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ECG ROUNDS Navpreet Sahsi
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“ED Doc to Bed 9”
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Patient - Sent from Pre-admission clinic because of ECG findings
“I feel fine, I don’t know what the big deal is!” Asymptomatic, resting comfortably Obese, 50 years old, male. Meds: Spironolactone, lisinopril T- 36.7, HR 70, BP – 205/118, RR 12, 96 % RA Thoughts?
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“Oh, and by the way I have these bilateral adrenal tumors.”
Chart shows a recent diagosis of bilateral adrenal tumors -> hypercortisolemia Does this change anything?
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ECG Findings in Metabolic/Endocrine Disease
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The Ultimate “Pimp” Question
What are the “classic” ECG manifestations of pheochromocytoma???
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ECG in Pheo No “classic” ECG
Often present with ST elevation in a variety of patterns, mimicking acute infarction Can also present with other ST-T changes, most commonly T wave inversions QTc often prolonged – risk of arrythmias Case series – 25 patients with eventual diagnosis of pheo – 17 had abnormal ECG findings, 6 had initial diagnosis of acute STEMI - > urgent angiography - > all were normal Cardiovascular Manifestations of Pheocromocytoma.AM J Em Med, 18:5; : 2000. ECG manifestations of endocrine disease. Heart 2001, 86; 679.
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DONCKIER, J. E et al. Heart 2001;85:679
Copyright ©2001 BMJ Publishing Group Ltd.
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Hyper K+ Peaked T waves P wave flattening, PR prolongation, eventual loss of p waves QRS widening Sine wave appearance
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Hypo K Depression of T waves ST depression (> 0.5 mm)
Appearance of U waves
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Hypothyroidism Sinus brady Low voltage complexes
Prolonged pr and qt intervals Flattened or inverted T waves Pericardial effusions occur in 30% of patients and may account for some of the changes
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Hyperthyroid Sinus Tach – 40 % A. Fib – 10 – 22 %
Nonspecific ST-T abnormalities – 25 % Interventricular conduction disturbances – LAFB most common – 15 %
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HyperCa Shortenes plateau phase (phase 2) of action potential and shortens effective refractory period ST shortening Short QT interval
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Two abnormalities?
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Hypothermia T < 35.0 Tremor arifact
One of earliest signs – secondary to shivering Slowing of sinus rate - > bradycardia Prolongation of PR and QT intervals Osborn/J wave
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Osborn or J wave “Camel Hump sign”
Extra deflection off of terminal portion of QRS and ST segment takeoff Size correlates directly with degree of hypothermia Usually present when temp < 32.0 deg. C Can occur in HyperCa, Massive head injury, subarachnoid hemmorrhage
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Back to the case Cardiology consulted
Not concerned about an acute event because patient completely asymptomatic Decided to admit patient for pre-op workup since he next in queue for surgery Led to angiogram - > normal Booked for surgery
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