Ecg in Emergency

8/8/2019 Ecg in Emergency

1/41

ECG IN EMERGENCYECG IN EMERGENCY

Adi SulistyantoAdi Sulistyanto


2/41

OBJECTIVESOBJECTIVES

1.1. Review ECG InterpretationReview ECG Interpretation

2. Review Cardiac Arrest Management2. Review Cardiac Arrest Management

3. Know when to start and stop resuscitation3. Know when to start and stop resuscitation


3/41

ECGs and stripsECGs and strips


4/41

What?What?

ElektrokardiogrammElektrokardiogramm ((JermanJerman))

NoninvasiveNoninvasive transthoracictransthoracic graphicgraphic

Is a test that records the electrical activityIs a test that records the electrical activity

of the heart.of the heart.


5/41

IndicationIndication

Chest PainChest Pain

PalpitationPalpitation

SyncopeSyncopeAny suspected cardiac patientAny suspected cardiac patient

Cardiac monitoring for critically ill patientsCardiac monitoring for critically ill patients


6/41

What types of pathology can weWhat types of pathology can we

identify and study from EKGs?identify and study from EKGs?

ArrhythmiasArrhythmias

Myocardial ischemia and infarctionMyocardial ischemia and infarction

PericarditisPericarditis

Chamber hypertrophyChamber hypertrophy

Electrolyte disturbances (i.e.Electrolyte disturbances (i.e.

hyperkalemiahyperkalemia,, hypokalemiahypokalemia)) Drug toxicity (i.e.Drug toxicity (i.e. digoxindigoxin and drugs whichand drugs which

prolong the QT interval)prolong the QT interval)


7/41

TREAT THE PATIENTTREAT THE PATIENT

NOT THE ECGNOT THE ECG


8/41

Lead PositionLead Position


9/41

Anatomic GroupsAnatomic Groups(Summary)(Summary)


10/41

The Normal Conduction SystemThe Normal Conduction System


11/41


12/41

BASIC ECGBASIC ECG

INTERPRETATIONINTERPRETATIONSimple, quick method inSimple, quick method in

emergenciesemergencies


13/41

Step 1: Heart RateStep 1: Heart Rate

Step 2:Step 2: RhytmRhytm

Step 3: P wavesStep 3: P waves

Step 4: PR IntervalStep 4: PR Interval

Step 5: QRS ComplexStep 5: QRS Complex


14/41

Waveforms and IntervalsWaveforms and Intervals


15/41

Determining the Heart RateDetermining the Heart Rate

Rule of 300Rule of 300

6 Second Rule6 Second Rule


16/41

The Rule of 300The Rule of 300

It may be easiest to memorize the following table:It may be easiest to memorize the following table:

# of big# of big

boxesboxes

RateRate

11 300300

22 150150

33 100100

44 7575

55 6060

66 5050


17/41

What is the heart rate?What is the heart rate?

(300 / ~ 4) = ~ 75 bpm

www.uptodate.com


18/41

6 Second Rule6 Second Rule

Count the number of complexes on a 6 secondCount the number of complexes on a 6 second

strip and multiply them by 10strip and multiply them by 10

This method works well for irregular rhythms.This method works well for irregular rhythms.


19/41

P WavesP Waves

Are they present?Are they present?

OccuringOccuring regularly?regularly?

Is there P Waves for each QRS?Is there P Waves for each QRS?

Normal appearance?Normal appearance?

Do all P waves look similar?Do all P waves look similar?


20/41


21/41

PR IntervalPR Interval

0.120.12 0.20 seconds0.20 seconds

ConstantConstant


22/41


23/41

QRS ComplexQRS Complex

Narrow (0.12 seconds)?

Similar?Similar?


24/41


25/41


26/41

FOUR LETHAL RHYTMSFOUR LETHAL RHYTMS


27/41


28/41

TheThe mostmost commoncommon causecause ofof aa atlineatline tracingtracing

onon ECGECG isis aa detacheddetached leadlead or or

malfunctioningmalfunctioning equipment,equipment, notnot asystoleasystole;;

therefore,therefore, alwaysalways conrmconrm asystoleasystole inin moremore

thanthan oneone lead!lead!

NeverNever shockshock asystoleasystole (no(no mattermatter whatwhat youyou

seesee onon TV)TV)..


29/41

AsystoleAsystole interventions :interventions :

1. ABCs, O2, IV access, cardiac monitor,1. ABCs, O2, IV access, cardiac monitor,

pulsepulse oximetryoximetry

2. CPR.2. CPR.

3. Consider possible causes.3. Consider possible causes.

4. Consider immediate4. Consider immediate transcutaneoustranscutaneous

pacing (Classpacing (Class IIbIIb).).

5. Epinephrine 1 mg IV push q 35. Epinephrine 1 mg IV push q 35 minutes.5 minutes.


30/41

PulselessPulseless Electrical ActivityElectrical Activity

Any normallyAny normally perfusingperfusing rhythm in whichrhythm in which

there is no detectable pulse.there is no detectable pulse.


31/41

Possible Causes ofPossible Causes of AsystoleAsystole &&

PEAPEA 6 H & 5T6 H & 5T

HypovolemiaHypovolemia

HypoxiaHypoxiaHydrogenHydrogen

Hypo/Hypo/HyperkalemiaHyperkalemia

HypoglycemiaHypoglycemiaHypothermiaHypothermia

ToxinsToxins

TamponadeTamponadeTensionTension

PneumothoraxPneumothorax

ThrombosisThrombosisTraumaTrauma


32/41


33/41


34/41

DebrillationDebrillation should take precedence over establishingshould take precedence over establishing

IV access, intubation, or the administration of any drug!IV access, intubation, or the administration of any drug!

ABCsABCs

Initiate and continue CPR untilInitiate and continue CPR until debrillatordebrillator is attached.is attached.

DebrillateDebrillate (shock), 120(shock), 120--200 J (biphasic) or 360J200 J (biphasic) or 360J

((monophasicmonophasic).).

Epinephrine 1 mg IV q 3Epinephrine 1 mg IV q 35 minutes or vasopressin 40 U5 minutes or vasopressin 40 U

IVIV 1.1.

AmiodaroneAmiodarone 300 mg IV for VF/300 mg IV for VF/pulselesspulseless VT, repeat 150VT, repeat 150

mgmg

LidocaineLidocaine 1 to 1.5 mg/kg repeat 0.51 to 1.5 mg/kg repeat 0.5--0.75 mg/kg until max0.75 mg/kg until max

3 mg/kg3 mg/kg


35/41


36/41

Causes of cardiac arrestCauses of cardiac arrest

In Adults:In Adults:

VentricularVentricularFibrilationFibrilation (65(65--85%)85%)

SHOCK EARLY !SHOCK EARLY !Chances decrease 7Chances decrease 7--10% each minute10% each minute

In ChildrenIn Children

Respiratory insufficiency (60%)Respiratory insufficiency (60%)VF (


37/41


38/41

Stopping resuscitationStopping resuscitation

ROSCROSC

ExhaustionExhaustion

Apparent signs of deathApparent signs of death

Depending on local regulation andDepending on local regulation and

physician medicalphysician medical judgementjudgement


39/41

Death In MedicineDeath In Medicine

1.1. Clinical Death:Clinical Death:

Cessation of respiration and heart beatCessation of respiration and heart beat

2. Brain death ( Biological death):2. Brain death ( Biological death):

Permanent cessation of electrical activityPermanent cessation of electrical activity

in the brainin the brainSpecific criteria from differentSpecific criteria from different

organizationsorganizations


40/41

Brain death criteriaBrain death criteria

Prerequisite:Prerequisite:

Structural CNS disease, no complicatingStructural CNS disease, no complicating

medical condition/toxins, and coremedical condition/toxins, and coretemperature > 32 Ctemperature > 32 C

Cardinal findings:Cardinal findings:

1. Coma or unresponsiveness1. Coma or unresponsiveness2. Absence of brainstem reflexes2. Absence of brainstem reflexes

3. Positive apnea testing3. Positive apnea testing


41/41

The endThe end

Ecg in Emergency

Documents

Transcript of Ecg in Emergency