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EKG Case Presentations
Lindsay Saleski, DO
7/27/2015
EKG Case Presentations
Lindsay Saleski DO, MBA
Family Medicine/Emergency Medicine
Midlands Emergency Physicians
Tuomey Hospital
Case #1
• 65 yo female presents to the ED with
shortness of breath, palpitations and
generalized weakness for the last 3
weeks. Denies associated chest pain.
• Pmhx: CAD
• VS: 110/75, HR 150, Pulseox 98%
• The patients EKG is as follows:
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Case #1: Question #1
• What should you do at this time?
a. Synchronized cardioversion
b. Treat the patient with metoprolol
c. Treat the patient with Digoxin
d. Massage the carotid arteries
e. Treat the patient with IV Adenosine
Case #1: Question #1
• What should you do at this time?
a. Synchronized cardioversion
b. Treat the patient with metoprolol
c. Treat the patient with IV Digoxin
d. Massage his carotid arteries
e. Treat the patient with IV Adenosine
Atrial Fibrillation
• Several characteristic electrocardiogram (ECG) changes
define AF:
– Presence of low-amplitude fibrillatory waves on ECG without
defined P-waves
– “Irregularly irregular” ventricular rhythm
– Fibrillatory waves typically have a rate of > 300 beats per minute
– Ventricular rate is typically between 100 and 160 beats per
minute
• Treatment
– Unstable – synchronized cardioversion
– Stable – Assess for anticoagulation, rate control
• B-blockers or Calcium channel blockers
• Resting rate goal ≤ 110bpm
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Case #1: Question #2
• Patients with chronic atrial fibrillation are at
increased risk for which of the following
conditions?
a. Acute MI
b. Ventricular tachycardia
c. Sudden cardiac death
d. Cerebrovascular accident
e. Ventricular fibrillation
Case #1: Question #2
• Patients with chronic atrial fibrillation are at
increased risk for which of the following
conditions?
a. Acute MI
b. Ventricular tachycardia
c. Sudden cardiac death
d. Cerebrovascular accident
e. Ventricular fibrillation
AFIB Anticoagulation
• Ischemic CVA is most frequent SE
– 5% risk per year
• CHADS2 score - stroke risk assessment
– Warfarin for score of ≥ 2
• Warfarin is superior to ASA/Plavix combo
• If risk of embolization exceeds the risk of
bleeding, patient is candidate for long-term
antithrombotic therapy
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Case #2
• 68 yo female presents to the ED with intermittent
palpitations, lightheadedness and shortness of
breath. Symptoms worsened at church this
morning. Patient did not feel well, walked to the
bathroom and syncopized.
• Pmhx: DM, HTN, CAD with stent placement
• VS: HR 200, BP 135/100, RR 20, Pox 100%, T 98.6
• Current: Patient is awake, alert and providing
history.
• The patients EKG is as follows:
Case #2: Question #1
• What is the antiarrhythmic of choice in
management of stable ventricular
tachycardia?
a. Adenosine 6mg IV push
b. B-blockers for rate control
c. Digoxin load the patient
d. Amiodarone 150mg IV
e. Calcium channel blockers for rate control
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Case #2: Question # 1
• What is the antiarrhythmic of choice in
management of stable ventricular
tachycardia?
a. Adenosine 6mg IV push
b. B-blockers for rate control
c. Digoxin load the patient
d. Amiodarone 150mg IV
e. Calcium channel blockers for rate control
Tachycardia Algorithm.
Neumar R et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association, Inc. All rights reserved.
Case #2: Question #2
• Just prior to floor transfer to the patient arrests.
The rhythm strip reveals (see below). CPR is
initiated. What is the next step in treatment
according to ACLS?
a. Administer epinephrine 1mg IV
b. Administer calcium chloride
c. Administer sodium bicarbonate
d. Defibrillation
e. Continue CPR – do not administer medications
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Case #2: Question #2
• Just prior to floor transfer to the patient arrests.
The rhythm strip reveals (see below). CPR is
initiated. What is the next step in treatment
according to ACLS?
a. Administer epinephrine 1mg IV
b. Administer calcium chloride
c. Administer sodium bicarbonate
d. Defibrillation
e. Continue CPR – do not administer medications
ACLS Cardiac Arrest Algorithm.
Neumar R et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association, Inc. All rights reserved.
Ventricular Tachycardia
• >3 consecutive ectopic ventricular beats
• Widened QRS (>120msec)
• Regular rhythm
• Rate >100 bpm
• MC sign causes are ischemic heart disease and AMI
• ALL wide complex ventricular rhythms treated as Vtach
until proven otherwise
• Stable – no evidence of hemodynamic compromise
despite a sustained rapid heart rate
• Unstable – evidence of hemodynamic compromise,
but who remains awake with a pulse
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VT Treatment
• STABLE with pulse
– Amiodarone 150mg IV over 10 minutes, repeat as needed to max
dose of 2.2g/24 hours
– Prepare for elective synchronized cardioversion
• UNSTABLE with pulse
– Immediate synchronized cardioversion
– IV access and sedation, but don’t delay tx
• Pulseless arrest
– IV, O2, monitor, CPR
– Biphasic 200J/Monophasic 360J/AED devise specific
– CPR 5 cycles
– Check pulse and rhythm
– Epinephrine 1mg IV/IO whenever initially available and redose
every 3-5 minutes
Case # 3
• 55 yo male presents to the ED became
suddenly unresponsive at home. Wife is a
nurse and CPR was started immediately. On
ED arrival the cardiac monitor has the
following rhythm:
Case #3: Question # 1
What is the first line medical therapy?
a. Magnesium 2 gram IV bolus
b. Cardioversion
c. Lidocaine 1mg/kg IV
d. IV fluids 1000ml bolus
e. Epinephrine 1 mg IVP
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Case #3: Question # 1
What is the first line medical therapy?
a. Magnesium 2 gram IV bolus
b. Cardioversion
c. Lidocaine 1mg/kg IV
d. IV fluids 1000ml bolus
e. Epinephrine 1 mg IVP
Torsades de Pointes
• “Twisting of the points”
• Clinical Criteria
– Ventricular rate >200bpm
– QRS structure with undulating axis, polarity of
complexes appearing to shift about the baseline
• Causes:
– Acquired
• Medications, electrolyte disturbances (↓K, Ca & Mag), MI,
CVA
– Congenital
Torsades Treatment
• Stable Patient
– IV Magnesium
– IV Isoproterenol: B1 & B2 agonist
– Overdrive pacing to ventricular rate of 100120bpm
• Unstable
– Unsynchronized cardioversion
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Case # 4
• 41 yo female presents to the FP office as a
new patient with acute onset substernal, nonradiating chest pain that started while she was
out working in the yard 15 minutes prior to
arrival. She states the pain is currently 10/10.
She has associated SOB and nausea. No pmhx
but has not seen a PCP in 5 years.
• VS: 160/100, HR: 92, RR: 22, Pox: 98%, T98.9
• The patients EKG is as follows
Case #4: Question#1
• Which of the following time dependent
interventions will most likely benefit this
patient?
a. CK-MB level
b. Stress test
c. Angioplasty
d. Metoprolol IV
e. Atorvastatin PO
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Case #4: Question #1
• Which of the following time dependent
interventions will most likely benefit this
patient?
a. CK-MB level
b. Stress test
c. Angioplasty
d. Metoprolol IV
e. Atorvastatin PO
STEMI
• EKG evolves through a typical sequence
–
–
–
–
Hyperacute or peaked T wave
Elevation of the J point and the ST segment retains its concavity
ST segment elevation becomes more pronounced and convex
ST segment may be indistinguishable from the T wave
• The joint ESC/ACCF/AHA/WHF committee: definition of MI
established specific ECG criteria for the diagnosis of STEMI:
– 2 mm of ST segment elevation in precordial leads V2-V3 for men
and 1.5 mm for women
– greater than 1 mm in 2 contiguous leads in other leads
• ACS also = STEMI if:
– new left bundle branch block
– posterior MI
STEMI Treatment
• Continuous cardiac monitoring, IV access, O2
• Reperfusion Therapy
– Percutaneous coronary Intervention (PCI)
• 90 minutes or less for patients transported to PCI-capable
hospital
– Fibrinolytic agents
• If within 12 hours of onset and no PCI available
• Aspirin
• Nitrates
• β-Blockers
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Case # 5
• 51 yo female presents with palpitations, nausea,
and chest pain. The CP is substernal and nonradiating. She states she was having a nightmare
and woke up with palpitations. She has had
multiple prior episodes for which she has been
seen in the ED. She has not obtained outpatient
follow up.
• PMHx: CAD, CHF, HTN, drug abuse
• BP: 200/148, HR: 177, RR: 36, T: 98.9, Pox: 96%
on RA
• The patients EKG is as follows:
Case #5: Question #1
• In this patient ACLS Protocol states that you
should immediately:
a. Administer Amiodarone 150mg IV
b. Administer Adenosine 6mg IV
c. Initiate CPR
d. Synchronized cardioversion
e. Administer Sotolol 100mg IV
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Case #5: Question #1
• In this patient ACLS Protocol states that you
should immediately:
a. Administer Amiodarone 150mg IV
b. Administer Adenosine 6mg IV
c. Initiate CPR
d. Synchronized cardioversion
e. Administer Sotolol 100mg IV
Neumar R et al. Circulation 2010;122:S729-S767
Copyright © American Heart Association, Inc. All rights reserved.
SVT
• Narrow complex tachycardia
– QRS complex duration < 0.12 sec
– Ventricular rate >100bpm
– MC type is AvnRT
• Tx: SVT that is not associated with severe
symptoms or hemodynamic collapse
– Vagal maneuvers
– IV adenosine
– IV non-dihydropyridine calcium channel blocker or an
IV beta blocker
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Case # 6
• 66 yo female with pmhx DMII presents to the
PCP office for CC of intermittent dizzy spells
and two episodes of near syncope over the
last week. An EKG is done and she is found to
have a heart block. She is sent to the ED for
further evaluation. She denies any other
complaints at time of ED evaluation.
• VS: 146/78, 40, 20, 98.6, 100% on RA
• The patients EKG is as follows:
Case #6: Question # 1
• What are indications for permanent pacemaker
placement in patients with 3rd degree heart block?
a. Symptom free patients with asystole > 3 seconds
b. Dizziness and near-syncope
c. Heart block during exercise in the absence of
myocardial ischemia
d. Asymptomatic patients with asystole of 5 seconds or
longer
e. Escape rate < 40bpm
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Case #6: Question # 1
• What are indications for permanent pacemaker
placement in patients with 3rd degree heart block?
a. Symptom free patients with asystole > 3 seconds
b. Dizziness and near-syncope
c. Heart block during exercise in the absence of
myocardial ischemia
d. Asymptomatic patients with asystole of 5 seconds or
longer
e. Escape rate < 40bpm
• Correct answer: All of the above
http://content.onlinejacc.org/article.aspx?articleid=1138927
Third Degree Heart Block
• Absent conduction of ALL atrial impulses resulting
in complete electromechanical AV dissociation
• P waves and QRS complexes are present but
unrelated and occur at different rates
• Treatment:
– Pacemaker for those with associated symptoms,
ventricular pauses ≥3 seconds, or a resting heart rate
<40 beats/min while awake
– Atropine reverses decrease in AV nodal conduction
from vagal tone
EKG Extras
• To review on your own…
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I. Cardiac Anatomy
www.edoctoronline.com
I. EKG Regions
Coronary Anatomy:
V1, V2: posterior wall
V1, V2, V3: anterior septum
V4: apex
V5, V6: low lateral wall
I, avL: high lateral wall
II, III, avF: inferior wall (possible RV)
http://www.nottingham.ac.uk/nursing/practice/resources/cardiology/ima
ges/ecg_regions_old.gif
II. Lead Placement: Normal
www.usfca.edu
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III. Rate
• Rule of 300- Divide 300 by the number of
boxes between each QRS = rate
Rate 60 – 100 Normal
Rate < 60 Bradycardia
Rate >100 Tachycardia
Left Bundle Branch Block
•
•
•
•
•
The heart rhythm must be supraventricular in origin
The QRS duration must be ≥ 120 ms
There should be a QS or rS complex in lead V1
There should be a RsR' wave in lead V6
The T wave should be deflected opposite the terminal
deflection of the QRS complex. This is known as
appropriate T wave discordance with bundle branch
block. A concordant T wave may suggest ischemia or
myocardial infarction.
• New onset LBBB in setting of chest pain considered a
STEMI
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Early Repolarization
• Concave ST elevation in multiple leads
– Not AVR or V1
• J-point elevation with slurring or notching
• Absence of reciprocal changes
• Usually considered benign however some
studies showing possible association with Vfib,
sudden death, cardiac arrest. Must correlate
clinically.
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Pericarditis
• Inflammation of pericardium
– Causes: Virus, bacteria, cancer, MI, fungal,
autoimmune
• Symtpoms: Pleuritic CP, improves when
leaning forward, shortness of breath
• EKG:
– Diffuse ST elevation, concave ST segment
– Absence of reciprocal changes
– PR- segment depression
Rhythm, “Buzzwords,” & ACLS
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•
•
•
•
•
•
•
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Normal Sinus Rhythm: Originating from SA node, P wave before every QRS, P wave
in same direction as QRS
Sinus Bradycardia: stable vs unstable, atropine, prepare for transcutaneous pacing,
consider epinephrine or dopamine
Sinus Tachycardia: determine etiology
Atrial Fibrillation, “irregularly irregular”: stable vs unstable, control rate vs
cardioversion, diltiazem or beta-blockers, avoid AV nodal blocking agents
(adenosine, digoxin, diltiazem, verapamil) in setting of AF + WPW
Atrial Flutter, “sawtooth pattern”: stable vs unstable, control rate vs cardioversion,
diltiazem or beta-blockers
Supraventricular Tachycardia (SVT), “narrow complex tachycardia”: stable vs
unstable, control rate vs cardioversion, vagal maneuvers, adenosine
Torsades de Pointes, “twisting of the points,”: magnesium
Ventricular Tachycardia, “wide complex tachycardia,”: with or without a pulse,
without = defibrillation, with = amiodarone, synchronized cardioversion
Ventricular Fibrillation, “erratic tracing”: defibrillation
http://www.heart.org/HEARTORG/CPRAndECC/HealthcareProviders/AdvancedCardiovascularLifeSupportACLS/Advanced-Cardiovascular-LifeSupport-ACLS_UCM_001280_SubHomePage.jsp
References
•
Atrial Fibrillation:
– Atrial Fibrillation Management Strategies in the Emergency Department. Emergency Medicine
Practice. February 2013. Volume 15, No 2.
– Antithrombotic Therapy in Atrial Fibrillation to Prevent Embolization. UTD. Accessed
6/2/2014.
– Atrial Fibrillation: Diagnosis and Treatment. Am Fam Physician. 2011 Jan 1;83(1):61-68.
•
Ventricular Tachycardia & Torsades
– Polymorphic Ventricular Tachycardia and Torsades de Pointes. Rosen’s Emergency Medicine.
Sixth Edition, Volume 2. pp1243-1244
– Piktel JS. Piktel J.S. Chapter 22. Cardiac Rhythm Disturbances. In: Tintinalli JE, Stapczynski J, Ma
O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka
R.K., Meckler G.D., T eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e.
New York, NY: McGraw-Hill; 2011.
http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381483.
Accessed August 15, 2014.
– Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP,
McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ.
Part 8: adult advanced cardiovascular life support: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2010;122(suppl 3):S729 –S767.
– Aquired Long QT Syndrome. UTD. Accessed 7/24/2014
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References Continued
•
STEMI
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Hollander JE, Diercks DB. Hollander J.E., Diercks D.B. Chapter 53. Acute Coronary Syndromes: Acute Myocardial Infarction and
Unstable Angina. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O,
Cline D.M., Cydulka R.K., Meckler G.D., T eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY:
McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381518. Accessed August
15, 2014.
O'Gara PT, Kushner FG, Ascheim DD, et al. 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. J Am
Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019
Circulation. 2013; 127: 529-555 Published online before print December 2012, doi: 10.1161/​CIR.0b013e3182742c84
ACC/AHA Guideline Update for the Management of ST-Segment Elevation Myocardial Infarction. American Family Physician.
2009; 79 (12):1080-1086
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SVT
•
Heart Block
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–
–
•
•
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An Evidence-Based Approach to Supraventricular Tachydysrhythmias. Emergency Medicine Practice. EBMedicine.net. April 2008.
Volume 10 Number 4. Accessed Online 8/19/2014.
`Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and
Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic
Surgeons. J Am Coll Cardiol. 2008;51(21):e1-e62. doi:10.1016/j.jacc.2008.02.032. Accessed online 7/13/2015.
Am Fam Physician. 2014 Feb 15;89(4):279-82. Common questions about pacemakers. Denay KL1, Johansen M2.
http://www.aafp.org/afp/2014/0215/p279.html. Accessed online 7/13/2015.
Definition of Early Repolarization: A Tug of War. Circulation. 2011; 124: 2185-2186 doi:
10.1161/CIRCULATIONAHA.111.064063
What is Pericarditis? AHA. http://www.heart.org/HEARTORG/Conditions/More/What-isPericarditis_UCM_444931_Article.jsp. Accessed 7/13/2015
Mattu, Amal and Brady, William. ECGs for the Emergency Physician 1. BMJ Publishing Group 2003.
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