Ekg

[drahmed]

bismillah...
ecg is used for;
arrhythmias(eg;blocks,VTs...)
ischemias(eg;stemi,nste-acs...)
structral myocardial dysfunction(eg;LVH,LAH...)
and also,
metabolic abnormalities(eg;hyperkalemia...)
drug intox.(eg;digoxin intox...)
when reading an ecg, we should evalate the ecg step by step;
1. is it a true ecg recaord (negative D1, positive aVR is frequently wrong ecg record)
2. is it sinus rhtym or is there any arrhythmia (P wave, PR/QRS prolongation..)
3. is there any ischemic findings (eg;st segment deviation, T wave invertion..)
4. other findings

all blocks ---> QRS prolongation(100ms:incomplete,>120ms:complete block
each small squres:40 ms)
at left bundle branch block you should see;
1.QRS prolongation
2.Rr or rR at D1,aVL,V5-6
3.no initial q waves at D1,aVL,V5-6
4.qS or rS form at V1
if it is new or presumed new, it is equal to st segment elevation
if it is old, it is frequantly due to a strutral mycardial dysfunction or coronary artery diseases
at right bundle branch block you should see;
1.QRS prolongation
2.rSR at V1
3.wide (abnormal) S wave at V5-6
incomplete forms can be seen in normal men or women
if you want to see ecg examples
send me your e-mail address please
I don't know if you are a doctor or student?...
my e-mail address is:
PERSONAL EMAIL ADDRESSES ARE NOT PERMITTED TO BE POSTED

 

[جوري]

aslaamu 3lykoum wr

Jazaka Allah khyran

could you go over this

as pertain to St segment elevation, depression, Q waves -- which leads are more important and why.. when going over EGK folks always look at leads II,III, V and AVF, and I am not sure the significance of that...

in other words if you have some time and dedication, every day you can cover five points about the EKG as I have done on this thread
http://www.islamicboard.com/health-science/134270536-medical-student-review.html

only it will be an EKG review.. I try to look at it in a single lead but I find that I am lost with the shapes of the P waves or not noticing things like bigeminy, or even understand their clinical correlation to metabolic disorders...

I don't want to incommode you but I think many on board would appreciate it.. there are many medical students and residents on board and the EKG is often dreaded by many, unfortunately it is a part of life that needs to be covered on rounds so there is no escaping...


Jazaka Allah khyran

 

[drahmed]

I advise the following address for beginners may be most of you know;
http://www.skillstat.com/ECG_Sim_demo.html
in fact, for learning ecg the books are so boring...
I think the best method of learning ecg is analysing a lot of ecg examples...

 

[جوري]

I agree with you, I have a couple of books including one on arrhythmia, I just wish I could go over it with someone.. the link you've provided above isn't working..

but if you have the time can you bring any interesting EKG from your work and go over it with us?

I don't want to incommode you of course.. so only if you have the time for it..

Jazaka Allah khyran

 

[drahmed]

this is a real case about 2 weeks ago
applied to emergency service at 03:30 am
38 year old man
acute dispnea, dizziness and sweating
started about 30-45 mintes ago
no chest pain
TA:140/90 mmHg
Pulse:regular,80 bpm
Breath:22/min
Blood sugar: 180 mg/dL
SpO2: %92
ABG: pH:7.40 paO2:88 mmHg paCO2:40 mmHg HCO3:23 mEq/L
ECG: NSR
3 mm ST segment elevation at D3 and aVF
1-2 mm ST segment depression at D1,aVL,V1 and V2
Medical history: type-I DM(for 5 years)
dyslipidemia(for 1 year)
smoking(20-30 packett/year)
using only NPH insulin
(HUMULİN-N 2X6 units morning and evening)
Examination: sweaty,anxious,dyspneic
cardiovascular:
regular, no S3, no murmur, JVD+, pretibial edema -/-
pulmoner:
tachypneic,no raller, no ronchus or wheezing
what would you do
step by step...
and
then what happened...

 

[جوري]

A STEMI patient should have continuous cardiac monitoring and oxygen with IV access to relieve the pain of ischemia ( by using MONA) -- you should stabilize his hemodynamic status, and assess for fibrinolysis or PCI?


is this correct?

 

[drahmed]

definition of STEMI according to Europen Heart Journal,29:2909-2945,2008
(ESC guidelines 2008 management of AMI in patients presenting with STEMI)
: ischaemic symptoms+persistant ST segment elevation on the ECG
if we analyse the case step by step...
what can we do?...
1.initial diagnosis and early risk stratification
2.relief of pain,breathlessness and anxiety
3.defibrillation and cardiopulmonary resuscitation
4.restoring coronary flow and myocardial tissue reperfusion
a.PCI
b.fibrinolytic treatment
1.initial diagnosis and early risk stratification:
STEMI-->inferoposterior MI-->silent ischaemia-->DM
additional ECG recordings of lead V7-9 and V4R(posterior MI or right ventricle infarction)
ECG monitoring should be initiated as soon as possible in all patients to detect life-threatining arrhytmias
serial ECGs should be taken
discriminative diagnosis:
*pulmonary embolism
*cardiac tamponad
*aortic dissection
*pneumothorax
the most important independent predictors of early mortality are:
*older age
*higher Killip
*low SBP
*elevated HR
*anterior MI
2.relief of pain,breathlessness and anxiety
i.v. opioids(morphin 4-8 mg)
O2 2-4 L/min
3.defibrillation and cardiopulmonary resuscitation
if the rhtym is VF or pulseless VT, defibrillation is indicated
if asistoly occurs, cardiopulmonary resuscitation(CPR) is indicated
4.restoring coronary flow and myocardial tissue reperfusion
a.PCI; if possible in 2 hours of first medical contact
b.fibrinolytic treatment; if PCI is not possible in 2 hours and
if fibrinolytic is not contraindicated

and what did we do to the 38 year old patient?
60-70 iu/kg i.v. (5000 iü) heparin bolus and 162-320mg (300mg) chewable aspirin administered, then with monitorization, referred to PCI-capable hospital
transport time was under 90 min (about 30 min)
04:00 am
60-75 min from symptoms onset
while the patient came to our emergency room, the rhtym was VF...
after defibrillation (200 J) cardiac arrest occur
we started CPR... in 2 minutes the rhtym was VF again...
after defibrillation (300 J) cardiac arrest occur again...
we started CPR again...in 2 minutes the rhtym was VF again...
after defibrillation (300 J) normal sinus rhtym returned
klopidogrel 75 mg 1x8
atorvastatin 80 mg 1x1 are given
coronary angiography;
RCAroximal %100
Cx:distal %90
LAD:distal %60
RCA-successful primer PCI
the patient wasn't remembering what happenened at emergency room
but discharged from the hospital with the advises and the medications following;
*stop smoking
*daily exercises(>30min/day quick walking) after resting for 1 month
*mediterian diet
*asethil salisilic acid 100 mg tb 1x1
*klopidogrel 75 mg tb 1x1
*metoprolol 100 mg tb 1x1
*lisinopryl 10 mg tb 1x1
*trimetazidin 20 mg tb 3x1
*atorvastatin 20 mg tb 1x1
*insulin NPH 2x6 ü
*control after 2 weeks

 

[جوري]

Jazaka Allah khyran..

I am not familiar with *higher Killip

I am so glad your patient made it, can't believe vfib at his age..
there is a saying here, once in vfib always in vfib..
how is this guy's prognosis looking for the future?

 

[drahmed]

The Killip classification[1] is a system used in individuals with an acute myocardial infarction (heart attack), in order to risk stratify them. Individuals with a low Killip class are less likely to die within the first 30 days after their myocardial infarction than individuals with a high Killip class

Patients were ranked by Killip class in the following way:
Killip class I includes individuals with no clinical signs of heart failure.
Killip class II includes individuals with rales or crackles in the lungs, an S3 gallop, and elevated jugular venous pressure.
Killip class III describes individuals with frank acute pulmonary edema.
Killip class IV describes individuals in cardiogenic shock or hypotension (measured as systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).
Killip class I: 81/250 patients; 32% (27–38%).
Mortality rate was found to be at 6%.
Killip class II: 96/250 patients; 38% (32–44%).
Mortality rate was found to be at 17%.
Killip class III: 26/250 patients; 10% (6.6–14%).
Mortality rate was found to be at 38%.
Killip class IV: 47/250 patients; 19% (14–24%).
Mortality rate was found to be at 81%.
Killip T, Kimball JT (Oct 1967).
Source
[1]Treatment of myocardial infarction in a coronary care unit.
A two year experience with 250 patients". Am J Cardiol. 20 (4): 457–64. doi:10.1016/0002-9149(67)90023-9. PMID 6059183.

 

[جوري]

Jazaka Allah khyran akhi.. I enjoyed this case, learned something new and hope you share more when you have the time

..

 

[جوري]

such a good thread I am bumping it for the med students..

 

[CosmicPathos]

I have this pavlov's dog's allergic reaction to ekgs. Memeorize tons criteria like a madman and then scan each ekg to see which ones of them are present. Thank God I do not like cardiology. missed a bradyarrythmia yesterday, I kept on focussing on neurological sx of syncope like sx in him (give past hx of stroke). especially when emerg doc's notes said 55 bpm for HR. What the hell was I thinking. Got insulted at morning rounds for missing that. Oh well.

felt like crap afterwards. ECG, the bane of my existence. In med school you become convinced that you are an idiot and not intelligent at all. Or maybe you are forced to think so. I dont know.
I like interpreteding pfts!
*end of rant.*