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CRITICAL CARE ECG’S

Preeta John

In the diagram normal range - 30 to +90.  Left axis deviation superior and leftward -30 to -90  Right axis deviation inferior and rightward +90 to +150


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

QT Interval  beginning of QRS to end of T wave  Normal: heart rate dependent (corrected QT = QTc = measured QT % sq-root RR in seconds. upper limit for QTc = 0.44 sec)  .

How to read an ECG Standardisation  Rate  Rhythm  Axis  Chamber enlargement & hypertrophy  Arrythmias & conduction delays  Ischaemia / infarction  .

Case scenario 1 26 year old man  Run over by a truck  Managed in local hospital  Brought to casualty 24 hours later  head injuries and extensive crush injury to lower limbs  GCS 10/15  BP: 90/60 HR:46/min  .

 Admitted in ICU and stabilised .

ECG .

1 mEq/l  CPK: 36.000  .5 mg%  S.S.creat: 4. K: 7.

Course Pharmacological measures to decrease pottassium  Dialysis  Surgery  Patient did well and was discharged 2 weeks later  .

ECG .

Take home message Consider potassium derangements in any arrythmia in the ICU  Focus on treating the underlying dyselectrolytemia promptly  .

Case scenario 2 20 year old primigravida from Chittoor  Fever. jaundice and altered sensorium for 5 days  GCS: 12/15  Blood smear positive for plasmodium falciparum  Parasitic index 10%  .

Started on Quinine infusion  On day 2. Sudden hypotension  BP:80 sys HR: 200/min  .

ECG .

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     Polymorphous ventricular tachycardia -Torsade de pointes. IHD .g.g. wide QRS complexes with multiple morphologies changing R .R intervals the axis twists about the isoelectric line recognise this pattern .number of reversible causes      heart block hypokalaemia or hypomagnesaemia drugs e. tricyclic antidepressant overdose congenital long QT syndromes other causes of long QT (e.

DC cardioversion  Causes  Treatment – hemodynamically stable and unstable  Monitor QT interval while on quinine!  .

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

QT   Normal upto 0.45 Stop quinine if ≥ 0.60 .

Quinine discontinued. changed to artemether  QT interval normalised  Delivered fresh stillborn  Gradual recovery  .

Take home message Monitor QT interval while on quinine!  Consider iatrogenic causes of arrythmias .inotropes .drugs .central lines  .

110/60mm Hg  .Case scenario 3 72 year old man  Diabetic with urosepsis  Emphysematous pyelonephritis-post nephrectomy  Being ventilated in ICU  On inotropic support-noradrenaline 5ug/min: BP.

On day 3. sudden hypotension  Cold clammy extremities  BP: 60 sys HR: 140/min  CVP:25cms  Chest: bilateral crackles  CVS: muffled  .

ECG .

Serial ECGs and Cardiac enzymes  Thrombolysis/ UFheparin/ LMWH  Differentials  .

Trop I :12  Thrombolysis contraindicated  Progressive hypotension on increasing inotropes  Expired  .

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Take home message  Consider myocardial ischemia in every case of sudden hypotension .

Smoke  . cough  No DM.Case scenario 4 55yr old man  Sudden onset progressive BOE for 2 days. HTN. fever.  Sudden worsening of breathlessness today  No chest pain.

sharp S2  Abd: NAD  . edema  BP: 110/70mmHg HR:110/min  JVP: elevated 3cms  Resp : clear  CVS: S3.Examination Obese  No pallor.

  Sudden hypoxia and hypotension BP: not recordable .

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Admitted to MICU  Thrombolysed with STK  Improvement over 24 hours  .

On the first post operative day –high grade fever followed by hypotension started on ionotropes . A day later blood culture – heavy growth of pseudomonas  .Case scenario-5  A 30 year old lady diagnosed to have ruptured empyema gall bladder with peritonitis underwent cholecystectomy.

HR.O/E:  BP: 90/40mmHg.160/minute  Interpret her ECG  .

Takotsubo cardiomyopathy .

Takotsubo cardiomyopathy ICU cardiomyopathy  Seen in critically ill patients  Mimics myocardial ischemia  No specific treatment  Reverts as patient improves  No residual complications  .

Case scenario-6 50 year old man known alcoholic presented with a history of acute abdomen  He was diagnosed to have pancreatitis  He had a similar episode 6 months ago and a syncopial attack was admitted in the ICU and discharged a week later  .

Diagnosis .

prothiadine  .Brugada syndrome Congenital channelopathy  Seen in asians  Prone for sudden onset of ventricular tachycardia/cardiac arrest  ICD only treatment  Precipitated by alcohol.

Case scenario-7 25 year old man with a history of corrosive acid poisoning presented a day later with a history of chest pain and fever  O/E: He was febrile BP100/60 PR 140/minute  .

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Case scenario-8 60 year old man with CA stomach underwent a total gastrectomy.He was started on an amiodarone infusion and he settled  24 hours later  .  Subsequently he was intubated.  Common causes ruled out . was febrile and had multiple ventricular ectopics assosiated with hemodynamic instability. Three days later became breathless.

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Take home message All anti arrythmics are proarrythmics too  All patients on amiodarone infusion once stabilised slowly overlap with oral route & taper infusion  Amiodarone half life -prolonged  .

Interesting ECGs .

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Thank you .