple prior episodes. Has not seen cardio or her PCP for this.

• PMhx: CAD, CHF, HTN, drug abuse

• BP: 200/148, HR: 177, RR: 36, T: 98.9, Pox: 96% on RA

• The patients EKG is as follows:

Question #1

• In this patient ACLS Protocol states that you should immediately:

a. Administer Amiodarone 150mg IV

b. Administer Adenosine 6mg IV

c. Initiate CPR

d. Cardiovert the patient

e. Administer Sotolol 100mg IV

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Tachycardia Algorithm.

Neumar R et al. Circulation 2010;122:S729-S767

Copyright © American Heart Association, Inc. All rights reserved.

SVT

• Narrow complex tachycardia – QRS complex duration < 0.12 sec

– Ventricular rate >100bpm

• Tx: SVT that is not associated with severe symptoms or hemodynamic collapse – Vagal maneuvers

– IV adenosine

– IV non-dihydropyridine calcium channel blocker or an IV beta blocker

Case # 6

• 66 yo female with pmhx DMII presents to the PCP office for CC of intermittent dizzy spells and two episodes of near syncope over the last week. An EKG is done and she is found to have a heart block. She is sent to the ED for further evaluation. She denies any other complaints at time of ED evaluation.

• VS: 146/78, 40, 20, 98.6, 100% on RA

• The patients EKG is as follows:

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Question # 1

• What are indications for pacemaker placement in this patient?

a. Ventricular pauses > 3 seconds

b. Dizziness and near-syncope

c. Patients age >65

d. Comorbidities including HTN and diabetes

e. First degree heart block

Third Degree Heart Block

• Absent conduction of all atrial impulses resulting in complete electromechanical AV dissociation

• P waves and QRS complexes are present but unrelated and occur at different rates

• Treatment: – Pacemaker for those with associated symptoms,

ventricular pauses ≥3 seconds, or a resting heart rate <40 beats/min while awake

– Atropine reverses decrease in AV nodal conduction from vagal tone

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References

• Atrial Fibrillation Management Strategies in the Emergency Department. Emergency Medicine Practice. February 2013. Volume 15, No 2.

• Antithrombotic Therapy in Atrial Fibrillation to Prevent Embolization. UTD. Accessed 6/2/2014.

• Polymorphic Ventricular Tachycardia and Torsades de Pointes. Rosen’s Emergency Medicine. Sixth Edition, Volume 2. pp1243-1244

• Aquired Long QT Syndrome. UTD. Accessed 7/24/2014 • Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW,

Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729 –S767.