INTRODUCTION

What is emergency ECG

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Chain of Survival

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Cardiac abnormalities: Acute Coronary Syndromes

Clinical syndromes form spectrum of the same disease process:
Unstable angina Non-Q wave myocardial infarction Q wave myocardial infarction
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Immediate treatment in all acute coronary syndromes

MONA Morphine (or diamorphine) Oxygen Nitroglycerine (GTN spray or tablet) Aspirin 300 mg orally (crushed/chewed)
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Patients with ST segment elevation MI or MI with LBBB

Early coronary reperfusion therapy: Thrombolytic therapy
streptokinase alteplase

Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass surgery (CABG)
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CARDIAC MONITORING & RHYTHM RECOGNITION

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Which patients?
Cardiac arrest or other important arrhythmias Chest pain Heart failure Collapse / syncope Shock / hypotension Palpitations
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How to read a rhythm strip

1. Is there any electrical activity? 2. What is the ventricular (QRS) rate? 3. Is the QRS rhythm regular or irregular? 4. Is the QRS width normal or prolonged? 5. Is atrial activity present? 6. How is it related to ventricular activity?
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ECG rhythm interpretation

Effective treatment often possible without precise ECG diagnosis Haemodynamic consequences of any given rhythm will vary Treat the patient not the rhythm

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What is the ventricular rate?

Normal Bradycardia Tachycardia Rate = 60-100 min-1 < 60 min-1 > 100 min-1

300 Number of large squares between consecutive QRS complexes*

* At standard paper speed of 25 mm sec-1, 5 large squares = 1 second

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Is the QRS rhythm regular or irregular?

Unclear at rapid heart rates Compare R-R intervals Irregularly irregular = AF

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Is the QRS width normal or prolonged?

Normal QRS: < 0.12 s (< 3 small squares) originates from above bifurcation of bundle of His

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Is the QRS width normal or prolonged?

Prolonged QRS (> 0.12 s) arises from: ventricular myocardium, or supraventricular with aberrant conduction

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Is atrial activity present?

P waves (leads II and V1) Rate, regularity, morphology Flutter waves Atrial activity may be revealed by slowing QRS rate with adenosine

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How is atrial activity related to ventricular activity?

Consistent, fixed PR interval Variable, but recognisable pattern No relationship - atrioventricular dissociation

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Heart Block: First Degree

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Heart Block: Second Degree

Mbitz Type I (Wenckebach) Block

Mbitz Type II Block

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Heart Block: Third Degree

Site of pacemaker:
AV node 40 - 50 min-1 Ventricular myocardium 30 - 40 min-1
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DEFIBRILLATION

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Mechanism of defibrillation
Definition The termination of fibrillation or absence of VF/VT at 5 seconds after shock delivery Critical mass of myocardium depolarised Natural pacemaker tissue resumes control
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Defibrillation
Success depends on delivery of current to the myocardium Current flow depends upon: Electrode position Transthoracic impedance Energy delivered Body size
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Transthoracic Impedance
Dependent upon: Electrode size Electrode/skin interface Contact pressure Phase of respiration Sequential shocks
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Ventricular fibrillation
Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Unco-ordinated electrical activity Coarse / fine Exclude artifact
movement electrical interference
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Pulseless ventricular tachycardia

Monomorphic VT Broad complex rhythm Rapid rate Constant QRS morphology Polymorphic VT Torsade de pointes
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Asystole
Absent ventricular (QRS) activity Atrial activity (P waves) may persist Rarely a straight line trace Consider fine VF

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Pulseless Electrical Activity

Clinical features of cardiac arrest ECG normally associated with an output

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Cardiac Arrest
Precordial Thump if appropriate

Universal ALS Algorithm

BLS Algorithm if appropriate Attach Defib-Monitor

Assess Rhythm

VF/VT
Defibrillate X 1 CPR 2 min

+/- Check Pulse

Non-VF/VT

During CPR
Correct reversible causes If not already: check electrodes, paddle position and contact attempt / verify airway & O2 i.v. access give epinephrine every 3 min Consider: amiodarone, atropine / pacing buffers

CPR 2 min

Potential reversible causes:

Hypoxia Hypovolaemia Hypo/hyperkalaemia & metabolic disorders Hypothermia Tension pneumothorax Tamponade Toxic/therapeutic disorders Thrombo-embolic & mechanical obstruction

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Cardiac Arrest
Precordial Thump if appropriate BLS Algorithm if appropriate

Attach Defib-Monitor

Assess Rhythm +/- Check Pulse

VF/VT

Non-VF/VT
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Case ECG

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Thank U

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