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Ecg Essentials

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    • 1. ECG Essentials Steven J. Sager, MPAS, PA-C PAC5229 - Electrocardiography
    • 2. Learning Objectives
      • Upon satisfactory completion of the course, and in conjunction with textbooks, lecture handouts, and any recommended internet Web Sites, the student will be able to:
        • Recognize the components of the following lists:
          • List #1 – Causes of regular, narrow-complex tachycardia
          • List #2 – Causes of regular, wide-complex tachycardia
          • List #3 – Common causes of prolonged QT interval
          • List #4 – Common causes of ST segment depression
          • List #5 – Common causes of a tall R wave in lead V 1
          • List #6 – Causes of anterior ST segment depression in the setting of acute inferior infarct
    • 3. Learning Objectives
        • Discuss the pathophysiology of dysrhythmias
        • List the factors which determine if a patient is hemodynamically stable
        • List the advantages of 12-lead vs. single lead ECGs
        • Explain the importance of ECG comparisons
        • Describe the benefits and limitations of ECG interpretation by computer analysis
        • Recognize common dysrhythmias
    • 4. Six Essential Lists
      • List #1 – Causes of regular, narrow-complex tachycardia
      • List #2 – Causes of regular, wide-complex tachycardia
      • List #3 – Common causes of prolonged QT interval
      • List #4 – Common causes of ST segment depression
      • List #5 – Common causes of a tall R wave in lead V 1
      • List #6 – Causes of anterior ST segment depression in the setting of acute inferior infarct
    • 5. Evaluating regular, narrow-complex tachycardia
      • P = P waves?
      • Q = Q RS wide or narrow?
      • R = R egular rhythm?
      • S = P waves & QRS complexes “ S ingle”?
    • 6. Hemodynamically stable?
      • Symptomatic?
        • Chest pain
        • Dyspnea/SOB
        • Altered mental status
        • Hypotension
        • Shock
        • Heart failure
        • Pulmonary edema
        • AMI
    • 7. Causes of regular, narrow-complex tachycardia
    • 8.  
    • 9.  
    • 10.  
    • 11. Treatment of regular, narrow-complex tachycardia
      • Vagal Maneuver
        • May transiently slow the ventricular response
        • Will either convert PSVT to sinus rhythm or have no affect at all
        • Types:
          • Carotid sinus massage
          • Valsalva
          • Facial submersion in ice
          • Gagging
          • Ocular pressure
          • Digital rectal massage
          • Squatting and bearing down
      • Adenosine
        • “ chemical Valsalva”
        • almost immediate slowing of ventricular response
    • 12. Causes of regular, wide-complex tachycardia (WCT)
    • 13. Treatment of regular, WCT
      • Hemodynamically unstable
        • Cardiovert (synchronized)
      • Hemodynamically stable
        • Determine etiology
        • Review prior tracings
        • If in doubt, treat for VT
          • Procainamide
    • 14. QT prolongation
      • Prolongation of the QT interval on the ECG is the major marker for Long QT Syndrome
      • Long QT syndrome is one of the causes of sudden death in adolescents and young adults
        • “ sudden death” = unexpected death that occurs in a someone who is apparently healthy
        • Long QT Syndrome is thought to be the cause when sudden death occurs from ventricular fibrillation
    • 15. QT prolongation
      • It most frequently occurs during sporting events and is usually attributed to a sudden, unpredictable disturbance in the rhythm of the heart.
        • the symptoms can occur during less strenuous activities and even on awakening from sleep
        • may become apparent when a young person with fainting or secondary seizures has an ECG as part of their evaluation
        • it is especially important to look for the syndrome when the fainting or seizures are excercise-related
    • 16. Causes of QT prolongation
      • Ischemia
      • Infarction
      • Drugs
        • Type IA and type III antiarrhythmic agents
        • TCAs
        • Phenothiazines
    • 17. Causes of QT prolongation
      • Electrolyte deficiencies
        • hypokalemia
        • hypomagnesia
        • hypocalcemia
      • Catastrophic CNS event
        • CVA
        • intracerebral hemorrhage
        • seizures
    • 18.  
    • 19. Common causes of ST segment depression
      • Ischemia - symmetric
      • “ Strain” - asymmetric
      • Digitalis effect – scooped or strain pattern
      • Hypokalemia
      • Hypomagnesia
    • 20. ST-segment depression
    • 21.  
    • 22. Common causes of a tall R wave in lead V 1
      • Wolff-Parkinson-White (WPW) syndrome
      • Right bundle branch block (RBBB)
      • Right ventricular hypertrophy (RVH)
      • Acute infero-postero-lateral infarction
      • Hypertrophic cardiomyopathy
      • Muscular dystrophy
      • Dextrocardia
      • Normal variant
    • 23. Differentiate the causes of a tall R wave in lead V 1 Causes QRS ECG ∆’s W-P-W Widened Delta waves Short PR interval RBBB Widened rSR ´ in V 1 Wide terminal S wave in I and V 6 RVH Normal RAD R ventricular strain Infarct Normal Changes in inferior leads Positive “mirror test”
    • 24. 60 y.o. ♂ with history of heart disease. 72 y.o. ♀ with history of palpitations. 28 y.o. ♂ with no medical problems or heart disease. 66 y.o. ♂ 2ppd smoker with history of COPD. 48 y.o. ♂ with new onset chest pain.
    • 25. Causes of anterior ST segment depression in the setting of acute inferior infarct
      • Reciprocal changes
      • Concomitant anterior ischemia
      • Posterior infarction
        • Mirror test
      • Combination of above
      • ∆ ’ s (ST depression) c ommon in:
        • V 1 , V 2 , and V 3
    • 26. Why 12-lead vs. 1-lead?
      • 12-lead provides more information
        • improves arrhythmia interpretation
      • CXR?
      • ABG?
    • 27. 60 y.o. ♀ c/o rapid heart beat. Denies CP. No meds. B/P = 140/90mmHg
      • Rate?
      • P?
      • Q?
      • R?
      • S?
    • 28. 50 y.o. ♂ with CAD c/o rapid heart beat. Denies CP. B/P = 160/100mmHg
      • Rate?
      • P?
      • Q?
      • R?
      • S?
    • 29. 60 y.o. ♂ with COPD c/o wheezing & mild dyspnea. Hx of rapid heart beats. B/P = 130/80mmHg.
    • 30. 60y.o. ♂ c/o “palpitations”
    • 31. Comparing Tracings
      • Find as many as possible
      • Evaluate previous tracings
        • valid regardless of age and interval
      • Evaluate new tracing
      • Compare the two most recent tracings
        • systematically move from one lead to the next
        • start at I and proceed through V 6
      • Comment on ANY and ALL differences !
    • 32. Important Comparison Points to Consider
      • Review all available tracings
        • request old charts
        • look for “patterns”
      • Lead placement variables
        • may alter axis, wave amplitude/morphology, etc.
      • Request serial ECGs when appropriate
        • angina
        • evolving MI
        • interval?
    • 33. Benefits of Computer Analyses
      • Save time
      • Accurate calculations of:
        • heart rate
        • intervals
        • axis
      • Provide legible interpretations
      • May suggest additional findings
        • write your interpretation first, then compare
      • Educational
        • improve provider accuracy
    • 34. Are Computer Analyses Accurate?
      • Sometimes
        • only as good as their programming!
        • reliably recognize sinus/normal tracings
      • Most accurate in computing values
      • Routinely miss subtle infarctions
      • Tend to overinterpret
      • Should be used to enhance the provider’s interpretation
        • provide a good “ second opinion”
    • 35. Reviewing a Computer Analysis √ √ Agree as corrected. S. J. Sager, PA-C Intervals/durations in milliseconds Date & time are CRITICAL! Includes patient identification
    • 36. Thought for the day!
      • Our background and circumstances may have influenced who we are ,
      • but only we are responsible for who we become !
    • 37.  
    • 38. Mirror test