How to Interpret Ecg

8/8/2019 How to Interpret Ecg

1/17

1

HEART LINKS ISSUE 1 SPRING 2005

The Cardiac Newsletter for Lincolnshire

Welcome to the first issue of Heart Links, aquarterly newsletter written for anyone with aninterest in cardiology and the management ofpatients with acute coronary syndromes. Thisnewsletter is produced within Lincolnshire andwill contain updates and information about theactivities of teams working in the communityand in secondary care across the county. Youwill also find regular teaching articles, casestudies and competitions (with prizes!). If youwould like to contribute material for futureissues please contact Jacqui Larder at:

[email protected] .

I hope you find this and future issues bothinteresting and informative and we wouldwelcome your suggestions as to how we canimprove the content.

Dr Andrew R. Houghton (Editor)Consultant CardiologistGrantham & District Hospital

MAKING SENSE OF THE ECGBy Dr Andrew HoughtonPart 1: PUTTING THE ECG IN CONTEXT

CASE HISTORIESMINAP INFORMATIONWEB LINK OF THE MONTHLETTER PAGECOMPETITION

BOSTON CARDIAC CARETEAM WIN BPICC AWARD

Pilgrim Cardiology Nurses and the LincolnshireAmbulance Service have recently been awarded theBest Practice in Integrated Cardiac Care Award2004 .

In the UK, more than 270,000 people each year haveheart attacks and the BPICC Award recognises thatcardiac care services all over the country arecontinually being put to the test to ensure quick andsafe responses to meet the tough governmenttargets set by the NSF for CHD for Acute MyocardialInfarction patients. Targets include the delivery ofthrombolysis within 60 minutes of calling forprofessional help (call-to-needle time) or within 30minutes of arrival at hospital (door-to-needle time,DTNT).

The combined nursing, paramedic and cardiologyteam have dramatically improved their DTNT with anumber of initiatives including a staff swap pilotscheme allowing nurses to spend time withparamedic teams and vice versa. In addition, PGDshave been introduced for the administration of pre-hospital thrombolysis by paramedics before thepatient reaches the hospital.

Maria Willoughby, Cardiac Assessment Nurse fromPilgrim Hospital, commented: We are delighted to

have won the BPICC Award as it is recognition for the hard work that ambulance, emergency and cardiac care teams have put into improving cardiac care in the Boston region.

The Lincolnshire team were awarded the first prize of2,500, which will go towards team training orequipment.

[email protected]

Editorial Team: Dr Andrew R. Houghton (Editor), ULHTJacqui Larder, Trent Cardiac NetworkNick Sentence, Lincolnshire Ambulance Service

EDITORIAL

ARTICLES OF INTEREST IN THIS ISSUE
mailto:[email protected]:[email protected]:[email protected]:[email protected]


2/17

2

Making Sense of the ECG Dr Andrew R. Houghton, Consultant Cardiologist (Grantham & District Hospital)

Part 1: Putting the ECG in contextThe 12-lead ECG is a remarkably useful andversatile investigation. It can help us to diagnoseand assess arrhythmias, myocardial ischaemia orinfarction, cardiomyopathies, electrolyte disordersand a host of other conditions.

However, the ECG can also be misleading,particularly when interpreted out of context. Clinicalcontext is all-important - never be tempted tointerpret an ECG without knowing thecircumstances in which it was recorded.

For instance, what does the following ECG show?

The knee-jerk response is to say ventricularfibrillation and to reach for a defibrillator. If theECG had been recorded in the context of a patientwho was unresponsive and pulseless that wouldcertainly seem appropriate.

But what if the patient is alert and well? This couldsimply be muscle artefact - perhaps the patienthas a tremor, or is brushing his teeth. The clinicalcontext makes a huge difference to theinterpretation.

Take another example - what does the followingECG show?

Again, the immediate response is to say normalsinus rhythm , and in the context of a patient whois alert and well that would seem reasonable.

But what if the patient is unconscious andpulseless? The diagnosis then would be pulselesselectrical activity (PEA) . Once again, the clinicalcontext is all-important.

So what can be done to avoid these pitfalls?

If youre interpreting an ECG, always ask for theclinical context of the recording before making yourassessment - be sure to check:

1. Whether there is any relevant past medicalhistory (is the patient hypertensive or taking anyrelevant medication?).2. Whether the patient had any symptoms duringthe ECG recording - always ask: How was the

patient feeling?

If youre recording an ECG, always be sure tomake a note of any relevant history or symptoms atthe top of the recording, along with patients IDdetails and the date/time of the recording. Afrequent example in a CCU setting is Chest pain,severity 6/10. If the patient is asymptomatic, sayso. When someone else comes to review the ECGlater, he or she will then be able to make anappropriate interpretation in the light of the clinicalcontext.

One final examplewhat does this complex (takenfrom lead V5) show?

There is clearly downsloping ST segmentdepression, but what is the cause?

One possibility is left ventricular hypertrophy withstrain - so it would help to know if the patient hasa history of hypertension. Another possibility ismyocardial ischaemia - so we need to know if thepatient was experiencing chest pain at the time ofthe recording.

In fact its a patient taking digoxin, with theclassical reverse tick ST segment depression - aneasy diagnosis, but only if the person whorecorded the ECG has written Taking digoxin250mcg daily at the top.

Next issue - Part 2: Assessing heart rate


3/17

3

CASE HISTORIESCASE 1: A 60 YEAR OLD FEMALE WITH CHEST PAIN A 60 year old lady presented via the ambulance service to A&E after 1 hour of chest pain. She had had asharp, central chest pain with no radiation; it had been worse during exercise and was relieved by rest.She had no SOB but was warm and sweaty on examination. She has no previous cardiac history,although she had experienced a similar episode 5 weeks earlier which lasted 20 minutes while walkinguphill.

What are your observations of this ECG?

After two days in hospital her ECG now looked like this.What is your diagnosis and recommended treatment, considering that she had remained pain freesince admission?


4/17

4

On day four she was discharged home. The following morning she represented after further chestpain. Her ECG now looked like this. What is your treatment plan?

On contacting CCU, they were happy to review this patient, her discharge ECG was almostidentical to the ECG above. Does this change your plan?


5/17

5

CASE HISTORIESCASE 2: A 54 YEAR OLD MALE WITH CHEST PAIN A 54 year old gentleman called for an ambulance after 1 hour of severe central chest pain,associated with SOB, sweating, nausea, with no radiation.

The crew, fearing the worst, appropriately red called the patient in.

He smoked 20 cigarettes a day despite having an MI 5 years previously.Normally hypertensive. He was also a heavy drinker of 40+ units a week.Pain felt like similar pain to MI.

Family history mother and father had IHD

He was pale, sweating and was restless and feeling very unwell.Blood pressure 149/93.

What is your diagnosis and treatment?


6/17

6

CASE HISTORIESCASE 3: A 63 YEAR OLD MALE WITH CHEST PAIN A 63 year old male arrived at A&E with a 5 day history of chest pain radiating down left arm.No other associated symptoms.

Smoker of 20 a day.Drinks 10 units 3 4 times a week.

What are your ECG findings?What is your treatment?


7/17

7

CASE HISTORIESCASE 4: A 50 YEAR OLD MALE WITH CHEST PAIN A 50 year old male presented at 17.36 on 10.9.04.Red Call to resus with 30 minutes of central chest pain.

This gentleman almost had pre-hospital thrombolysis; unfortunately he had had surgery 4 weeksprior for a detached retina. This left the paramedic unable to deliver the Reteplase. On arrivalin the ER and during questioning he promptly went in to VF. Following an unsuccessfulpre-cordial thump, a 200J shock was administered with the desired effect.He had severe pain radiating to left and right arms. Pain was burning in nature.He was vomiting and sweaty.Life long smoker, smoking 20 a day.Positive family history. Father had an MI at 45.Drinks 40+ units a week.

What is your diagnosis and treatment?


8/17


9/17

9

CASE HISTORIESCASE 6: AN 81 YEAR OLD FEMALE WITH DIZZINESS An 81 year old lady presented with a sudden onset of dizziness but no LOC.No chest pain.

What rhythm is this lady in?


10/17

10

CASE HISTORIESCASE 7: AN 80 YEAR OLD MALE WITH CHEST PAIN An 80 year old gentleman arrived via ambulance service at 07:50 hrs.

He had central chest pain since 5 a.m., radiating through to his back.He was complaining of SOB, sweating and felt dizzy.He had pins and needles down both arms and into his hands.The pain was getting worse. He had taken GTN without effect.He had had a similar episode 1 week ago.

What are your ECG findings, how would you treat and would you thrombolyse?

Right ventricular and posteriorleads were completed.Nothing abnormal found.

PMHHypertensionDiverticulitis


11/17

11

CASE HISTORIESCASE 8: A 57 YEAR OLD MALE WITH CHEST PAIN A 57 year old gentleman arrived in A&E at 00:52 hrs.He had had pain since 22:50 hrs. He had no radiation of pain.

He did however feel dizzy, had difficulty in breathing and was nauseated and vomiting.His pain score was 7/10.

The ECG changes are?

The patient was actually seen by a Paramedic who decided that the patient was having an MI.Following his criteria, he continued to give 5000 units of Heparin and 10 units of Reteplase.

Was this the right decision?

MEDICATIONAtenololTildiemAspirinISMN

PMHCABGStentMI x 3

ACKNOWLEDGEMENT:

Our thanks to Glen Sibbick from the Leicestershire,Northamptonshire and Rutland Cardiac Network whose original ideait was to produce a cardiac newsletter and in the spirit of nobleplagiarism (see Dr Richard Andrews letter) generously allowed us to copyhis idea and case histories. Can we start collecting some of our own

please?


12/17

12

CASE HISTORIESCASE 9: A 90 YEAR OLD FEMALE WITH CHEST PAIN A 90 year old lady was red called to the emergency room from ambulance control.She described a heavy pressure type pain in the centre of her chest.She had been resting when the pain had come on, rated 9/10.She was sweating, SOB and felt nauseous. The pain had started some 1 1 / 2 hours ago.

She lived in residential/sheltered accommodation and was normally fit and well.Completely self caring and independently mobile.

She looked young for her age, and could have been mistaken for being less than70 years of age.

What would you do now?

What can you see on the ECG?Should you thrombolyse?

PMHHypertension

MEDICATIONBendroflumethiazideRamipril


13/17

13

CASE HISTORIES - ANSWERS 1-5Case 1Initial ECG looks unremarkable. It highlights any complacency you may have for a normal ECG.The second ECG, 24 hrs later, shows deep arrowhead T wave inversion in V2 V5; this is of concern.Not all ECGs will show up problems, the second ECG suggests a lesion on her LAD.

So from this we need to be aware that although the 1st ECG does not pick up problems immediately, it doesreinforce the need for an overnight stay with a Troponin at 12 hours including serial ECGs.CK = 82, Trop I = 0.98. These levels are consistent with the evolving damage that has occurred. As the third ECGwas very similar to her discharge ECG, no further action was taken, however she did stay in hospital for anangiogram at Glenfield Hospital. Angiogram found a critical lesion on her distal LAD. However, as it was a tortuousvessel, and small, medical treatment was chosen.

Case 2ECG findings: ST elevation in I, AVL with reciprocal changes in II, III, and AVF.He also has hyperacute Ts in V2 V6.Diagnosis: Anterolateral MI. Interestingly his CK rise was only 146.With his history, presentation and ECG findings we went on to thrombolyse. He was also given IV Atenolol 3mg.His call to needle time just missed the 60 minute target by 3 minutes.

Case 3ECG shows deep arrow head T wave inversion in leads V2 V5 and T wave inversion in I, AVL, V6.As you will have read from Case 1, this is either a NSTEMI (non ST elevation MI) or unstable angina, in either caseconsistent with a lesion in his LAD (Left Anterior Descending) coronary artery.CK= 369, Troponin I = 1.74. He was started on Tirofiban and heparin, and referred for an angiogram at GlenfieldHospital.

Case 4ECG shows ST elevation II, III, AVF. ST Depression, I, AVL, V2 V6. Changes in V1 V4.Consider posterior involvement (nil found in V7 V9) but ST elevation was found in right sided chest leads.

Diagnosis: Acute inferior infarct (STEMI).

Despite the issues around his eye surgery, he was subsequently given Reteplase 10 units.2nd CK 2770.Eyesight has not deteriorated.Despite slight delay with the VF he was successfully thrombolysed within the 60-minute target.

Case 5ECG shows LBBB (and AF as no obvious P waves and irregular rhythm).Normally with LBBB it is not possible to comment on ST segment (you can with RBBB). But the ST segment on theinferior leads II, III, AVF do look suspicious and combined with his previous MI and presenting complaint he wasthrombolysed, with Reteplase.


14/17

14

CASE HISTORIES - ANSWERS 6-9Case 6This very similar ECG to the previous case. However this lady has a pacemaker in situ.The widening of the QRS you are seeing is normal and consistent with someone who has apacemaker. It is a dual chamber pacemaker (DDD), as it appears to be tracking her own sinus rate.

Sometimes the pacing spike can be lost if the ECG machine has the filter on. Repeat with the filter off if you areunsure.

Case 7ECG suggests ST elevation in leads II, III, AVF. ST depression in I, AVL, V1-V6.ST segment depression seen here in V2 and V3 could be consistent with a posterior MI.Posterior leads should be completed as soon as practical.ST depression of greater than 3mm is found to be 90% specific for MI.

After excluding any contra-indications to thrombolysis, Reteplase 10 units was given. Also Diamorphine andMetoclopramide.The patient made a full recovery and went home 4 days laterCK rise >262, Troponin 28.56

Case 8ST elevation in II, III, AVF, V6. Good reciprocal changes in I, AVL.The ECG is consistent with a inferior MI, but with elevation in V6, there is also lateral wall involvement.Subsequent ECGs show ST elevation in V5 as well.The decision to thrombolyse was a good one. CK rise 2485

Case 9ECG shows LBBB.

Normally you are unable to comment on the ST segment with LBBB, so we just have to decide whether it is new orold. No old ECGs to go on.The other observation is that there does appear to be ST elevation in V1-V6 , probably most noticeable inV4 and V5. She looked good for her age and the fact she was normally independent, with no contra-indication tothrombolysis, she was treated with Reteplase.CK rose to 3054.


15/17

15

NEWS

Working together for the patient

We all have a 60 minute target to meet.together. The new target encourages aseamless service between the ambulance service and the receiving hospital. From thetime the patient calls for help (call time) to the time thrombolysis is given (if appropriate),should be no more than 60 minutes.

This target is a tough target to achieve in rural Lincolnshire, but both ambulance andhospitals may be assessed on star ratings for this target. So it is in our interest to seethis being met. Using blue lights with sirens, combined with a courtesy call can savevaluable minutes. If we know that a patient is coming we can often halve the door toneedle time.

Can you help us with complete data? Yes you can!!The recording (or non-recording) of times on the Patient Report Forms creates an awfullot of work for Audit staff , both in the Ambulance Trust and in ULHT as well as staff inClinical Effectiveness who gather data for MINAP.

The main area of concern for the hospitals is the Time of Call. The current PRF in usewith the Ambulance Service does not record the time of call but does record the time thatthe incident was passed to the crew. Unfortunately these times may not be the same.

Ambulance Crews are now being advised that ALL timings should be taken from theirMobile Data Terminals and recorded on their PRF.

The Hospitals use the Atomic Clock to record their timings for CHD events and the use ofthe MDT for recording of Ambulance times will ensure that all timings are as accurate aspossible.

PRIMARY ANGIOPLASTYIn the future primary angioplasty may well become the treatment for MIs.In some parts of England this is already a routine treatment, but it does require cath labsupport, 24 hours a day, seven days a week. Current research suggests that smalldelays in conventional treatment appear not to be detrimental.

Web link of the Month - http://www.heartcenteronline.comThis is a great web site for staff, students and patients. It has some great animated video clips of plaquerupture and angioplasty and stents, well worth a look. If you link in to the All animations you will findclips on bradycardia, regurgitation, diabetes, plaque rupture, PTCA and stenting etc. It has around 25

animations of about 1-3 minutes each, which take a while to down load if you do not have broadband.If you know of a worthy web site let me know and I will publish it in subsequent issues.


16/17

16

LETTERSDear Dr Protheroe,

I should like to express my appreciation and gratitude to the Lincolnshire Ambulance Service forthe prompt response and first class treatment I received when I had my heart attack on 5September.

The ambulance arrived within minutes of the 999 call and the paramedics were absolutelymarvellous, losing no time in either diagnosis or treatment with the new clot busting drug. Theyeven came to see me in the afternoon in CCU to see how I was progressing. I am pleased tosay that I am now recovering very well and very quickly.

Once again I would like to thank the Ambulance Service and the paramedics concerned for theirexcellent treatment.

Yours sincerely,

Letter received from Patient.

Dear Reader,

Welcome to the first edition of the Heart Links newsletter. We know that throughoutLincolnshire you are all achieving high quality patient care and often with limited resources.What we are bad at is telling other people about it! We work within a big county and links andcommunications between our workplaces are often patchy.

The aim of this newsletter is to try and share examples of good practice and of innovation inservice delivery. The ethos of the Trent Cardiac Network could be summed up as the spirit ofnoble plagiarism. So if you have improved your service then tell us about it! Most of us willgladly copy than reinvent the wheel for ourselves, so please forget your natural reticence (someof my colleagues have no such problem!) and tell us about it. There will also be a modestattempt to educate and entertain and if you have an interesting case or ECG then please pass it

on so others can also learn from your experience.

We hope that this newsletter will thrive but to do so it really does need to have yourcontributions and enthusiasm so please be forthcoming. As a county we have moved a longway in the last few years in the service we give to cardiac patients and we hope that with yourhelp this newsletter will be another contribution.

Dr Richard Andrews,Consultant Cardiologist, Lincoln County HospitalClinical Lead, Trent Cardiac Network


17/17

17

COMPETITION!

WIN! WIN! WIN!

A copy of Making Sense of the ECG A Hands-On Guide

by Andrew R. Houghton and David GrayTo enter this competition, simply name the coronary arteries labelled 1 and 7 on the diagram below and send your answers via e-mail to:

[email protected] no later than 20 th April 2005.

First correct answer drawn out wins!

SUMMER 2005 ISSUE will be published in June
mailto:[email protected]:[email protected]://images-eu.amazon.com/images/P/0340809787.02.LZZZZZZZ.jpg

How to Interpret Ecg

Documents

Transcript of How to Interpret Ecg