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ECG III
Pacemakers/ICD
Prolong QT Syndrome
Brugada Syndrome
Wellens Syndrome
Prepared and presented by:
Dr. Matt Davis Medical Director of Education
Justine Jewell CBRN specialist, Interim Education
Coordinator
Christine Hardie ACP, Regional Educator
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Goal
The goals of this webinar are to:
Gain familiarity with various cardiac conditions
that may present in the pre-hospital setting
Generate interest in advanced concepts and
associate them with paramedic practice
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Objectives
Upon completion of the webinar the paramedic
should:
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Demonstrate an ability to recognize pacemaker rhythms
Recognize the purpose of an ICD and how it affects patient
care during a cardiac arrest
Identify some conditions associated with sudden cardiac
death
Relate the knowledge gained from case study investigation
to pre hospital care
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Case 1- Cardiac Arrest
59 yo male found on couch. Wife states they
were watching TV when patient let out a moan
and then became unresponsive. She states “He
has a bad heart and had ‘a device’ put in his
chest a few years ago, that shocks his heart.”
PMHx: previous cardiac arrest
Meds: bottles in bathroom
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Case 1- Cardiac Arrest
• Physical
Exam
Airway patent, no visible chest rise, no pulses
• Generally: cool, clammy, diaphoretic
• Rhythm strip:
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“A device put in his chest a few
years ago”
Pacemaker
ICD
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Pacemaker Basics
Provides electrical stimuli to cause cardiac
contraction when intrinsic cardiac activity is
inappropriately slow or absent
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ICD Basics
Designed to treat tachydysrhythmias
• Performs cardioversion/defibrillation
• ATP (antitachycardia pacing)
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Pacemaker and ICD Basics
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Pulse Generators
Placed subcutaneously or submuscularly
Connected to leads
Battery operated
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Pacemaker Nomenclature
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Most Common Pacing Modes
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AAI
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VVI
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DDD
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Examine carefully – Poll Question
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Pacemaker Indications
Common indications for pacemakers:
• Sick
sinus syndrome (Tachy-brady
syndrome)
• Symptomatic bradycardia’s
• Afib with slow ventricular response
• 3rd degree heart block
• Prolonged QT syndrome
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ICD Indications
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ICD implantation is generally considered the
first-line treatment option for the prevention of
SCD in high risk patients
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ICD\Pacemaker Complications
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Similar
• Operative
failures
• Sensing and pacing failures
• Inappropriate cardioversion
• Ineffective cardioversion/defibrillation
• Inadequate energy output
• Device deactivation
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ICD Failure to Deliver or Ineffective
Cardioversion
• Management
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External pacing/defibrillation or
cardioversion
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Do not withhold therapy for fear of damaging
ICD
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If pt’s internal defibrillator activates during
chest compressions, you may feel a mild
shock (no significant adverse effects related
to this)
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Case 1- Cardiac Arrest
• Physical
Exam
Airway patent, no visible chest rise, no pulses
• Generally: cool, clammy, diaphoretic
• ECG:
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Case 1- Cardiac Arrest Cont.
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Cardiac Arrest with ICD
Treat using ALS directives:
CPR
Defibrillate/shock as warranted
(Avoid pad placement over pulse generator)
Airway/Ventilation management
IV/Meds
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Question: There have been a few discussions flying
around about a call where the patient had an internal
defib whose activity was captured shocking the
patient X 3 by the EMS defib. Of course, the whole
discussion is treat vs. transport and shock once vs.
follow the entire protocol. Can you provide some
insight into these rare cases?
• Posted on: 5-Sep-2013
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ANSWER: Great question. Occasionally paramedics may be in contact with
a patient with an Implantable Cardioverter Defibrillator (ICD) who is
conscious and alert however the ICD has discharged or continues to do so.
In such cases, rapid transport is the key as long as the patient remains
stable and/or has a return of spontaneous circulation following the
shocks.
If a patient with an ICD presents in cardiac arrest and the rhythm is
ventricular fibrillation (VF), then clearly the ICD is not functioning properly
in failing to concert the VF into a perfusing rhythm.
Paramedics when confronted with a patient with an ICD who is in full
cardiac arrest should follow their Medical Cardiac Arrest Medical Directive.
The Advanced Life Support Patient Care Standards (the medical directives)
apply to patients with an ICD in the same way as patients who do not have
an ICD.
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Sudden Cardiac Death
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Incidence
(cases/year)
Survival
Worldwide
3 000 000
‹1%
U.S.
450 000
5%
W. Europe
400 000
‹5%
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Ontario Study on SCD
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Ontario, 174 cases of sudden cardiac death
Structural heart disease was present in 126 cases
(72%), 78% of which was unrecognized
There was no identifiable cause of death in 48 cases
(28%), representing primary arrhythmia syndromes.
Pilmer CM, et al. Scope and nature of sudden cardiac death before age 40 in
Ontario: a report from the cardiac death advisory committee of the office of
the chief coroner. Heart Rhythm. 2013 Apr;10(4):517-23.
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Case Study 2- Syncope
Paramedics presented to the ER with a 50 y/o
female.
C/C-syncope
Incident hx
PMHx
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Interpret
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QT Interval?...........What is that????
A measure of time between the start of the Q
wave and the end of the T wave
The QT interval represents electrical
depolarization and repolarizatoin of the
ventricles
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Measuring the QT Interval
LEAD II
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Case Study 2 - Cont.
Physical Assessment
at ER
HR-54 regular
BP-142/72
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Name:
ID: Patient ID: Incident ID: Age: 50 Sex: 12‐Lead 1
PR 0.186s QT/QTc P‐QRS‐T Axes: HR 54 BPM Abnormal ECG **Unconfirmed**
10:15:29 AM ***Suspect arm lead reversal QRS 0.088s Sinus bradycardia 0.368s/0.618s 113 127 145 12 Lead Information
Name: ID: Patient ID: Incident ID: Age: 50 Sex: 12‐Lead 1
PR 0.186s QT/QTc P‐QRS‐T Axes: HR 54 BPM Abnormal ECG **Unconfirmed**
10:15:29 AM ***Suspect arm lead reversal QRS 0.088s Sinus bradycardia 0.368s/0.618s 113 127 145 **Normal QTc is < 0.400.46 s
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Case study -2 Cont.
During this evaluation in the ED the patient
suddenly lost consciousness and her cardiac
rhythm revealed a polymorphic tachycardia
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Examine carefully – Poll question
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Case Study 2 - Cont.
• ED
care:
• Next
step is to
increase HR to
decrease QT
• Overdrive
pacing or
isopreternonol
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Putting it all together
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How does this affect field treatment?
What about performing 12-leads? When are
they required?
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Prolonged QT Discussion
A patient with LQTS does not necessarily have
a PQT at all times ex. May appear with exercise
Congenital LQTS
Other: medications (the “anti-”), the “hypos”,
MI, ICP
Symptoms: syncope, seizures, sudden death
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Case Study -3: Sudden Death
You are called to a residence for a 36 y/o male
VSA at 2am
No significant past medical history, wife states
she heard her husband cry out in his sleep and
then start shaking in the bed.
She called 911 when he would not respond to
her then started CPR
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Case Study -3 Cont.
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Patient hooked up to monitor, you see this:
1st shock delivered
• Patient now in Asystole
• ACP crew arrives-3 rounds of epi given-called
for pronouncement
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Brugada Syndrome
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characterized by:
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ECG findings of RBBB “like” pattern and persistent ST
elevation in V1 – V3
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structurally normal hearts
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propensity for life-threatening ventricular arrhythmias
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J point elevation
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Brugada Syndrome: ECG
Typical electrocardiogram of Brugada syndrome.
Note the pattern resembling a right bundle branch block,
and the ST elevation in leads V1-V3.
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Brugada Syndrome: Clinical
Features
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unexpectad sudden death
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syncope, seizures
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agonal nocturnal respirations, thrashing
nightmares
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affects male patients predominantly (8:1)
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cases reported worldwide
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Brugada Syndrome: ECG
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Brugada Syndrome: Diagnosis
• symptoms:
syncope, SCD (usually during
sleep)
• physical exam: normal
• family history: strong history of SCD
• ECG: best test to identify Brugada patients
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ST elevation, RBBB “like”
• imaging
tests: usually no underlying
structural disease
• stress tests: symptoms and ECG findings not
usually reproducible with exercise
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Brugada Syndrome: Diagnostic
Criteria
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major criteria:
presence of ECG marker in structurally normal hearts
• appearance of ECG marker after administration of Na+
channel blockers
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minor criteria:
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Documented ventricular fibrillation (VF) or polymorphic
ventricular tachycardia (VT).
Family history of sudden cardiac death at <45 years old .
Coved-type ECGs in family members.
Inducibility of VT with programmed electrical stimulation
Syncope.
Nocturnal agonal respiration
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Brugada Syndrome: Treatment
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IMPLANTABLE CARDIOVERTERDEFIBRILLATOR (ICD)
asymptomatic with family history of SCD: with
normal ECG – EP work up (drug study, EP studies,
genetic testing)
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Case Study -4: Chest Pain
37 year old male called 911c/o intermittent
c/p x 3 days
Episode described as:
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7/10 on the pain scale
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Retrosternal and radiating down left arm
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Diaphoresis, palpitations, dizziness
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Case Study -4: Chest Pain
Also reported to EMS:
No n/v associated
• Two episodes the previous day lasted about
15 min and were relieved with rest.
• One episode the previous awoke him from
sleep.
• Most recent episode was immediately prior to
calling 911.
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Case Study -4 Chest Pain
Pre hospital Assessment and Care:
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O2 NRM
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Cardiac monitoring including a 12-lead
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Vital Signs: HR 83 RR 18 BP 125/80 Temp 36.6 O2 Sats 99%
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IV TKVO
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Ntg/ASA
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Pre-hospital ECG – pain 5/10
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Upon arrival at ER – Patient pain
free post EMS treatment – Examine
carefully
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Case Study -4 Chest Pain
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In Hospital Diagnosis – Wellens
Syndrome
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A characteristic T-wave on an
electrocardiogram during a pain-free period
in a patient with intermittent chest pain
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Type I vs Type II
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776372 Retrieved November 13, 2012
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Wellens Syndrome – Type 1
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In Hospital Diagnosis – Wellens
Syndrome
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Suggests a high-degree stenosis of the
proximal LAD coronary artery that will soon
result in an acute anterior MI
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LAD occlusion– The Widow Maker
This term is used because if the artery
becomes abruptly and completely occluded it
will cause a massive anterior wall MI and can
lead to a sudden death
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What happened to patient
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The patients ECG (in hospital) was
immediately recognized as Wellen’s syndrome
by the physician
Admitted to CCU, cardiac catherization
occurred and he was discharged the following
day with some additional medication
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Summary
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There is great
importance in
obtaining a full and
complete incident
history and having a
high level of suspicion
Your pre-hospital
care makes a
difference
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Question: Would SWORBHP ever consider putting a system
in place for medics to learn the in hospital diagnosis of
patients they transported. There are times when we
transport patients and never learn what was causing them
to present as they did. I think it would be beneficial to learn
what the cause of the patient's condition in those instances
for our own improvement and growth. I understand it
would be unreasonable to do this for every patient but it
would not be difficult to set up a flagging system to tag
specific interesting calls. A system similar to the follow up
after a ROSC may be a model to base it on.
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ANSWER: Excellent question. You are not alone in your interest for patient
follow up. The bottom line is that the Base Hospital is unable to
implement a system such as you describe: we wish we could!
Not only are paramedics not privy to this type of information which could
be valuable on a number of levels (research, education, closure for the
provider following traumatic cases), but many other health care
practitioners are unable to access this information (nurses, emergency
physicians) due to privacy legislation.
Unless you are actively involved the "circle of care" and access to patient
information is necessary at that moment in time in order to directly
influence the management of that patient, we are prevented from
accessing patient information
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Conclusion
Discussion?
Comments?
Questions?
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References
Hayes, David L MD (2012, May) Modes of cardiac pacing: Nomenclature and selection retrieved from:
http://www.uptodate.com/contents/modes-of-cardiac-pacing-nomenclature-andselection?source=search_result&search=pacemaker&selectedTitle=1%7E150
Ganz, Leonard I MD, FHRS, FACC (2013, Nov 6) General principles of the implantable cardioverterdefibrillator retrieved from: http://www.uptodate.com/contents/general-principles-of-theimplantable-cardioverter-defibrillator?source=search_result&search=icd&selectedTitle=1%7E150
Ganz, Leonard I MD, FHRS, FACC (2012, Nov 26) Role of implantable cardioverter-defibrillators for the
primary prevention of sudden cardiac death after myocardial infarction retrieved from:
http://www.uptodate.com/contents/role-of-implantable-cardioverter-defibrillators-for-theprimary-prevention-of-sudden-cardiac-death-after-myocardialinfarction?source=search_result&search=icd&selectedTitle=3%7E150
Aimetbaum, Peter J MD; Josephson, Mark E MD (2012, Sept 14) Pathophysiology of the long QT
syndrome retrieved from: http://www.uptodate.com/contents/pathophysiology-of-the-long-qtsyndrome?source=search_result&search=prolonged+qt&selectedTitle=6%7E150
Mead, Nicole E; O’Keefe, Kelly P (2009 Sept-Dec; 2 (3) 206-208 Wellen’s syndrome: An ominous EKG
pattern retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776372/
Zimetbaum, Peter J MD; Josephson, Mark E MD (2012 Sept 14) Pathophysiology of the long QT
syndrome retrieved from:http://www.uptodate.com/contents/pathophysiology-of-the-long-qtsyndrome?source=search_result&search=torsades+de+pointes&selectedTitle=7%7E150
American College of Cardiology Foundation?American Heart Association Task Force on Practice
Guidelines and the Heart Rhythm Society: 2012 ACCF/AHA/HRS Focused Update Incorporated Into the
ACC/AHA/ARS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities:
downloaded from: http://content.onlinejacc.org/on 10/09/2013
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References
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Emedicine
– http://www.emedicine.com/emerg/topic805.htm
Pacemakers and AICD’s in Emergency Medicine, Ryan Ngiam, ppt
Pacing images found at
http://www.aic.cuhk.edu.hk/web8/pacing.htm
Minish, Travis. Pacemaker Emergencies.
– http://www.cgi.ualberta.ca/emergency/rounds/files/pacers3.ppt
The Implantable Pacemaker, a short historical overview.
–
http://igitur-archive.library.uu.nl/dissertations/2006-0426-200006/c1.pdf
–
http://www.healthyhearts.com/pacemaker.htm
–
http://www.medtronic.com/patients/heart.html
Healthy Hearts
Medtronic
Shelton State University
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Google Images
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http://www.sheltonstate.edu/userfiles/File/faculty/s%20warren/NUR%2020
2%20EKG%20Dysrrhythmias-Sinus,%20Atrial,%20Junctional,%20Vent%20.pdf
http://images.google.com
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