Extreme ECG Encounters

Dr John LarkinAdvanced Trainee Emergency Medicine

Joondalup Health CampusWestern Australia

jhcedecg.blogspot.com

Image source: Wikipedia (http://en.wikipedia.org/wiki/Electrocardiography)

Own The Oxylog 3000!

Own The Wound!

Own The Oxygen!

Own The Chest Tube!

Own The ECMO!Own The Echo!

Own The Airway!

Own the ECG !

Why should we ‘Own the ECG’?

• ECGs regularly performed in the ED

• Influential test

• Large amount of information

• Patient Advocates

EM Tests

• Indication

• Perform the test

• Interpret the test

• Apply this interpretation to a patient

We’re pretty good at ECGs

2008.1

2008.1

2008.2

2008.2

2009.1

2009.1

2009.2

2009.2

2010.1

2010.1

2010.2

2010.2

2011.1

2011.1

2011.2

2011.2

2012.1

2012.1

2012.2

2012.20

10

20

30

40

50

60

70

80

90

100

ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012

Exam Sitting

%

2008.1

2008.1

2008.2

2008.2

2009.1

2009.1

2009.2

2009.2

2010.1

2010.1

2010.2

2010.2

2011.1

2011.1

2011.2

2011.2

2012.1

2012.1

2012.2

2012.20

10

20

30

40

50

60

70

80

90

100

ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012

Exam Sitting

%

2008.1

2008.1

2008.2

2008.2

2009.1

2009.1

2009.2

2009.2

2010.1

2010.1

2010.2

2010.2

2011.1

2011.1

2011.2

2011.2

2012.1

2012.1

2012.2

2012.20

10

20

30

40

50

60

70

80

90

100

ECG VAQs Question Pass Rate FACEM Part 2 Exam 2008 - 2012

Exam Sitting

%

Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published Evidence

• ECG Diagnosis correctly identified by non-cardiologist in 36-96%

• Inappropriate management up to 11% of cases

• Even one cardiologist reading the same ECG on separate occasions may have substantially different interpretations

Salerno et al AIM 2003

Posterior MI: Are we failing to diagnose this ?

Khan et al EMJ 2012

Accuracy of ECG Interpretation Improves with EM Training

Hoyle et al EMA 2007

Improving Competency

• Review the ECG– Look at the whole ECG– Know what you are looking at

• Interpretation of the ECG

• Look at the patient with the ECG

Cruz et al MJA 2012

Systematic Interpretation

• Patient Identification

• Calibration / Configuration

• Rate

• Rhythm

• Axis

• Intervals

• Segments

• Additional

Image source: Wikipedia (http://en.wikipedia.org/wiki/Electrocardiography)

Smartphone ECG Interpretation

Can you just take a photo of the ECG and send it to me ?

Gonzales et al J Interv Cardiol. 2011Bilgi et al Telemed J E Health. 2012

AliveCor EKG Case

• FDA Cleared December 2012

• Physician use only

• Issued by prescription

• Cost 200 USD

• Uploads single lead rhythm to a cloud server

ECG Encounters

Spotting lead reversal

• Abnormal axis

• Look at p wave morphology in limb leads– Normal p waves

• Positive in leads I, II• Negative in lead aVR

• Look at T wave in relation to p wave & QRS complex

• Flat lead I, II or III

Source: Dr Stephen Smith Dr Smith’s ECG Blog http://hqmeded-ecg.blogspot.com.au/

Source: Dr Stephen Smith Dr Smith’s ECG Blog http://hqmeded-ecg.blogspot.com.au/

De Winter’s Hyperacute T Waves

• Acute LAD Occlusion

• 30 Patients – (2% of Anterior MIs)

• ECG Features– 1-3 mm ST depression V1-6 at J-point– Tall positive symmetrical T waves– ST Elevation aVR 1-2mm

• Did not progress to ST elevation

Third Universal Definition of MI

• New ST elevation at the J point in two contiguous leads

• ≥0.1 mV in all leads other than leads V2–V3 where the following cut points apply:– ≥0.2 mV in men ≥40 years– ≥0.25 mV in men <40 years– ≥0.15 mV in women.

Joint ESC/ACCF/AHA/WHF Task Force EHJ 2012

Source: Professor Martin Green, University of Ottawa Heart Institute, Ontario CanadaDr Arieh Keren

‘Giant’ T Wave Inversion• Deep symmetrically inverted T waves >5mm

• Raised ICP– Associated with QT prolongation– Rarely associated with STEMI-like changes

• Apical hypertrophic cardiomyopathy– Yamaguchi syndrome

• Myocarditis• Ischaemia• Post-tachycardia

Source: Dr Shakeeb Razak QT 320ms QTc <340ms

Source: Professor Martin Green, University of Ottawa Heart Institute, Ontario CanadaDr Arieh Keren

Some Other Extreme Encounters

• Paediatric ECG

• Wellen’s pattern

• Loss of pre-cordial balance - NTTV1

• STEMI in LBBB - Sgarbossa & Modified Sgarbossa Rule

• Brugada syndrome

• Paced Rhythms

SMACC-ing the ECG

Web 2.0, FOAM & The ECG

• Provided a safe haven for ECG Enthusiasts

• Share and discuss interesting cases & ECGs

• Asynchronous learning

• Formation of networks & communities

• Large number of ECG related on-line resources

• ECG Library– ECG Basics– A-Z by diagnosis– ECG Exigency

cases

EKG Videos – Dr Amal Mattu

• ekgumem.tumblr.com

• Updated weekly

• Case based video tutorials

Dr Smith’s ECG Blog

• http://hqmeded-ecg.blogspot.com.au/

• Extensive collection of – ECG cases– Topic Reviews– Video lectures– Article links

ECG of the Week

• jhcedecg.blogspot.com

• Locally sourced ECGs

• Updated weekly

• Incorporated into EM education program

Acknowledgement & Thanks

• Dr Cameron Burrows• Dr Arieh Keren• Dr Shakeeb Razak• Dr Colin Parker

• Prof Martin Green

• Dr Mike Cadogan• Dr Chris Nickson• Dr Ed Burns• Kane Guthrie

• Dr Stephen Smith

References• Salerno SM, Alguire PC,Waxman HS Competency in Interpretation of 12-Lead Electrocardiograms: A Summary and Appraisal of Published Evidence. Ann Intern

Med. 6 May 2003;138(9):751-760

• Cruz MF, Edwards J, Dinh MM, Barnes EH. The effect of clinical history on accuracy of electrocardiograph Interpretation among doctors working in emergency departments. Med J Aust. 2012 Aug 6;197(3):161-5.

• Hoyle RJ, Walker KJ, Thomson G, Bailey M. Accuracy of electrocardiogram interpretation improves with emergency medicine training. Emerg Med Australas. 2007

Feb;19(2):143-150.

• Gonzalez MA, Satler LF, Rodrigo ME, Gaglia MA Jr, Ben-Dor I, Maluenda G, Hanna N, Suddath WO, Torguson R, Pichard AD, Waksman R. Cellular video-phone assisted transmission and interpretation of prehospital 12-lead electrocardiogram in acute st-segment elevation myocardial infarction. J Interv Cardiol. 2011 Apr;24(2):112-8.

• Bilgi M, Gülalp B, Erol T, Güllü H, Karagün Ö, Altay H, Müderrisoğlu H. Interpretation of electrocardiogram images sent through the mobile phone multimedia messaging service. Telemed J E Health. 2012 Mar;18(2):126-31.

• O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Jan 29;127(4):e362-425.

• Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial. Third universal definition of myocardial infarction. Eur Heart J. 2012 Oct;33(20):2551-67.

• Pillarisetti J, Gupta K. Giant Inverted T waves in the emergency department: case report and review of differential diagnoses. J Electrocardiol. 2010 Jan-Feb;43(1):40-2.

• de Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A New Sign of Proximal LAD Occlusion. N Engl J Med. 2008 Nov;359(19):2071-2073.

• Maluli HA, Meshkov AB. A short story of the short QT syndrome. Cleve Clin J Med. 2013 Jan;80(1):41-7.

• Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, Stone GW. Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec;160(6):995-1003, 1003.e1-8.

Thank you