1. EKGs, Beyond the Basics
Dr. Umar Malik

2. Learning Objectives Apply the ACLS protocol
Determine when certain conditions are emergencies
Review common EKG findings you may encounter as a senior resident

3. Case 1
65yoM w HTN, CKD3 is BIBA w chest pain since he woke up 1hr ago. He describes the pain as substernal and associated w SOB. He describes prior episodes of palpitations but no prior CP. ROS also w productive cough x3ds.
Afebrile, HR 160, BP 105/48, RR 29, 92% 2L
Skin is pale no cyanosis. HEENT reveals no JVD, lungs are clear. Heart exam is tachy and regular. Exts without edema.
Given this history, what is your immediate intervention/test?
Review Vitals and PE, what is concerning or not? Answer: EKG and/or cardiac monitoring

4. Case 1 initial ekg:
Answer: Wide complex tachycardia with short cycle length. VT until proven otherwise

5. Case 1 continued What would you like to do next?
Discuss ACLS protocol for this patient and the reason you would run a particular pathway. ACLS protocol: VT with pulse. Sustained VT with hemodynamic compromise, likely requires ICU level care vs 7S vs SDU.

6. The pt returned into NSR after amiodarone bolus and gtt
The pt returned into NSR after amiodarone bolus and gtt. He was also given Ativan in preparation for cardioversion, but was not cardioverted. He is stabilized for the time being.
The next evening you are the night resident taking care of this pt in the SDU as he was “too stable” for MICU. He is off of all drips. You are called to the bedside due to a “change in rhythm.”

7. Now what is your first step?
He is confused and is not sure of where he is. When you ask him what is bothering him, he points to his chest.
VS: P >200, weak, BP 85/40 RR 30, O2S 92% 4L, Exam grossly unchanged.
Now what is your first step?
Signs of hemodynamic instability in a setting of tachycardia requires a STAT EKG

8. Case 1 EKG #2
Torsades de points

9. What do you want to know/order? What do you need to do?
You want to know why is in in Torsades, (ie chem10), but do you have time for this? Of course not, he needs to come out of the rhythm asap 2/2 BP. Let’s shock him!

10. You administer a second shock. The following rhythm is shown:
200J is administered with no change in rhythm. Now what do you do? How long do you wait until the next intervention?
You administer a second shock. The following rhythm is shown:
Consider administering Magnesium.

11. This looks like V.Fib on the monitor…check for pulses and responsiveness
Now what?

12. The pt is now completely unresponsive and pulseless
The pt is now completely unresponsive and pulseless. What is your next step?
ACLS: VF/pulseless VT. Start CPR first

13. Epinephrine is administered and 1 additional shock delivered
Epinephrine is administered and 1 additional shock delivered. CPR started, 2 minutes later the new rhythm shows:
Sinus tach

14. What is this and what do we do?
PEA if no pulse. Protocol: asystole, PEA arrest. Now we can circle back and start thinking about causes:
No pulse is noted.
What is this and what do we do?

15. What are those H’s and T’s again?
What are the pertinent findings here regarding PEA treatment?
Hypovolemia
Hypoxia
Hydrogen ion (acidosis),
Hyper-/hypokalemia,
Hypoglycemia
Hypothermia
Toxins
Tamponade(cardiac
Tension pneumothorax
Thrombosis (coronary and pulmonary)
Trauma

16. Case 2
67 Y/o M w CAD s/p CABG, IDDMII, HTN, HLD, admitted with COPD exacerbation.
The telemetry room calls you regarding the patient’s “brady” rate.
What do you want to know right now?
Elevator thoughts? Anticipatory plans?
What was his rate prior to this? What are his other vital signs. Change in mental status? Other pertinent physical exam findings? As you are approaching the patient, run the bradycardia ACLS protocol. What will you do if he is not HDS? What will you do if he is HDS?

17. VS: HR 48 BP 96/60 RR 24 90% 5L NC
GEN: AO X 3
CV: brady/regular no m/r/g
Lungs: CTA
LE: no edema
EKG:

18. Case #2 EKG Interpretation
Sinus brady

20. Same pt now develops chest pain, dyspnea, and AMS
HR 30, BP 80/55, RR 16, 89% on 5L NC
EKG: Sinus brady HR 38
Telemetry review remarkable for:
Notice: HR slowed down even more

21. EKG interpretation

22. Second degree heart block type 2, P-R intervals are the same, random QRS is dropped

23. Now what do you do? Why?
Pacemaker? Cardiology consult? Transfer to the MICU 2/2 hemodynamic instability

24. Case 3
38yoF w dizziness over the last few ds. She works in many homes with non-functioning air conditioners. She denies any change in sxs a/w position. She denies CP, SOB, Palpitations. She has not seen a doctor in the last 6yrs but believes she has high BP and is not taking any medications.
Afebrile, BP 70/40, HR 32, RR 15, 96% on RA
Gen: Pt laying in bed, Awake, but feeling very dizzy
Lungs: bi-basilar crackles
CV: Brady, regular, equal pulses

25. Case 3 EKG
Mobitz
Mobitz
3rd degree block?

26. Case 3 Questions What is the diagnosis? What is the first step?
What do you do next?
3rd degree heart block causing bradycardia. 1st step EKG and check for pulse. 2nd step: get ready to give atropine.

27. Additional Questions How much atropine can you give?
What would you do if she had been taking Metoprolol PO?
ACLS, Atropine 0.5mg q3-5mins. If beta blocker overdose, use glucagon.

28. Case 4
45yoF w palpitations. She reports dizziness but denies LOC, no N/V, SOB or CP. She reports that she has felt this way since riding the "6" to work this a.m. -the air wasn't working, so instead of going to work she came into the ED.
Afebrile, HR is 240, BP 110/70, RR 18, 97%RA.
HEENT reveals no JVD, no bruits. Lungs are clear, heart is tachy and regular. Extremities show no edema.
What is your initial management of this patient?

29. Case 4 EKG
Narrow complex tachycardia SVT vs AVNRT

30. What non-pharmacological intervention would be appropriate?
What pharmacological intervention would be appropriate?
Can you vasalvagal maneuvers like coughing or bearing down. Carotid massage. If doesn’t work then you can admin 6mg Adenosine. Make sure they understand that sedation may be necessary for adenosine and use to pacemaker pads in case she has underlying heart disease which may cause her heart not to jumpstart back up.

31. After a dose of Adenosine the patient felt better and returned into sinus rhythm with HR of 75

32. Case #5: The patient is asymptomatic. What is the management?
Wolff-Parkinson-White maybe with A. Fib (might be getting too fancy)
Short PR interval (due to the absence of a delay via the AV node by the accessory pathway) with a mildly wide QRS. Delta waves present most prominently in the inferior and anterior leads in this EKG

33. Wolf Parkinson WhitE Look at those delta waves!
Avoid ALL AV nodal blockers
Can consider procainamide or other non- AV-nodal-acting antiarrhythmic

34. Case #6 Inferior/posterior MI
ST elevation seen in leads III and aVF. Large R-waves seen in the anterior leads along with a depressed ST segment should be considered a STEMI equivalent. Discuss the differences in managing a pure RV infarct, most notably the fact that the patient is pre-load dependent and should receive aggressive IVF therapy to maintain cardiac output. All vasodilatory medications (most notably nitrates) should be avoided.

35. Case #7
Anterior NSTEMI
ST depression clearly seen in the V2-V6

36. Case #8 Right bundle branch block
Regular QRS complexes that are conducted by p-waves, but are prolonged, with the terminal portion of the prolonged QRS complex showing rightward (as evidence by the negative terminal deflection of the QRS in lead I) and anterior (as evidenced by the positive terminal deflection of the QRS in lead V1) axis

37. Questions?