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ECG IN EMERGENCYECG IN EMERGENCY
Adi SulistyantoAdi Sulistyanto
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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
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ECGs and stripsECGs and strips
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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.
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IndicationIndication
Chest PainChest Pain
PalpitationPalpitation
SyncopeSyncopeAny suspected cardiac patientAny suspected cardiac patient
Cardiac monitoring for critically ill patientsCardiac monitoring for critically ill patients
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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)
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TREAT THE PATIENTTREAT THE PATIENT
NOT THE ECGNOT THE ECG
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Lead PositionLead Position
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Anatomic GroupsAnatomic Groups(Summary)(Summary)
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The Normal Conduction SystemThe Normal Conduction System
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BASIC ECGBASIC ECG
INTERPRETATIONINTERPRETATIONSimple, quick method inSimple, quick method in
emergenciesemergencies
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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
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Waveforms and IntervalsWaveforms and Intervals
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Determining the Heart RateDetermining the Heart Rate
Rule of 300Rule of 300
6 Second Rule6 Second Rule
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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
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What is the heart rate?What is the heart rate?
(300 / ~ 4) = ~ 75 bpm
www.uptodate.com
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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.
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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?
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PR IntervalPR Interval
0.120.12 0.20 seconds0.20 seconds
ConstantConstant
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QRS ComplexQRS Complex
Narrow (0.12 seconds)?
Similar?Similar?
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FOUR LETHAL RHYTMSFOUR LETHAL RHYTMS
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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)..
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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.
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PulselessPulseless Electrical ActivityElectrical Activity
Any normallyAny normally perfusingperfusing rhythm in whichrhythm in which
there is no detectable pulse.there is no detectable pulse.
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Possible Causes ofPossible Causes of AsystoleAsystole &&
PEAPEA 6 H & 5T6 H & 5T
HypovolemiaHypovolemia
HypoxiaHypoxiaHydrogenHydrogen
Hypo/Hypo/HyperkalemiaHyperkalemia
HypoglycemiaHypoglycemiaHypothermiaHypothermia
ToxinsToxins
TamponadeTamponadeTensionTension
PneumothoraxPneumothorax
ThrombosisThrombosisTraumaTrauma
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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
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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 (
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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
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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
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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
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The endThe end