Critical Care ECG's

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Critical Care ECG's

  1. 1. CRITICAL CARE ECG’SCRITICAL CARE ECG’S Preeta JohnPreeta John
  2. 2.  In the diagram normal range - 30 to +90.In the diagram normal range - 30 to +90.  Left axis deviation superior and leftwardLeft axis deviation superior and leftward -30 to -90-30 to -90  Right axis deviation inferior and rightwardRight axis deviation inferior and rightward +90 to +150+90 to +150
  3. 3.  PR IntervalPR Interval  beginning of P to beginning of QRSbeginning of P to beginning of QRS  Normal: 0.12 - 0.20sNormal: 0.12 - 0.20s  Short PR: < 0.12sShort PR: < 0.12s  QRS DurationQRS Duration  duration of QRS complexduration of QRS complex  Normal: 0.06 - 0.12sNormal: 0.06 - 0.12s
  4. 4.  QT IntervalQT Interval  beginning of QRS to end of T wavebeginning of QRS to end of T wave  Normal: heart rate dependent (correctedNormal: heart rate dependent (corrected QTQT == QTQTcc = measured QT % sq-root RR= measured QT % sq-root RR in seconds; upper limit for QTin seconds; upper limit for QTcc = 0.44 sec)= 0.44 sec)
  5. 5. How to read an ECGHow to read an ECG  StandardisationStandardisation  RateRate  RhythmRhythm  AxisAxis  Chamber enlargement & hypertrophyChamber enlargement & hypertrophy  Arrythmias & conduction delaysArrythmias & conduction delays  Ischaemia / infarctionIschaemia / infarction
  6. 6. Case scenario 1Case scenario 1  26 year old man26 year old man  Run over by a truckRun over by a truck  Managed in local hospitalManaged in local hospital  Brought to casualty 24 hours laterBrought to casualty 24 hours later  head injuries and extensive crush injury tohead injuries and extensive crush injury to lower limbslower limbs  GCS 10/15GCS 10/15  BP: 90/60BP: 90/60 HR:46/minHR:46/min
  7. 7.  Admitted in ICU and stabilisedAdmitted in ICU and stabilised
  8. 8. ECGECG
  9. 9.  S.creat: 4.5 mg%S.creat: 4.5 mg%  S. K: 7.1 mEq/lS. K: 7.1 mEq/l  CPK: 36,000CPK: 36,000
  10. 10. CourseCourse  Pharmacological measures to decreasePharmacological measures to decrease pottassiumpottassium  DialysisDialysis  SurgerySurgery  Patient did well and was discharged 2Patient did well and was discharged 2 weeks laterweeks later
  11. 11. ECGECG
  12. 12. Take home messageTake home message  Consider potassium derangements in anyConsider potassium derangements in any arrythmia in the ICUarrythmia in the ICU  Focus on treating the underlyingFocus on treating the underlying dyselectrolytemia promptlydyselectrolytemia promptly
  13. 13. Case scenario 2Case scenario 2  20 year old primigravida from Chittoor20 year old primigravida from Chittoor  Fever, jaundice and altered sensorium forFever, jaundice and altered sensorium for 5 days5 days  GCS: 12/15GCS: 12/15  Blood smear positive for plasmodiumBlood smear positive for plasmodium falciparumfalciparum  Parasitic index 10%Parasitic index 10%
  14. 14.  Started on Quinine infusionStarted on Quinine infusion  On day 2, Sudden hypotensionOn day 2, Sudden hypotension  BP:80 sysBP:80 sys HR: 200/minHR: 200/min
  15. 15. ECGECG
  16. 16.  Polymorphous ventricular tachycardia -Torsade dePolymorphous ventricular tachycardia -Torsade de pointes.pointes.  wide QRS complexes with multiple morphologieswide QRS complexes with multiple morphologies  changing R - R intervalschanging R - R intervals  the axis twists about the isoelectric linethe axis twists about the isoelectric line  recognise this pattern - number of reversible causesrecognise this pattern - number of reversible causes  heart blockheart block  hypokalaemia or hypomagnesaemiahypokalaemia or hypomagnesaemia  drugs e.g. tricyclic antidepressant overdosedrugs e.g. tricyclic antidepressant overdose  congenital long QT syndromescongenital long QT syndromes  other causes of long QT (e.g. IHDother causes of long QT (e.g. IHD
  17. 17.  DC cardioversionDC cardioversion  CausesCauses  Treatment – hemodynamically stable andTreatment – hemodynamically stable and unstableunstable  Monitor QT interval while on quinine!Monitor QT interval while on quinine!
  18. 18.  The QT interval duration is greater thanThe QT interval duration is greater than 50% of the RR interval, a good indication50% of the RR interval, a good indication that it is prolonged in this patient. Althoughthat it is prolonged in this patient. Although there are many causes for the long QT,there are many causes for the long QT, patients with this are at risk for malignantpatients with this are at risk for malignant ventricular arrhythmias, syncope, andventricular arrhythmias, syncope, and sudden death.sudden death.
  19. 19. QTQT  Normal upto 0.45Normal upto 0.45  Stop quinine ifStop quinine if ≥≥ 0.600.60
  20. 20.  Quinine discontinued, changed toQuinine discontinued, changed to artemetherartemether  QT interval normalisedQT interval normalised  Delivered fresh stillbornDelivered fresh stillborn  Gradual recoveryGradual recovery
  21. 21. Take home messageTake home message  Monitor QT interval while on quinine!Monitor QT interval while on quinine!  Consider iatrogenic causes of arrythmiasConsider iatrogenic causes of arrythmias - drugs- drugs - inotropes- inotropes - central lines- central lines
  22. 22. Case scenario 3Case scenario 3  72 year old man72 year old man  Diabetic with urosepsisDiabetic with urosepsis  Emphysematous pyelonephritis-postEmphysematous pyelonephritis-post nephrectomynephrectomy  Being ventilated in ICUBeing ventilated in ICU  On inotropic support-noradrenalineOn inotropic support-noradrenaline 5ug/min: BP- 110/60mm Hg5ug/min: BP- 110/60mm Hg
  23. 23.  On day 3, sudden hypotensionOn day 3, sudden hypotension  Cold clammy extremitiesCold clammy extremities  BP: 60 sysBP: 60 sys HR: 140/minHR: 140/min  CVP:25cmsCVP:25cms  Chest: bilateral cracklesChest: bilateral crackles  CVS: muffledCVS: muffled
  24. 24. ECGECG
  25. 25.  Serial ECGs and Cardiac enzymesSerial ECGs and Cardiac enzymes  Thrombolysis/ UFheparin/ LMWHThrombolysis/ UFheparin/ LMWH  DifferentialsDifferentials
  26. 26.  Trop I :12Trop I :12  Thrombolysis contraindicatedThrombolysis contraindicated  Progressive hypotension on increasingProgressive hypotension on increasing inotropesinotropes  ExpiredExpired
  27. 27. Take home messageTake home message  Consider myocardial ischemia in everyConsider myocardial ischemia in every case of sudden hypotensioncase of sudden hypotension
  28. 28. Case scenario 4Case scenario 4  55yr old man55yr old man  Sudden onset progressive BOE for 2Sudden onset progressive BOE for 2 days.days.  Sudden worsening of breathlessnessSudden worsening of breathlessness todaytoday  No chest pain, fever, coughNo chest pain, fever, cough  No DM, HTN, SmokeNo DM, HTN, Smoke
  29. 29. ExaminationExamination  ObeseObese  No pallor, edemaNo pallor, edema  BP: 110/70mmHg HR:110/minBP: 110/70mmHg HR:110/min  JVP: elevated 3cmsJVP: elevated 3cms  Resp : clearResp : clear  CVS: S3, sharp S2CVS: S3, sharp S2  Abd: NADAbd: NAD
  30. 30.  Sudden hypoxia andSudden hypoxia and hypotensionhypotension  BP: not recordableBP: not recordable
  31. 31.  Admitted to MICUAdmitted to MICU  Thrombolysed with STKThrombolysed with STK  Improvement over 24 hoursImprovement over 24 hours
  32. 32. Case scenario-5Case scenario-5  A 30 year old lady diagnosed to haveA 30 year old lady diagnosed to have ruptured empyema gall bladder withruptured empyema gall bladder with peritonitis underwent cholecystectomy. Onperitonitis underwent cholecystectomy. On the first post operative day –high gradethe first post operative day –high grade fever followed by hypotension started onfever followed by hypotension started on ionotropes . A day later blood culture –ionotropes . A day later blood culture – heavy growth of pseudomonasheavy growth of pseudomonas 
  33. 33.  O/E:O/E:  BP: 90/40mmHg. HR- 160/minuteBP: 90/40mmHg. HR- 160/minute  Interpret her ECGInterpret her ECG
  34. 34. Takotsubo cardiomyopathyTakotsubo cardiomyopathy
  35. 35. Takotsubo cardiomyopathyTakotsubo cardiomyopathy  ICU cardiomyopathyICU cardiomyopathy  Seen in critically ill patientsSeen in critically ill patients  Mimics myocardial ischemiaMimics myocardial ischemia  No specific treatmentNo specific treatment  Reverts as patient improvesReverts as patient improves  No residual complicationsNo residual complications
  36. 36. Case scenario-6Case scenario-6  50 year old man known alcoholic50 year old man known alcoholic presented with a history of acute abdomenpresented with a history of acute abdomen  He was diagnosed to have pancreatitisHe was diagnosed to have pancreatitis  He had a similar episode 6 months agoHe had a similar episode 6 months ago and a syncopial attack was admitted in theand a syncopial attack was admitted in the ICU and discharged a week laterICU and discharged a week later
  37. 37. DiagnosisDiagnosis
  38. 38. Brugada syndromeBrugada syndrome  Congenital channelopathyCongenital channelopathy  Seen in asiansSeen in asians  Prone for sudden onset of ventricularProne for sudden onset of ventricular tachycardia/cardiac arresttachycardia/cardiac arrest  ICD only treatmentICD only treatment  Precipitated by alcohol, prothiadinePrecipitated by alcohol, prothiadine
  39. 39. Case scenario-7Case scenario-7  25 year old man with a history of corrosive25 year old man with a history of corrosive acid poisoning presented a day later withacid poisoning presented a day later with a history of chest pain and fevera history of chest pain and fever  O/E: He was febrile BP100/60 PRO/E: He was febrile BP100/60 PR 140/minute140/minute
  40. 40. Case scenario-8Case scenario-8  60 year old man with CA stomach60 year old man with CA stomach underwent a total gastrectomy. Threeunderwent a total gastrectomy. Three days later became breathless, was febriledays later became breathless, was febrile and had multiple ventricular ectopicsand had multiple ventricular ectopics assosiated with hemodynamic instability.assosiated with hemodynamic instability.  Subsequently he was intubated.Subsequently he was intubated.  Common causes ruled out .He was startedCommon causes ruled out .He was started on an amiodarone infusion and heon an amiodarone infusion and he settledsettled  24 hours later24 hours later
  41. 41. Take home messageTake home message  All anti arrythmics are proarrythmics tooAll anti arrythmics are proarrythmics too  All patients on amiodarone infusion onceAll patients on amiodarone infusion once stabilised slowly overlap with oral route &stabilised slowly overlap with oral route & taper infusiontaper infusion  Amiodarone half life -prolongedAmiodarone half life -prolonged
  42. 42. Interesting ECGsInteresting ECGs
  43. 43. Thank youThank you

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