critical care ecg's

CRITICAL CARE ECG’SCRITICAL CARE ECG’S

Preeta JohnPreeta John

In the diagram normal range - 30 to +90. In the diagram normal range - 30 to +90. Left axis deviation superior and leftward Left axis deviation superior and leftward

-30 to -90-30 to -90Right axis deviation inferior and rightward Right axis deviation inferior and rightward

+90 to +150 +90 to +150

PR IntervalPR Interval beginning of P to beginning of QRS beginning of P to beginning of QRS Normal: 0.12 - 0.20s Normal: 0.12 - 0.20s Short PR: < 0.12sShort PR: < 0.12s QRS DurationQRS Duration duration of QRS complex duration of QRS complex Normal: 0.06 - 0.12s Normal: 0.06 - 0.12s

QT IntervalQT Interval beginning of QRS to end of T wave beginning of QRS to end of T wave Normal: heart rate dependent (corrected Normal: heart rate dependent (corrected

QTQT = = QTQTcc = measured QT % sq-root RR = measured QT % sq-root RR in seconds; upper limit for QTin seconds; upper limit for QTcc = 0.44 sec) = 0.44 sec)

How to read an ECG How to read an ECG

StandardisationStandardisationRateRateRhythmRhythmAxisAxisChamber enlargement & hypertrophyChamber enlargement & hypertrophyArrythmias & conduction delaysArrythmias & conduction delays Ischaemia / infarctionIschaemia / infarction

Case scenario 1Case scenario 1

26 year old man26 year old manRun over by a truckRun over by a truckManaged in local hospitalManaged in local hospitalBrought to casualty 24 hours later Brought to casualty 24 hours later head injuries and extensive crush injury to head injuries and extensive crush injury to

lower limbslower limbsGCS 10/15GCS 10/15BP: 90/60BP: 90/60 HR:46/minHR:46/min

Admitted in ICU and stabilisedAdmitted in ICU and stabilised

ECGECG

S.creat: 4.5 mg%S.creat: 4.5 mg%S. K: 7.1 mEq/lS. K: 7.1 mEq/lCPK: 36,000CPK: 36,000

CourseCourse

Pharmacological measures to decrease Pharmacological measures to decrease pottassiumpottassium

DialysisDialysisSurgerySurgeryPatient did well and was discharged 2 Patient did well and was discharged 2

weeks laterweeks later

ECGECG

Take home messageTake home message

Consider potassium derangements in any Consider potassium derangements in any arrythmia in the ICUarrythmia in the ICU

Focus on treating the underlying Focus on treating the underlying dyselectrolytemia promptlydyselectrolytemia promptly

Case scenario 2Case scenario 220 year old primigravida from Chittoor20 year old primigravida from ChittoorFever, jaundice and altered sensorium for Fever, jaundice and altered sensorium for

5 days5 daysGCS: 12/15GCS: 12/15Blood smear positive for plasmodium Blood smear positive for plasmodium

falciparumfalciparumParasitic index 10%Parasitic index 10%

Started on Quinine infusionStarted on Quinine infusionOn day 2, Sudden hypotensionOn day 2, Sudden hypotensionBP:80 sysBP:80 sys HR: 200/minHR: 200/min

ECGECG

Polymorphous ventricular tachycardia -Torsade de Polymorphous ventricular tachycardia -Torsade de pointes. pointes.

wide QRS complexes with multiple morphologies wide QRS complexes with multiple morphologies changing R - R intervals changing R - R intervals the axis twists about the isoelectric line the axis twists about the isoelectric line recognise this pattern - number of reversible causes recognise this pattern - number of reversible causes

heart block heart block hypokalaemia or hypomagnesaemia hypokalaemia or hypomagnesaemia drugs e.g. tricyclic antidepressant overdose drugs e.g. tricyclic antidepressant overdose congenital long QT syndromescongenital long QT syndromes other causes of long QT (e.g. IHDother causes of long QT (e.g. IHD

http://www.ecglibrary.com/l_qt.html

DC cardioversionDC cardioversionCausesCausesTreatment – hemodynamically stable and Treatment – hemodynamically stable and

unstableunstableMonitor QT interval while on quinine!Monitor QT interval while on quinine!

The QT interval duration is greater than The QT interval duration is greater than 50% of the RR interval, a good indication 50% of the RR interval, a good indication that it is prolonged in this patient. Although that it is prolonged in this patient. Although there are many causes for the long QT, there are many causes for the long QT, patients with this are at risk for malignant patients with this are at risk for malignant ventricular arrhythmias, syncope, and ventricular arrhythmias, syncope, and sudden death. sudden death.

QTQT

Normal upto 0.45Normal upto 0.45 Stop quinine if Stop quinine if ≥≥ 0.60 0.60

Quinine discontinued, changed to Quinine discontinued, changed to artemetherartemether

QT interval normalisedQT interval normalisedDelivered fresh stillbornDelivered fresh stillbornGradual recoveryGradual recovery


Monitor QT interval while on quinine!Monitor QT interval while on quinine!Consider iatrogenic causes of arrythmiasConsider iatrogenic causes of arrythmias

- drugs- drugs

- inotropes- inotropes

- central lines- central lines


72 year old man72 year old manDiabetic with urosepsisDiabetic with urosepsisEmphysematous pyelonephritis-post Emphysematous pyelonephritis-post

nephrectomynephrectomyBeing ventilated in ICUBeing ventilated in ICUOn inotropic support-noradrenaline On inotropic support-noradrenaline

5ug/min: BP- 110/60mm Hg5ug/min: BP- 110/60mm Hg

On day 3, sudden hypotensionOn day 3, sudden hypotensionCold clammy extremitiesCold clammy extremitiesBP: 60 sysBP: 60 sys HR: 140/minHR: 140/minCVP:25cmsCVP:25cmsChest: bilateral cracklesChest: bilateral cracklesCVS: muffledCVS: muffled

ECGECG

Serial ECGs and Cardiac enzymesSerial ECGs and Cardiac enzymesThrombolysis/ UFheparin/ LMWHThrombolysis/ UFheparin/ LMWHDifferentialsDifferentials

Trop I :12Trop I :12Thrombolysis contraindicatedThrombolysis contraindicatedProgressive hypotension on increasing Progressive hypotension on increasing

inotropesinotropesExpiredExpired


Consider myocardial ischemia in every Consider myocardial ischemia in every case of sudden hypotensioncase of sudden hypotension


55yr old man55yr old manSudden onset progressive BOE for 2 Sudden onset progressive BOE for 2

days. days. Sudden worsening of breathlessness Sudden worsening of breathlessness

todaytodayNo chest pain, fever, coughNo chest pain, fever, coughNo DM, HTN, SmokeNo DM, HTN, Smoke

ExaminationExamination

ObeseObeseNo pallor, edemaNo pallor, edemaBP: 110/70mmHg HR:110/minBP: 110/70mmHg HR:110/minJVP: elevated 3cmsJVP: elevated 3cmsResp : clearResp : clearCVS: S3, sharp S2CVS: S3, sharp S2Abd: NADAbd: NAD

Sudden hypoxia and Sudden hypoxia and hypotensionhypotension

BP: not recordableBP: not recordable

Admitted to MICUAdmitted to MICUThrombolysed with STKThrombolysed with STK Improvement over 24 hoursImprovement over 24 hours

Case scenario-5Case scenario-5

A 30 year old lady diagnosed to have A 30 year old lady diagnosed to have ruptured empyema gall bladder with ruptured empyema gall bladder with peritonitis underwent cholecystectomy. On peritonitis underwent cholecystectomy. On the first post operative day –high grade the first post operative day –high grade fever followed by hypotension started on fever followed by hypotension started on ionotropes . A day later blood culture –ionotropes . A day later blood culture –heavy growth of pseudomonas heavy growth of pseudomonas

O/E:O/E:BP: 90/40mmHg. HR- 160/minuteBP: 90/40mmHg. HR- 160/minute Interpret her ECGInterpret her ECG

Takotsubo cardiomyopathyTakotsubo cardiomyopathy

Takotsubo cardiomyopathyTakotsubo cardiomyopathy

ICU cardiomyopathyICU cardiomyopathySeen in critically ill patientsSeen in critically ill patientsMimics myocardial ischemiaMimics myocardial ischemiaNo specific treatment No specific treatment Reverts as patient improvesReverts as patient improvesNo residual complicationsNo residual complications


50 year old man known alcoholic 50 year old man known alcoholic presented with a history of acute abdomenpresented with a history of acute abdomen

He was diagnosed to have pancreatitisHe was diagnosed to have pancreatitisHe had a similar episode 6 months ago He had a similar episode 6 months ago

and a syncopial attack was admitted in the and a syncopial attack was admitted in the ICU and discharged a week laterICU and discharged a week later

DiagnosisDiagnosis

Brugada syndromeBrugada syndrome

Congenital channelopathyCongenital channelopathySeen in asians Seen in asians Prone for sudden onset of ventricular Prone for sudden onset of ventricular

tachycardia/cardiac arresttachycardia/cardiac arrest ICD only treatmentICD only treatmentPrecipitated by alcohol, prothiadinePrecipitated by alcohol, prothiadine


25 year old man with a history of corrosive 25 year old man with a history of corrosive acid poisoning presented a day later with a acid poisoning presented a day later with a history of chest pain and feverhistory of chest pain and fever

O/E: He was febrile BP100/60 PR O/E: He was febrile BP100/60 PR 140/minute140/minute


60 year old man with CA stomach 60 year old man with CA stomach underwent a total gastrectomy. Three days underwent a total gastrectomy. Three days later became breathless, was febrile and later became breathless, was febrile and had multiple ventricular ectopics had multiple ventricular ectopics assosiated with hemodynamic instability.assosiated with hemodynamic instability.

Subsequently he was intubated.Subsequently he was intubated.Common causes ruled out .He was started Common causes ruled out .He was started

on an amiodarone infusion and he settled on an amiodarone infusion and he settled 24 hours later 24 hours later


All anti arrythmics are proarrythmics tooAll anti arrythmics are proarrythmics tooAll patients on amiodarone infusion once All patients on amiodarone infusion once

stabilised slowly overlap with oral route & stabilised slowly overlap with oral route & taper infusiontaper infusion

Amiodarone half life -prolonged Amiodarone half life -prolonged

Interesting ECGsInteresting ECGs

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critical care ecg's

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