Larkin: Extreme ECG Encounters

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Larkin pulls a few hairy ecg's out of the bag before offering the solace of a host of brilliant foamed ecg references.

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  • Australasian College for Emergency Medicine Examination Handbook Learning and Examination Processes v02 March 2012College of Intensive Care Medicine of Australia & New Zealand – Objectives of advanced training and competencies CICM 2010 Section 6.6
  • Average pass rate over last 20 exam sittings is ~65%
  • Average pass rate over last 20 exam sittings is ~65%
  • Average pass rate over last 20 exam sittings is ~65%
  • Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published EvidenceSalerno et al Ann Internal Medicine 2003Literature review – 41 articles 1976 - 2001
  • Khan et al. EMJ 2012Posterior myocardial infarction: are we failing to diagnose this?117 doctors – 33 interns 54 SHOs 30 Registrars10% Paramedics able to Dx PMIED & AAU Doctors 50:50Only half of the people knew you needed to perform posterior leads
  • Hoyle at al.Accuracy of electrocardiogram interpretation improves with EM trainingProspective cross sectional double blinded study EM traineesVictorian EM Trainees10 ECGsSenior 4th year / fellowship n=48 vs junior trainees n=74 n=122Accuracy of diagnosis of VT 43.8% senior trainee vs. 37.8% junior trainees
  • Gonzales Journal of Interventional Cardiology 2011 n=27Prehospital transmission of STEMI ECG using video phone high interphysician reliability compared with printed copyBilgi et al Telemedicine & e-Health 2012 n = 305MMS interpretation by cardiologist vs paper interpretation by cardiologist & EM physicianLess errors than EM dr with MMS and better consitency of interpretaiton with gold standardBoth studies used Nokia phones - Nokia E71 & Nokia N9 Screen resolution 240 x 320
  • Taken with Samsung Galaxy S3 – 1280 x 720 - Camera 8 MpiPhone 5 - 1136 x 640 – 8 Mp camera
  • 58 year old maleAtypical chest painNorthern WADistance ~2500 km
  • Lead reversal LL   LA
  • One case 2.5 hrs post symptoms
  • 28 yr old male with palpatationsAF with pre-excitation
  • 22 year old female ECG 133 from blog
  • Ischaemia proximal LAD post transmuralischaemia
  • QT ~ 560ms QTc ~600ms
  • 23F sibling died in sleep
  • 277 posts
  • Larkin: Extreme ECG Encounters

    1. 1. Extreme ECG Encounters Dr John Larkin Advanced Trainee Emergency Medicine Joondalup Health Campus Western Australia jhcedecg.blogspot.com
    2. 2. Image source: Wikipedia (http://en.wikipedia.org/wiki/Electrocardiography)
    3. 3. Own The Oxylog 3000! Own The Wound! Own The Oxygen! Own The Chest Tube! Own The ECMO! Own The Echo! Own The Airway! Own the ECG !
    4. 4. Why should we ‘Own the ECG’? • ECGs regularly performed in the ED • Influential test • Large amount of information • Patient Advocates
    5. 5. EM Tests • Indication • Perform the test • Interpret the test • Apply this interpretation to a patient
    6. 6. We’re pretty good at ECGs
    7. 7. 0 10 20 30 40 50 60 70 80 90 100 % Exam Sitting ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012
    8. 8. 0 10 20 30 40 50 60 70 80 90 100 % Exam Sitting ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012
    9. 9. 0 10 20 30 40 50 60 70 80 90 100 % Exam Sitting ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012
    10. 10. Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published Evidence • ECG Diagnosis correctly identified by non-cardiologist in 36- 96% • Inappropriate management up to 11% of cases • Even one cardiologist reading the same ECG on separate occasions may have substantially different interpretations Salerno et al AIM 2003
    11. 11. Posterior MI: Are we failing to diagnose this ? Khan et al EMJ 2012
    12. 12. Accuracy of ECG Interpretation Improves with EM Training Hoyle et al EMA 2007
    13. 13. Improving Competency • Review the ECG – Look at the whole ECG – Know what you are looking at • Interpretation of the ECG • Look at the patient with the ECG Cruz et al MJA 2012
    14. 14. Systematic Interpretation • Patient Identification • Calibration / Configuration • Rate • Rhythm • Axis • Intervals • Segments • Additional
    15. 15. Image source: Wikipedia (http://en.wikipedia.org/wiki/Electrocardiography)
    16. 16. Smartphone ECG Interpretation Can you just take a photo of the ECG and send it to me ? Gonzales et al J Interv Cardiol. 2011 Bilgi et al Telemed J E Health. 2012
    17. 17. AliveCor EKG Case • FDA Cleared December 2012 • Physician use only • Issued by prescription • Cost 200 USD • Uploads single lead rhythm to a cloud server
    18. 18. ECG Encounters
    19. 19. Spotting lead reversal • Abnormal axis • Look at p wave morphology in limb leads – Normal p waves • Positive in leads I, II • Negative in lead aVR • Look at T wave in relation to p wave & QRS complex • Flat lead I, II or III
    20. 20. Source: Dr Stephen Smith Dr Smith’s ECG Blog http://hqmeded-ecg.blogspot.com.au/
    21. 21. Source: Dr Stephen Smith Dr Smith’s ECG Blog http://hqmeded-ecg.blogspot.com.au/
    22. 22. De Winter’s Hyperacute T Waves • Acute LAD Occlusion • 30 Patients – (2% of Anterior MIs) • ECG Features – 1-3 mm ST depression V1-6 at J-point – Tall positive symmetrical T waves – ST Elevation aVR 1-2mm • Did not progress to ST elevation
    23. 23. Third Universal Definition of MI • New ST elevation at the J point in two contiguous leads • ≥0.1 mV in all leads other than leads V2–V3 where the following cut points apply: – ≥0.2 mV in men ≥40 years – ≥0.25 mV in men <40 years – ≥0.15 mV in women. Joint ESC/ACCF/AHA/WHF Task Force EHJ 2012
    24. 24. Source: Professor Martin Green, University of Ottawa Heart Institute, Ontario Canada Dr Arieh Keren
    25. 25. ‘Giant’ T Wave Inversion • Deep symmetrically inverted T waves >5mm • Raised ICP – Associated with QT prolongation – Rarely associated with STEMI-like changes • Apical hypertrophic cardiomyopathy – Yamaguchi syndrome • Myocarditis • Ischaemia • Post-tachycardia
    26. 26. Source: Dr Shakeeb Razak QT 320ms QTc <340ms
    27. 27. Source: Professor Martin Green, University of Ottawa Heart Institute, Ontario Canada Dr Arieh Keren
    28. 28. Some Other Extreme Encounters • Paediatric ECG • Wellen’s pattern • Loss of pre-cordial balance - NTTV1 • STEMI in LBBB - Sgarbossa & Modified Sgarbossa Rule • Brugada syndrome • Paced Rhythms
    29. 29. SMACC-ing the ECG
    30. 30. Web 2.0, FOAM & The ECG • Provided a safe haven for ECG Enthusiasts • Share and discuss interesting cases & ECGs • Asynchronous learning • Formation of networks & communities • Large number of ECG related on-line resources
    31. 31. • ECG Library – ECG Basics – A-Z by diagnosis – ECG Exigency cases
    32. 32. EKG Videos – Dr Amal Mattu • ekgumem.tumblr.com • Updated weekly • Case based video tutorials
    33. 33. Dr Smith’s ECG Blog • http://hqmeded-ecg.blogspot.com.au/ • Extensive collection of – ECG cases – Topic Reviews – Video lectures – Article links
    34. 34. ECG of the Week • jhcedecg.blogspot.com • Locally sourced ECGs • Updated weekly • Incorporated into EM education program
    35. 35. Acknowledgement & Thanks • Dr Cameron Burrows • Dr Arieh Keren • Dr Shakeeb Razak • Dr Colin Parker • Prof Martin Green • Dr Mike Cadogan • Dr Chris Nickson • Dr Ed Burns • Kane Guthrie • Dr Stephen Smith
    36. 36. References • Salerno SM, Alguire PC,Waxman HS Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published Evidence. Ann Intern Med. 6 May 2003;138(9):751-760 • Cruz MF, Edwards J, Dinh MM, Barnes EH. The effect of clinical history on accuracy of electrocardiograph Interpretation among doctors working in emergency departments. Med J Aust. 2012 Aug 6;197(3):161-5. • Hoyle RJ, Walker KJ, Thomson G, Bailey M. Accuracy of electrocardiogram interpretation improves with emergency medicine training. Emerg Med Australas. 2007 Feb;19(2):143-150. • Gonzalez MA, Satler LF, Rodrigo ME, Gaglia MA Jr, Ben-Dor I, Maluenda G, Hanna N, Suddath WO, Torguson R, Pichard AD, Waksman R. Cellular video-phone assisted transmission and interpretation of prehospital 12-lead electrocardiogram in acute st-segment elevation myocardial infarction. J Interv Cardiol. 2011 Apr;24(2):112-8. • Bilgi M, Gülalp B, Erol T, Güllü H, Karagün Ö, Altay H, Müderrisoğlu H. Interpretation of electrocardiogram images sent through the mobile phone multimedia messaging service. Telemed J E Health. 2012 Mar;18(2):126-31. • O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425. • Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial. Third universal definition of myocardial infarction. Eur Heart J. 2012 Oct;33(20):2551-67. • Pillarisetti J, Gupta K. Giant Inverted T waves in the emergency department: case report and review of differential diagnoses. J Electrocardiol. 2010 Jan-Feb;43(1):40-2. • de Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A New Sign of Proximal LAD Occlusion. N Engl J Med. 2008 Nov;359(19):2071-2073. • Maluli HA, Meshkov AB. A short story of the short QT syndrome. Cleve Clin J Med. 2013 Jan;80(1):41-7. • Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW. Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec;160(6):995-1003, 1003.e1-8.
    37. 37. Thank you

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