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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