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Case-Based ECG
The document outlines the 10 step approach to interpreting electrocardiograms (ECGs) and presents two case studies from remote Aboriginal communities. It details the steps of an ECG including assessing the rate, rhythm, waves, intervals, segments, and complexes. The first case involves a 10 year old girl named Thomasina presenting with jerky movements and fever, who is diagnosed with rheumatic fever based on her ECG and blood tests. The second case describes a pilot named Frank who develops palpitations and is found to be in supraventricular tachycardia based on his ECG, which is terminated with carotid sinus massage.
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Case-Based ECG
- 1. Case-Based ECG Hung TheNguyen hung@hmvtteachingspace.com
- 2. Outline ‣10 Steps ECG ‣2cases from the bush
- 3. Ten Steps ECG ‣name,age, sex ‣time performed ‣chest pain? ‣BP ‣digoxin? 1.Importantbasicinformation
- 4. ‣300/number of big squares 2.RateTen Steps ECG
- 5. ‣ sinus rhythm ‣ectopics, premature beats ‣ narrow based arrhythmias; ➡ AF, atrial flutter ➡ SVT ‣ broad based arrhythmias: ➡ VT, VF ‣ asytole 3.Rhythm Ten Steps ECG Does this ECG look right?
- 6. ‣look at leadsII, III, aVF, V1 ‣P pulmonale ➡amp >3 mm = RA dilatation eg pulmonary HT (COAD, secondary LVF) ‣P mitrale ➡notched P wave and sinus wave inV1 >1 mm = MR, MS 4.Pwave Ten Steps ECG
- 7. ‣AV node conduction, normally3-5 mm (0.12 to 0.2 sec) ‣shortened ➡accessory pathway = WPW (delta wave) ➡Digoxin, ➡hyper Ca, K, Mg 5.PRinterval Ten Steps ECG
- 8.
- 9. ‣prolonged ➡1st degree heartblock (constant prolonged PR int) = past inf and ant AMI, drugs (B-blocker, Digoxin, Ca channel blockers), age related, rheumatic fever ➡2nd degree HB – Mobitz type I (Wenkebach); Mobitz type II can progress to complete HB ➡3rd HB – atrial rate (P) 100-300, ventricular rate (QRS) 30-40 5.PRinterval Ten Steps ECG
- 10. ‣Presence of theQ wave Physiological Q <1mm, ¼ height of R Pathological Q = AMI ➡Lead II, III, aVF = inferior wall; ➡Lead I, aVL,V3-4 = anterior wall; ➡LeadV1-2 = septal wall ➡LeadV5-6 = lateral wall Q+ = full thickness AMI, Q- = subendocardial AMI 6.QRScomplex Ten Steps ECG
- 11. ‣Amplitude <10 mm inVleads; V1 R = RV, S = LV; V6 Q = septum, R = LV, S = RV determined by amount of fluid (pericardial effusion), fat (breast, obesity), air (emphysema); determined by strength of signal (heart failure) ➡LVH =V1orV2 S plusV6 orV5 > 35 mm ➡RVH R>S inV1 plus prominent S inV6 ➡Prominent R wave in V1 = post AMI, RVH, WPW, RBBB, PE 6.QRScomplex Ten Steps ECG
- 12. ‣Duration <3 mm (0.12) forBBB look at I,V1,V6 (note cannot Dx AMI, LVH when LBBB or RBBB present) ➡RBBB ↑S in I,V6 plus rSR’ inV1 (MaRRoW) ➡LBBB ↑R in I,V6 plus ↑S inV1 (WiLLiaM) 6.QRScomplex Ten Steps ECG
- 13. ‣Axis deviation Physiological =pregnant, tall and thin (short and obese) Pathological ➡ant fascicular damage, left ant hemiblock (LAXD); ➡post fascicular damage, left post hemiblock (RAXD); ➡MI (necrosis), ➡HT (hypertrophy) 6.QRScomplex N LAXD RAXD I ↑ ↑ ↓ II ↑ ↓ ↓ III ↓ ↓ ↑ Ten Steps ECG
- 14. Absolute refractory period ‣Depression ➡Angina Exercisestress test – peak performance HR 200-age, SBP +60, DBP stay the same or ↓, monitorV5 + when >1 mm depression 2 mm after the J point; 2/3 women have + exercise stress with normal coronary arteries ➡LV strain Severe LVH; signs of LVH with ST ↓ in anterolat leads = HT ➡LBBB ➡Digoxin ‣ST sag 7.STsegment Ten Steps ECG
- 15. Elevated ‣AMI ‣Ant ‣Inf – RCA95%, CXA 5% →1st degree HB (AV nodal art) ➡Variant angina – ST↑ without ↑cardiac enzymes ➡LV aneurysm – persistent ↑ST ➡Pericarditis – widespread ST↑, saddled shaped 7.STsegment Ten Steps ECG
- 16. ‣inversion T inleads III, aVR, aVF, V1-2, can be normal ‣normal if in the same direction as QRS and amplitude <10 mm inV leads 8.Twave Ten Steps ECG
- 17. Repol of septum/papillary muscleinV2-V4 septal leads 9.Uwave Ten Steps ECG
- 18. Depol and repoltime <1/2 RR interval QTc = QT/√RR <0.44 sec ‣Prolonged ➡↑risk ofVT (torsade de point) ➡familial, ➡electrolyte imbalance (K. Mg, Ca), ➡drugs (phenothiazines,TCA, ventricular anti-arrhythmic drugs = 10% risk of pro- arrhythmia) ‣Shortened No clinical significance 10.QTinterval Ten Steps ECG
- 19. Thomasina ‣ Thomasina isa 10 year old girl presenting with her grandmother. She is visiting a Community Health Clinic in a remote Aboriginal community. ‣ The grandmother says to you in broken English that she is very worried about Thomasina who is having strange movements of her hands. “She’s going mad!”
- 20. Thomasina ‣ with furtherquestioning she is feeling unwell, lethargic and has a mild fever. ‣ she complained of sore elbows and wrists. she also had sore knees as few days ago but it has abated. ‣ she never had this before
- 21. Thomasina ‣ When youexamine her, she was short of breath (RR 20), HR= 92 ‣ she has jerky and uncoordinated movements of her right upper limb. She says that she cannot control it. ‣ her elbow and wrist joints are tender but not swollen ‣ she had no rash ‣ she does not have a heart murmur
- 22. Thomasina ‣ you didthe following tests according to the CARPA Standard Treatment Manual: ‣ throat swab MCS ‣ bloods for ASOT, ANTiDNAse B, CRP, FBC, ESR, blood cultures ‣ ECG
- 23.
- 24.
- 25. Thomasina ‣ you giveher paracetamol
- 26. Thomasina ‣ you callthe DMO and discussed the case ‣ Thomasina will be evacuated by plane
- 27. Thomasina ‣ when shereturned to the community, you instruct the health staff to put her on the rheumatic fever, heart disease list ‣ Thomosina will have Bicillin LA 2 ml IM every 4 weeks until she is 21 years of age ‣ she will need to see a doctor every year for review ‣ she is to have pneumococcal and flu vaccines ‣ she is to see the dentist once a year
- 28. Frank ‣ You arehaving a restful Friday afternoon in remote Aboriginal Community Health Centre. This is quite unusual but welcomed. ‣ Frank came in wondering if the clinic is opened. He said that he is the pilot of the mail plane that just arrived and he is having trouble breathing.
- 29. Frank ‣ Frank isa 40 year old pilot for 20 years. ‣ he is healthy and fit. ‣ he says that he suddenly developed short of breath and palpitations just before he landed the plane in your community. He feels faint and worries that he is having a heart attack.
- 30. Frank ‣ he doesnot have chest pain. ‣ he has no reasons to be stressed or anxious. ‣ he drinks coffee 4 times a day ‣ takes no alcohol nor does he smoke
- 31. Frank ‣ you examinehim and found that he is short of breath (RR 24) and tachycardic (HR 150), afebrile, with a BP = 130/80 ‣ his cardiac examination is normal and he is not in heart failure
- 32. Frank ‣ you askedthe nurse to do a 12 lead ECG
- 33.
- 34. Frank ‣ you tellFrank that he has SVT and that you will need him to help you slow the heart rate down ‣ you ask him to perform a valsalva manoeuvre ‣ after a few goes, it did not work
- 35. Frank ‣ you tellFrank that there is something else you can try called the “carotid sinus massage” ‣ he asks “What happens if that doesn’t work?”
- 36. Frank ‣ you tellhim that there are drugs that can slow the heart down.“Lets not think about those until we have to,” you said to him. ‣ you proceed to perform the carotid sinus massage
- 37. Frank ‣ his heartrate is now in sinus rhythm!
- 38. Frank ‣ He thanksyou for an exceptional job, asked whether he needs to pay for anything and proceeded to walk out the of the clinic.
- 39. Frank ‣ unfortunately forFrank, you stopped him and told him that he cannot fly today and you have to let the authorities know about his condition ‣ you arranged for another plane to fly him home.
- 40. Close ‣10 Steps ECG ‣2cases from the bush
- 41.