Indiana ENA 2013 Lead aVr

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Indiana ENA 2013 Lead aVr

  1. 1. EKG Lead aVr: What You DON’T Know May Kill Your Patient
  2. 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. 3. Disclosures  No financial disclosures
  4. 4. EKG Club  Co-Founder  Facebook – 1500+ (1800+ as of today)
  5. 5. History EKG  First recorded 1887 – Waller  Clinical tool - Einthoven
  6. 6. Einthoven’s EKG
  7. 7. Leads  Limb Leads  Augmented  Precordial Limb Leads Leads
  8. 8. Limb Leads & Augmented Limb Leads
  9. 9. Einthoven’s Triangle
  10. 10. Normal Ventricular Axis
  11. 11. Limb Leads I  II  III
  12. 12. Augmented Limb Leads  aVr  aVl  aVf
  13. 13. Precordial Leads  V1  V2  V3  V4  V5  V6
  14. 14. Normal EKG
  15. 15. “Map’ of EKG
  16. 16. “Map’ of EKG
  17. 17. “Map’ of EKG ?? ?
  18. 18. “Map” of EKG
  19. 19. Analogy
  20. 20. Anterior
  21. 21. Lateral
  22. 22. Lead aVr (or How Many View It)
  23. 23. Why EKG?  Cardiac  Problems Non-Cardiac Problems
  24. 24. Cardiac Problems  Ischemia  Injury  Infarction  Arrhythmia  Cardiomyopathy
  25. 25. Non-Cardiac Problems  Electrolyte Disorders  Toxidromes  Pulmonary Embolism
  26. 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. 27. “Forgotten 12 th Lead” 11
  28. 28. Lead aVr  Actual several good reasons to carefully evaluate lead aVr
  29. 29. Lead aVr  STEMI / STEMI Equivalent  SVT r/t WPW  VT vs. SVT in WCT  Pericarditis  Na+ Channel Blocker Toxicity
  30. 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. 31. STEMI Patterns to Know  Inferior  Lateral  Septal  Anterior  Posterior
  32. 32. STEMI Patterns to Know
  33. 33. STEMI Patterns to Know
  34. 34. Inferior STEMI
  35. 35. Lateral STEMI
  36. 36. Anterior-Septal STEMI
  37. 37. Inferior-Posterior STEMI
  38. 38. How is aVr Helpful in STEMI?
  39. 39. Case  64 year old man  Hx MI, HTN, DM  Left arm pain
  40. 40. Case EKG
  41. 41. What Do We See?
  42. 42. Case Progression  ACS  Widespread – ST depression (STD) STE aVr & aVl & V1  ASA  NTG  Heparin
  43. 43. Case Evolution  Admitted 8 to ICU Hours Later  Cardiogenic  Died Shock
  44. 44. STE Lead aVr  In setting of ACS, STE Lead aVr – LMCA Stenosis Proximal LAD Stenosis Triple Vessel Disease – All BAD!!!! – –
  45. 45. STE Lead aVr  STE aVr + aVl = LMCA Stenosis
  46. 46. STE Lead aVr  STE aVr + aVl = LMCA Stenosis  STE aVr > STE V1 = LMCA Stenosis
  47. 47. STE Lead aVr  STE aVr + aVl = LMCA Stenosis  STE aVr > STE V1 = LMCA Stenosis  Greater STE aVr, more likely LMCA Stenosis
  48. 48. ACS with LMCA Stenosis  HIGH Mortality w/o PCI  Medical Tx Does NOT Help!!
  49. 49. My Recent Case  47 yowm  Chest pain and heart racing 1 hr PTA  **Sweating**  Hx smokes, HTN  No Known CAD
  50. 50. Initial EKG
  51. 51. Initial Evaluation P - 178  R - 24  BP - 260/180  SpO2 – 95%  Pain – 2/10  Given ASA, IV Cardizem  Repeat EKG
  52. 52. EKG 2
  53. 53. Evolution  HR Better  Still CP 2/10  NTG with Better BP  EKG Repeated
  54. 54. EKG 3
  55. 55. Evolution 2  Concern for STEMI or Equivalent  Diffuse STD  STE aVr  STE V1  Concern for “BADNESS”
  56. 56. Evolution 2  Interventionalist  Patient to Cath Lab  Returned  “Not Paged and to ER 15 Minutes Later STEMI” “LVH”
  57. 57. Evolution 3  Initial Troponin 0.14 (0.10)  Admitted  AM Troponin 13.3!!  Cath Lab
  58. 58. Cath Lab  Triple Vessel Disease
  59. 59. Cath Lab  Triple Vessel Disease – “BADNESS”
  60. 60. Why Delay?  Cardiologists are often behind the times  Large percentage of STEMI EKG literature is from EM  We have to “convince” cardiology
  61. 61. Next Case  85 yowm  Chest Pain  EKG
  62. 62. EKG
  63. 63. What Do We See?  Widespread  STE aVr  STE aVl STD
  64. 64. Evolution  Elevated Troponin  Dx NSTEMI  Admitted  Continued to Have Pain!
  65. 65. Repeat EKG
  66. 66. STE aVr + deWinter ST-T
  67. 67. Lead aVr in STEMI  In setting of ACS, STE Lead aVr – LMCA Stenosis Proximal LAD Stenosis Triple Vessel Disease – All BAD!!!! – –
  68. 68. How Else Is aVr helpful?
  69. 69. SVT w WPW
  70. 70. SVT with WPW  14 yowm  Dizziness  Healthy  Exam – Tachycardia  EKG
  71. 71. EKG
  72. 72. SVT
  73. 73. SVT
  74. 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. 75. How Else May We Use aVr?
  76. 76. VT vs SVT in WCT
  77. 77. Numerous Old Algorithms  Brugada Criteria  Wellens Criteria  Akhtar Criteria  Griffith Criteria
  78. 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. 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. 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. 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. 82. What Makes It Easy?
  83. 83. Old EKG!
  84. 84. New Algorithm  Uses a SINGLE EKG lead
  85. 85. VT vs SVT Lead aVr (Verecki et al, January 2008, Heart Rhythm , 5/1)
  86. 86. WCT + SVT
  87. 87. WCT = VT
  88. 88. WCT = VT
  89. 89. Notched QS = VT
  90. 90. What Else is aVr Helpful For?
  91. 91. Pericarditis  Diffuse “global” STE or STD  PR segment depression inferior leads  PR segment elevation aVr
  92. 92. Pericarditis
  93. 93. Pericarditis
  94. 94. Pericarditis
  95. 95. Pericarditis
  96. 96. Finally, What Else?
  97. 97. Na+ Channel Blocker Toxicity        Amitriptyline Chlorimipramine Desipramine Doxepin Imipramine Nortriptyline Protriptyline        Elavil Clomipramine Norpramin Sinequan Tofranil Pamelor Vivactil
  98. 98. TCA OD Effects  AMS  Hypotension  Tachycardia  Prolonged QRS, QTc  Seizures  Cardio-Respiratory Arrest
  99. 99. Terminal R Wave
  100. 100. TCA OD
  101. 101. TCA OD
  102. 102. TCA OD
  103. 103. TCA OD
  104. 104. Poorly Responsive Young Male
  105. 105. After Tx
  106. 106. TCA OD and What Else??
  107. 107. TCA “SALT”  Shock  AMS  Long QRS & QTc  Terminal R in Lead aVr  “SALT” is also the cure NaHCO3
  108. 108. Lead aVr  May – – – – – be VERY helpful in… STEMI SVT r/t WPW VT vs SVT in WCT Pericarditis TCA OD
  109. 109. Handout  Thanks to Michelle Lin, MD  Academic Life in Emergency Medicine – – ALiEM academiclifeinem.com  Paucis Verbis cards
  110. 110. Questions  andrewj.bowman@gmail.com  Facebook – “EKG Club” Add your “cool” EKG’s and stump us
  111. 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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