CRITICAL CARE ECGS

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

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

S.creat: 4.5 mg% S. K: 7.1 mEq/l CPK: 36,000

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

Polymorphous ventricular tachycardia -Torsade de pointes. 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.g. tricyclic antidepressant overdose congenital long QT syndromes other causes of long QT (e.g. IHD

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

The QT interval duration is greater than 50% of the RR interval, a good indication that it is prolonged in this patient. Although there are many causes for the long QT, patients with this are at risk for malignant ventricular arrhythmias, syncope, 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 - drugs - inotropes - central lines

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- 110/60mm Hg

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

Take home message

Consider myocardial ischemia in every case of sudden hypotension

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

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

Sudden hypoxia and hypotension BP: not recordable

Admitted to MICU Thrombolysed with STK Improvement over 24 hours

Case scenario-5

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

O/E: BP: 90/40mmHg. HR- 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

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

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

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

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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