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A nurse gave you…A methodical approach • Date & time • Patient ID • Clinical context • Past medical history • Previous ECGsIs this normal?Sinus rhythm • What makes a sinus rhythm? • Regular rhythm at a rate of 60-100 bpm • Each QRS complex is preceded by a P wave • P waves upright in leads I and II, inverted in aVR • Constant PR interval • QRS complexes< 120 ms wideA methodical approach.. continued • Rate, rhythm • AxisCardiac axisCardiac axis Left axis deviation • Away from each other • I and II/III Left each other Right axis deviation • Towards each other • I and II/III meet Right in the middleA methodical approach.. continued • P waves • PR interval • QRS complex • QT interval • ST segment • T waves • Look at the patient!Leads & SitesLook at the rate • Normal • Tachycardia • BradycardiaT achycardia Narrow QRS Broad QRS • Sinus tachycardia • VT • AF • VF • Atrial flutter • SVT*Scenario 1 • 64M • Community- acquired pneumoniaAtrial Fibrillation (with FVR) What would you do next?Management • Are they stable?Management of stable AF • Rate or rhythm control • Anticoagulation • Onset of AF?Management of stable AF – cont. • Rate control • BB • CCB • Digoxin • Rhythm control • DC cardioversion • Flecainide • Amiodarone • AnticoagulationManagement of stable AF – cont. <48 hours >48 hours or unknown • Rate or rhythm control • Rate control, OR • Anticoagulate for 3 weeks then rhythm controlManagement of stable AF – cont. • Anticoagulation•64M •Community- acquired pneumonia Atrial Flutter • Saw-tooth appearance • 2:1 but can be variable • Atrial rate of 300 • Ventricular rate of 150Management of atrial flutter • Similar to AFA slightly different ECG…Is this atrial flutter?SVT • Tachycardia • Regular • QRS <0.12 • No p waves manage an SVT?Management • Are they stable?Management of SVT • Acute: • Valsalva manoeuvre • Carotid sinus massage • Adenosine 6 -> 12 -> 18 mg • Paroxysmal: • BB • CCB • Amiodarone • RF ablationWhat about this? Any thoughts?V entricular T achycardia • Tachycardia • Regular • QRS >0.12s • ± P waves What should you do?Are they conscious? • Pulseless: • DC shock • Adrenaline 1mg • Amiodarone 300mg (after 3 shock) th • Amiodarone 150mg (after 5 shock) • ALS!Management of VT • If haemodynamically stable: • Amiodarone infusion 300mg over 10-60 mins • Synchronised DC shock up to 3xScenario 2 • 58F with background of HF, HTN, CKD, and COPD presented with reduced oral intake. • Day 2 of admission • Medications: • Furosemide • Bisoprolol • Amlodipine • Spironolactone • Sacubitril-valsartan • Trimbow 87/5/9Scenario 2 • 58F - reduced oral intake • PMH: • HF • HTN • COPD • Medications: • Bisoprolol • Amlodipine • Spironolactone • Sacubitril- valsartanScenario 2 • Blood results today: • Na 130 (135-145) • K 9.1 (3.5-5.0) • Urea 18.7 (2.0-7.0) • Creatinine 489 (55-120) • eGFR 8 (>90)Hyperkalaemia • small or absent P waves • AF • wide QRS • shortened or absent ST segment • wide, tall and tented T wavesManagement of hyperkalaemia • Which would you prescribe? • IV fluids (0.9% normal saline) • 30 ml of 10% calcium gluconate • IV insulin • Calcium resonium • Salbutamol nebsScenario 2 – cont. • On review, the patient becomes much less responsive… Ventricular Fibrillation• ALS! Scenario 3 • A 73M was admitted to ED after being found on the floor with profuse diarrhoea and vomiting. Prolonged QT Significance? T orsades de Pointes Management? IV MgSO4 Scenario 4 • A 61-year-old female patient on day 4 of admission for IECOPD is still tachycardic and unable to wean down her oxygen. Anterolateral STEMINSTEMIManagement of ACS • Symptom control • MONA • Cardioprotective therapy • DAPT: aspirin 75mg + clopidogrel/ticagrelor (for 12 months) • Anticoagulation • BB • ACEi • Statin • Revascularisation • Angiography ± PCI • CABGHeart BlockHeart Block • First degree • Second degree • Third degreeFirst degree heart block Normal variant Increased vagal tone (eg, athletes) Benign, no treatment Inferior MI Mitral valve surgery Myocarditis(e.g. Lyme disease) Electrolyte disturbances (e.g. Hyperkalaemia) AV nodal blockingdrugs (BB,CCB,digoxin, amiodarone)Second degree heart block Drugs: BB,CCB,digoxin,amiodarone Asymptomatic – no treatment Increased vagal tone (e.g. athletes) Symptomatic - atropine Myocarditis Followingcardiacsurgery (mitral valve repair, Tetralogyof Fallotrepair)Second degree heart block Anterior MI • Risk of haemodynamic instability and Idiopathicfibrosis of the conductingsystem (Lenègre-Lev disease) asystole Cardiac surgery Inflammatory conditions(rheumatic fever, myocarditis,Lyme disease) • Mx – Cardiac monitoring & temporary Autoimmune (SLE, systemic sclerosis) pacing, pacemaker Infiltrative myocardialdisease (amyloidosis,haemochromatosis,sarcoidosis) Hyperkalaemia Drugs: BB, CCB, digoxin,amiodaroneThird degree heart block Inferior MI High risk of SCD AV-nodal blockingdrugs Mx – Cardiac monitoring & temporary Idiopathicdegeneration of the conductingsystem (Lenegre’s or Lev’s pacing, pacemaker disease), causing true trifascicular blockIn summary … 1. AF with FVR • Atrial flutter 2. VT • VF 3. Torsades de Pointes 4. STEMI and NSTEMI 5. AV blockReferences & Figures • https://www.nataliescasebook.com/tag/s-t-elevation • ecglibrary.com • UK Resus Council Guidelines 2021 • https://edhub.ama-assn.org/jn-learning/video-player/18853794 • https://manualofmedicine.com/ecgs/atrial-flutter-ecg-interpretation/ • Life in the Fast Lane • https://www.researchgate.net/figure/Bleeding-risk-scores-validated-for-use-in-patients-with- nonvalvular-atrial-fibrillation_tbl2_309029628 • https://hqmeded-ecg.blogspot.com/2011/12/ventricular-fibrillation-on-12-lead-ecg.html • criteria/prolonged-qt-interval-reviewrn-the-heart/ecg-review/ecg-topic-reviews-and- • https://www.tamingthesru.com/blog/grand-rounds/stemi • https://en.taylanakgun.com/what-is-a-heart-block • ECG Made Easy