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Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
Indiana ENA 2013 Lead aVr
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Indiana ENA 2013 Lead aVr

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  • 1. EKG Lead aVr: What You DON’T Know May Kill Your Patient
  • 2. EKG Lead aVr: What You DON’T Know May Kill Your Patient Andrew J. Bowman Acute Care Nurse Practitioner Fellow American College CV Nurses Emergency Departments Witham Health Services Lebanon IU Health Arnett - Lafayette
  • 3. Disclosures  No financial disclosures
  • 4. EKG Club  Co-Founder  Facebook – 1500+ (1800+ as of today)
  • 5. History EKG  First recorded 1887 – Waller  Clinical tool - Einthoven
  • 6. Einthoven’s EKG
  • 7. Leads  Limb Leads  Augmented  Precordial Limb Leads Leads
  • 8. Limb Leads & Augmented Limb Leads
  • 9. Einthoven’s Triangle
  • 10. Normal Ventricular Axis
  • 11. Limb Leads I  II  III
  • 12. Augmented Limb Leads  aVr  aVl  aVf
  • 13. Precordial Leads  V1  V2  V3  V4  V5  V6
  • 14. Normal EKG
  • 15. “Map’ of EKG
  • 16. “Map’ of EKG
  • 17. “Map’ of EKG ?? ?
  • 18. “Map” of EKG
  • 19. Analogy
  • 20. Anterior
  • 21. Lateral
  • 22. Lead aVr (or How Many View It)
  • 23. Why EKG?  Cardiac  Problems Non-Cardiac Problems
  • 24. Cardiac Problems  Ischemia  Injury  Infarction  Arrhythmia  Cardiomyopathy
  • 25. Non-Cardiac Problems  Electrolyte Disorders  Toxidromes  Pulmonary Embolism
  • 26. Lead aVr  An augmented limb lead placed on right arm  Most commonly used to assure proper limb lead placement  Common belief rarely offers useful information “forgotten 12 th lead”
  • 27. “Forgotten 12 th Lead” 11
  • 28. Lead aVr  Actual several good reasons to carefully evaluate lead aVr
  • 29. Lead aVr  STEMI / STEMI Equivalent  SVT r/t WPW  VT vs. SVT in WCT  Pericarditis  Na+ Channel Blocker Toxicity
  • 30. STEMI  ST – segment Elevation Myocardial Infarction A need to recognize pattern indicating acute myocardial infarction and need for emergent reperfusion therapies (PCI preferred)
  • 31. STEMI Patterns to Know  Inferior  Lateral  Septal  Anterior  Posterior
  • 32. STEMI Patterns to Know
  • 33. STEMI Patterns to Know
  • 34. Inferior STEMI
  • 35. Lateral STEMI
  • 36. Anterior-Septal STEMI
  • 37. Inferior-Posterior STEMI
  • 38. How is aVr Helpful in STEMI?
  • 39. Case  64 year old man  Hx MI, HTN, DM  Left arm pain
  • 40. Case EKG
  • 41. What Do We See?
  • 42. Case Progression  ACS  Widespread – ST depression (STD) STE aVr & aVl & V1  ASA  NTG  Heparin
  • 43. Case Evolution  Admitted 8 to ICU Hours Later  Cardiogenic  Died Shock
  • 44. STE Lead aVr  In setting of ACS, STE Lead aVr – LMCA Stenosis Proximal LAD Stenosis Triple Vessel Disease – All BAD!!!! – –
  • 45. STE Lead aVr  STE aVr + aVl = LMCA Stenosis
  • 46. STE Lead aVr  STE aVr + aVl = LMCA Stenosis  STE aVr > STE V1 = LMCA Stenosis
  • 47. STE Lead aVr  STE aVr + aVl = LMCA Stenosis  STE aVr > STE V1 = LMCA Stenosis  Greater STE aVr, more likely LMCA Stenosis
  • 48. ACS with LMCA Stenosis  HIGH Mortality w/o PCI  Medical Tx Does NOT Help!!
  • 49. My Recent Case  47 yowm  Chest pain and heart racing 1 hr PTA  **Sweating**  Hx smokes, HTN  No Known CAD
  • 50. Initial EKG
  • 51. Initial Evaluation P - 178  R - 24  BP - 260/180  SpO2 – 95%  Pain – 2/10  Given ASA, IV Cardizem  Repeat EKG
  • 52. EKG 2
  • 53. Evolution  HR Better  Still CP 2/10  NTG with Better BP  EKG Repeated
  • 54. EKG 3
  • 55. Evolution 2  Concern for STEMI or Equivalent  Diffuse STD  STE aVr  STE V1  Concern for “BADNESS”
  • 56. Evolution 2  Interventionalist  Patient to Cath Lab  Returned  “Not Paged and to ER 15 Minutes Later STEMI” “LVH”
  • 57. Evolution 3  Initial Troponin 0.14 (0.10)  Admitted  AM Troponin 13.3!!  Cath Lab
  • 58. Cath Lab  Triple Vessel Disease
  • 59. Cath Lab  Triple Vessel Disease – “BADNESS”
  • 60. Why Delay?  Cardiologists are often behind the times  Large percentage of STEMI EKG literature is from EM  We have to “convince” cardiology
  • 61. Next Case  85 yowm  Chest Pain  EKG
  • 62. EKG
  • 63. What Do We See?  Widespread  STE aVr  STE aVl STD
  • 64. Evolution  Elevated Troponin  Dx NSTEMI  Admitted  Continued to Have Pain!
  • 65. Repeat EKG
  • 66. STE aVr + deWinter ST-T
  • 67. Lead aVr in STEMI  In setting of ACS, STE Lead aVr – LMCA Stenosis Proximal LAD Stenosis Triple Vessel Disease – All BAD!!!! – –
  • 68. How Else Is aVr helpful?
  • 69. SVT w WPW
  • 70. SVT with WPW  14 yowm  Dizziness  Healthy  Exam – Tachycardia  EKG
  • 71. EKG
  • 72. SVT
  • 73. SVT
  • 74. SVT  STE Lead aVr with NCT likely to be WPW  Confirm  STE delta waves on post conversion EKG & STD in SVT are not Dx ischemia
  • 75. How Else May We Use aVr?
  • 76. VT vs SVT in WCT
  • 77. Numerous Old Algorithms  Brugada Criteria  Wellens Criteria  Akhtar Criteria  Griffith Criteria
  • 78. Brugada Criteria 4 step process – No RS complex all precordial leads? – RS interval > 100ms in 1 precordial lead? – AV dissociation? – Morphology criteria for VT present in precordial leads V1-2 and V6?
  • 79. Wellens Criteria  QRS width > 0.14 secs  Left axis deviation > -30°  AV Dissociation  Certain QRS configurations – RBBB type QRS Monophasic R, qR, QR, RS in V1  R/S < 1, monophasic R, QR, QS in V6  – LBBB type QRS  qR or Qs in V6
  • 80. Akhtar Criteria  AV Dissociation  LBBB and rightward axis >90°  Positive QRS concordance  RBBB and QRS > 0.14 secs QRS axis between –90 ° and +180°  LBBB and QRS > 0.16 secs  QRS morphology during tachycardia different from baseline preexisting BBB 
  • 81. Griffith Criteria  SVT diagnosed only if QRS morphology is typical of a BBB – RBBB  rSR’ – in V1 and RS in V6 with R/S > 1 LBBB  rS or QS in V1 and V2 and delay to S nadir < 70 msecs  R wave and no Q wave in V6
  • 82. What Makes It Easy?
  • 83. Old EKG!
  • 84. New Algorithm  Uses a SINGLE EKG lead
  • 85. VT vs SVT Lead aVr (Verecki et al, January 2008, Heart Rhythm , 5/1)
  • 86. WCT + SVT
  • 87. WCT = VT
  • 88. WCT = VT
  • 89. Notched QS = VT
  • 90. What Else is aVr Helpful For?
  • 91. Pericarditis  Diffuse “global” STE or STD  PR segment depression inferior leads  PR segment elevation aVr
  • 92. Pericarditis
  • 93. Pericarditis
  • 94. Pericarditis
  • 95. Pericarditis
  • 96. Finally, What Else?
  • 97. Na+ Channel Blocker Toxicity        Amitriptyline Chlorimipramine Desipramine Doxepin Imipramine Nortriptyline Protriptyline        Elavil Clomipramine Norpramin Sinequan Tofranil Pamelor Vivactil
  • 98. TCA OD Effects  AMS  Hypotension  Tachycardia  Prolonged QRS, QTc  Seizures  Cardio-Respiratory Arrest
  • 99. Terminal R Wave
  • 100. TCA OD
  • 101. TCA OD
  • 102. TCA OD
  • 103. TCA OD
  • 104. Poorly Responsive Young Male
  • 105. After Tx
  • 106. TCA OD and What Else??
  • 107. TCA “SALT”  Shock  AMS  Long QRS & QTc  Terminal R in Lead aVr  “SALT” is also the cure NaHCO3
  • 108. Lead aVr  May – – – – – be VERY helpful in… STEMI SVT r/t WPW VT vs SVT in WCT Pericarditis TCA OD
  • 109. Handout  Thanks to Michelle Lin, MD  Academic Life in Emergency Medicine – – ALiEM academiclifeinem.com  Paucis Verbis cards
  • 110. Questions  andrewj.bowman@gmail.com  Facebook – “EKG Club” Add your “cool” EKG’s and stump us
  • 111. Web Sites  ekgumem.tumblr.com Dr. Mattu’s  ecg.bidmc.harvard.edu/maven EKG’s  hqmeded-ecg.blogspot.com  ecgguru.com  en.ecgpedia.org Lots of Dr. Smith Free Downloads Comprehensive Overview

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