indiana ena 2013 lead avr
TRANSCRIPT
EKG Lead aVr: What You DON’T Know May Kill Your
Patient
EKG Lead aVr: What You DON’T Know May Kill Your
PatientAndrew J. BowmanAcute Care Nurse PractitionerFellow American College CV Nurses
Emergency Departments
Witham Health Services - Lebanon
IU Health Arnett - Lafayette
Disclosures
No financial disclosures
EKG Club
Co-Founder Facebook – 1500+ (1800+ as of today)
History EKG
First recorded 1887 – Waller
Clinical tool - Einthoven
Einthoven’s EKG
Leads
Limb Leads
Augmented Limb Leads
Precordial Leads
Limb Leads & Augmented Limb Leads
Einthoven’s Triangle
Normal Ventricular Axis
Limb Leads
I II III
Augmented Limb Leads
aVr aVl aVf
Precordial Leads
V1 V2 V3 V4 V5 V6
Normal EKG
“Map’ of EKG
“Map’ of EKG
“Map’ of EKG
???
“Map” of EKG
Analogy
Anterior
Lateral
Lead aVr (or How Many View It)
Why EKG?
Cardiac Problems
Non-Cardiac Problems
Cardiac Problems
Ischemia Injury Infarction Arrhythmia Cardiomyopathy
Non-Cardiac Problems
Electrolyte Disorders Toxidromes Pulmonary Embolism
Lead aVr
An augmented limb lead placed on right arm
Most commonly used to assure proper limb lead placement
Common belief rarely offers useful information “forgotten 12th lead”
“Forgotten 12th Lead”
11
Lead aVr
Actual several good reasons to carefully evaluate lead aVr
Lead aVr
STEMI / STEMI Equivalent SVT r/t WPW VT vs. SVT in WCT Pericarditis Na+ Channel Blocker Toxicity
STEMI
ST segment Elevation Myocardial Infarction– A need to recognize pattern indicating
acute myocardial infarction and need for emergent reperfusion therapies (PCI preferred)
STEMI Patterns to Know
Inferior Lateral Septal Anterior Posterior
STEMI Patterns to Know
STEMI Patterns to Know
Inferior STEMI
Lateral STEMI
Anterior-Septal STEMI
Inferior-Posterior STEMI
How is aVr Helpful in STEMI?
Case
64 year old man Hx MI, HTN, DM Left arm pain
Case EKG
What Do We See?
Case Progression
ACS Widespread ST depression (STD)
– STE aVr & aVl & V1 ASA NTG Heparin
Case Evolution
Admitted to ICU
8 Hours Later
Cardiogenic Shock
Died
STE Lead aVr
In setting of ACS, STE Lead aVr– LMCA Stenosis– Proximal LAD Stenosis– Triple Vessel Disease
– All BAD!!!!
STE Lead aVr
STE aVr + aVl = LMCA Stenosis
STE Lead aVr
STE aVr + aVl = LMCA Stenosis STE aVr > STE V1 = LMCA Stenosis
STE Lead aVr
STE aVr + aVl = LMCA Stenosis STE aVr > STE V1 = LMCA Stenosis Greater STE aVr, more likely LMCA
Stenosis
ACS with LMCA Stenosis
HIGH Mortality w/o PCI
Medical Tx Does NOT Help!!
My Recent Case
47 yowm Chest pain and heart racing 1 hr PTA **Sweating** Hx smokes, HTN No Known CAD
Initial EKG
Initial Evaluation
P - 178 R - 24 BP - 260/180 SpO2 – 95% Pain – 2/10 Given ASA, IV Cardizem Repeat EKG
EKG 2
Evolution
HR Better Still CP 2/10 NTG with Better BP EKG Repeated
EKG 3
Evolution 2
Concern for STEMI or Equivalent Diffuse STD STE aVr STE V1 Concern for “BADNESS”
Evolution 2
Interventionalist Paged and to ER
Patient to Cath Lab
Returned 15 Minutes Later
“Not STEMI” “LVH”
Evolution 3
Initial Troponin 0.14 (0.10)
Admitted
AM Troponin 13.3!!
Cath Lab
Cath Lab
Triple Vessel Disease
Cath Lab
Triple Vessel Disease
– “BADNESS”
Why Delay?
Cardiologists are often behind the times
Large percentage of STEMI EKG literature is from EM
We have to “convince” cardiology
Next Case
85 yowm Chest Pain EKG
EKG
What Do We See?
Widespread STD STE aVr STE aVl
Evolution
Elevated Troponin Dx NSTEMI Admitted
Continued to Have Pain!
Repeat EKG
STE aVr + deWinter ST-T
Lead aVr in STEMI
In setting of ACS, STE Lead aVr– LMCA Stenosis– Proximal LAD Stenosis– Triple Vessel Disease
– All BAD!!!!
How Else Is aVr helpful?
SVT w WPW
SVT with WPW
14 yowm Dizziness Healthy Exam – Tachycardia EKG
EKG
SVT
SVT
SVT
STE Lead aVr with NCT likely to be WPW
Confirm delta waves on post conversion EKG
STE & STD in SVT are not Dx ischemia
How Else May We Use aVr?
VT vs SVT in WCT
Numerous Old Algorithms
Brugada Criteria Wellens Criteria Akhtar Criteria Griffith Criteria
Brugada Criteria
4 step process– No RS complex all precordial leads?
– RS interval > 100ms in 1 precordial lead?
– AV dissociation?
– Morphology criteria for VT present in precordial leads V1-2 and V6?
Wellens Criteria
QRS width > 0.14 secs
Left axis deviation > -30
AV Dissociation
Certain QRS configurations– RBBB type QRS
Monophasic R, qR, QR, RS in V1 R/S < 1, monophasic R, QR, QS in V6
– LBBB type QRS qR or Qs in V6
Akhtar Criteria
AV Dissociation
Positive QRS concordance
QRS axis between –90 and +180
LBBB and rightward axis >90
RBBB and QRS > 0.14 secs
LBBB and QRS > 0.16 secs
QRS morphology during tachycardia different from baseline preexisting BBB
Griffith Criteria
SVT diagnosed only if QRS morphology is typical of a BBB
– RBBB rSR’ in V1 and RS in V6 with R/S > 1
– LBBB rS or QS in V1 and V2 and delay to S nadir
< 70 msecsR wave and no Q wave in V6
What Makes It Easy?
Old EKG!
New Algorithm
Uses a SINGLE EKG lead
VT vs SVT Lead aVr (Verecki et al, January 2008, Heart Rhythm, 5/1)
WCT + SVT
WCT = VT
WCT = VT
Notched QS = VT
What Else is aVr Helpful For?
Pericarditis
Diffuse “global” STE or STD
PR segment depression inferior leads
PR segment elevation aVr
Pericarditis
Pericarditis
Pericarditis
Pericarditis
Finally, What Else?
Na+ Channel Blocker Toxicity
Amitriptyline Chlorimipramine Desipramine Doxepin Imipramine Nortriptyline Protriptyline
Elavil Clomipramine Norpramin Sinequan Tofranil Pamelor Vivactil
TCA OD Effects
AMS Hypotension Tachycardia Prolonged QRS, QTc Seizures Cardio-Respiratory Arrest
Terminal R Wave
TCA OD
TCA OD
TCA OD
TCA OD
Poorly Responsive Young Male
After Tx
TCA OD and What Else??
TCA “SALT”
Shock AMS Long QRS & QTc Terminal R in Lead aVr
“SALT” is also the cure NaHCO3
Lead aVr
May be VERY helpful in…– STEMI– SVT r/t WPW– VT vs SVT in WCT– Pericarditis– TCA OD
Handout
Thanks to Michelle Lin, MD Academic Life in Emergency Medicine
– ALiEM– academiclifeinem.com
Paucis Verbis cards
Web Sites
ekgumem.tumblr.com Dr. Mattu’s
ecg.bidmc.harvard.edu/maven Lots of EKG’s
hqmeded-ecg.blogspot.com Dr. Smith
ecgguru.com Free Downloads
en.ecgpedia.org Comprehensive Overview