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Transcript
• List the causes and clinical implications of various electrolyte abnormalities • Describe ECG changes in potassium and calcium Hypokalemia • Serum level below 3.5–5.0 mEq/L • Caused by vomiting, diarrhea, diuretics, gastric suctioning ,Hypomagnesemia • Muscle weakness, polyuria • Digitalis can take advantage and cause Torsades de pointes Hypokalemia • ECG Changes – ST segment depression – T waves flatten or join U waves – U waves get larger than Ts – QT interval appears to lengthen – PR interval increases Hypokalemia Hypokalemia: Flat T with K~3 ST depression with prominent T (actually U) and prolonged QT when K<2.5-3 Hyperkalemia • Most common cause is renal failure • Sinus node can quit at 7.5 mEq/L • VF or asystole at 10–12 mEq/L Hyperkalemia: T wave in hyperkalemia is typically tall and narrow, but does not have to be tall (may be just narrow and peaked pulling ST segment). Hyperkalemia Tall T waves with a narrow base QRS widens • Sine waves in severe cases Calcium • Hypercalcemia: Short QT interval • Hypocalcemia: Prolonged QT interval Hypocalcemia: Long QT that is due to a long ST segment, which is different from long QT due to congenital long QT syndrome, drugs, or hypokalemia. T wave is not wide, there is no T wave abnormality. Hypercalcemia: short QTc <390 ms. No significant ST or T wave abnormality The QT Interval • Measured from the start of the QRS complex to the end of the T wave • Measures the total ventricular activity: “refractory time” • QTc is corrected for rate 139 The QT/QTc Table • • • • • • • • Prolonged QT Etiologies • Familial long QT Syndrome • Congestive Heart Failure • Myocardial Infarction • Hypocalcemia • Hypomagnesemia • Type I Antiarrhythmic drugs • Myocarditis • • • • Shortened QT Etiologies • Digoxin (Digitalis) • Hypercalcemia • Hyperkalemia • Hypomagnesemia is not associated with characteristic or specific ECG findings • It is associated with a non-specific prolongation of QT and/or QRS intervals, and is often associated with hypokalemia and hypocalcemia. Therefore, changes related to the latter 2 abnormalities may be seen. Pathologic Q Waves I 28 Progression of Myocardial Infarction • During MI the ECG often evolves through three stages: – Ischemia – Injury – Infarction 29 Identification of MI • Reciprocal changes seen on 12lead ECG may assist with distinguishin g between MI and conditions that mimic it 30 View of Inferior Heart Wall • Leads II, III, aVF - Looks at inferior heart wall -Looks from the left leg up View of Lateral Heart Wall • Leads I and aVL – Looks at lateral heart wall – Looks from the left arm toward heart *Sometimes known as High Lateral* View of Lateral Heart Wall • Leads V5 & V6 – Looks at lateral heart wall – Looks from the left lateral chest toward heart View of Anterior Heart Wall • Leads V3, V4 – Looks at anterior heart wall – Looks from the left anterior chest View of Septal Heart Wall • Leads V1, V2 - Looks at septal heart wall - Looks along sternal borders Posterior Ischemia, Injury, Infarction • Can be identified through leads V7, V8 and V9 38 Right Ventricular Ischemia, Injury, Infarction • Can be identified using leads V3R, V4R, V5R, V6R 39 Right Ventricular MI Anterior MI Reciprocal ST segment depression Acute ST segment elevation Pericarditis Pericarditis • Signs and Symptoms – Chest pain, dyspnea, tachycardia, fever, weakness, chills – Chest pain sharp, radiating to back, neck, jaw – Made worse by lying flat, twisting – Made better by leaning forward Pericarditis • Often pleuritic pain, worse on inhalation • Pain can last for hours or days • Pericardial friction rub – Heard over left lower sternal border Pericarditis ECG Criteria • ST segment elevation • Concave in all leads • T wave elevation • PR depression Pericarditis Pericarditis: Diagnosis Early Repolarization ECG Criteria: APE • Deep S in Lead I • Abnormal Q in Lead III • Inverted T in Lead III 140 The Digitalis Effect • • • • 60% of those on “Dig” have it ST segment depression Scooped out appearance Best seen in inferior/lateral leads Questions