SlideShare uma empresa Scribd logo
1 de 72
Baixar para ler offline
Alastair Jones
ADVANCED ECGs
Beyond the basics…
Quiz Q1
✤ 55 year old man presents with central crushing chest pain.
✤ Comment on the ECG and what is you treatment plan?
Quiz Q1
Quiz Q2
✤ 78 year old diabetic man. Previous MI. Presents with sudden onset
SOB and an odd feeling in chest.
✤ Comment on the ECG and what is you treatment plan?
Quiz Q2
Quiz Q3
✤ 45 year old male. Brought in by wife after an episode of severe
indigestion last night. Now symptoms free. Insists he’s fine and wants
to go home. Thinks his wife is worrying unnecessarily.
✤ Obs fine. Bloods normal. Trop negative.
✤ Comment on the ECG and what is your management plan?
Quiz Q3
Quiz Q4
✤ 78 year old lady who presents with ischaemic chest pain.
✤ Comment on the ECG.
✤ How can you confirm your diagnosis and what is your management
plan?
Quiz Q4
Quiz Q5
✤ 20 year old student. Brought in after collapse.
✤ Went to feel lightheaded and then blacked out for a few seconds.
✤ Not happened before. Now feels fine and wants to go home.
✤ Comment on his ECG and what would you tell him?
Quiz Q5
Quiz Q6
✤ VT OR SVT?
Quiz Q6
Elevation in aVR
Elevation in aVR
✤ Single lead - significant?
✤ Yes. STE in aVR implies lesion of the left main coronary artery
Elevation in aVR
✤ STE in aVR itself of more than 1.5 mm carries a 75% specificity of
LMCA and ~75% mortality!
✤ STE in aVR + avL -- 90% specificity AMI
✤ STE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion but
✤ STE in aVR > V1 -- more suggestive of LMCA
✤ The significance of STE in aVR is dubious in the presence of BBB.
Sgarbossa Criteria
✤ Or how to detect AMI in LBBB
✤ ST elevation ≥1 mm in a lead with upward (concordant) QRS
complex - 5 points
✤ ST depression ≥1 mm in lead V1, V2, or V3 (concordant) - 3
points
✤ ST elevation ≥5 mm in a lead with downward (discordant) QRS
complex - 2 points
✤ ≥3 points = specificity of 98% and sensitivity of 20% (10 paper
meta-analysis of 614 patients)
Sgarbossa Criteria
Sgarbossa Criteria
✤ Only one lead required BUT the significance of elevation in aVR is no
longer certain.
✤ Serial / old ECG’s can also help
Wellens’ Syndrome
✤ Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3
(in patients presenting with ischaemic chest pain) that is highly
specific for critical stenosis of the left anterior descending artery.
✤ Patients may be pain free by the time the ECG is taken and have
normally or minimally elevated cardiac enzymes; however, they are
at extremely high risk for extensive anterior wall MI within the next 2-3
weeks.
✤ Type 1 Wellens’ T-waves are deeply and symmetrically inverted
✤ Type 2 Wellens’ T-waves are biphasic, with the initial deflection
positive and the terminal deflection negative
Wellens’ Syndrome - Type 1
Wellens’ Syndrome - Type 2
Wellen’s Syndrome
✤ Wellen's criteria is not dependent on ST changes, just the T inversion!
✤ VERY worrying...Signifies critical LAD stenosis!
✤ 100% of 180 patients with the pattern having >50% stenosis of the left
anterior descending coronary artery (mean = 85%), with complete or near
complete occlusion in almost 60%.
✤ Likely to need a cath lab rather than medical therapy...
✤ Should be investigated urgently even if now asymptomatic!
✤ BUT - young children and especially female up to 40 years, may have
normal variant of T inversion (the juvenile pattern).
Posterior MI
Posterior MI
✤ Be wary in any patient with infero-lateral ischaemia.
✤ Posterior MI is suggested by the following changes in V1-3:
✤ Horizontal ST depression
✤ Tall, broad R waves (>30ms)
✤ Upright T waves
✤ Dominant R wave (R/S ratio > 1) in V2
Posterior MI
✤ Posterior Leads:
✤ V7 – Left posterior axillary line, in the same horizontal plane as V6.
✤ V8 – Tip of the left scapula, in the same horizontal plane as V6.
✤ V9 – Left paraspinal region, in the same horizontal plane as V6.
Posterior MI
Posterior MI
✤ The degree of ST elevation seen in V7-9 is typically modest – note
that only 0.5 mm of ST elevation is required to make the diagnosis of
posterior MI!
Posterior MI
Posterior MI
Brugada Syndrome
✤ 25 year old Asian male has had a collapse. Now feels fine and wants
to go home...
Brugada Syndrome
✤ Brugada syndrome is an ECG abnormality with a high incidence of
sudden cardiac death in structurally normal hearts...
✤ Sodium channel mutation (at least 60 different types described so far)
✤ Diagnosis depends upon ECG criteria (which may be transient and
clinical criteria (VF, VT, syncope, FHx sudden cardiac death <45)
✤ Definitive treatment = ICD
Brugada Syndrome
✤ May be unmasked / augmented by the following:
✤ Fever
✤ Ischaemia
✤ Multiple Drugs: Sodium channel blockers (eg Flecainide, Propafenone),
Calcium channel blockers, Alpha agonists, Beta Blockers, Nitrates, Cholinergic
stimulation, Cocaine, Alcohol
✤ Hypokalaemia
✤ Hypothermia
✤ Post DC cardioversion
Brugada Syndrome - Type 1
Type 1: Coved ST segment elevation >2mm in >1 of V1-V3 followed by a
negative T wave (don’t confuse with RBBB which should have ST
depression)
Brugada Syndrome - Type 2
Type 2 has >2mm of saddleback shaped ST
elevation.
Brugada Syndrome - Type 3
Brugada type 3 can have either type 1 or type 2 morphology, but with <2mm
of ST segment elevation.
Brugada Syndrome
✤ Do they need admitting?
✤ Type 1 ECG and symptomatic = YES!
✤ If undiagnosed - 10% mortality per year...
✤ Asymptomatic patients with a type 1 ECG pattern and all type 2 + 3
ECG patterns can probably go home and have outpatient
electrophysiology...
Brugada Syndrome
✤ ...however, EPS is far from a gold standard, with a negative predictive
value of less than 50% and some studies suggest that we might be
getting a little over-excited about this relatively recently described
ECG finding (1992).
✤ One study followed 98 asymptomatic japanese patients with a type 1
ECG found incidentally for 7.8 years and found them to have no
greater mortality than the rest of a 14000 strong cohort. This
highlights the importance of the clinical criteria required for diagnosis
listed above.
Trifasicular block
✤ Disease in all 3 conduction fasicles (RBB, LAF, LPF)
✤ May be complete or incomplete:
✤ Incomplete (or Impending) – RBBB, LAD, 1st degree HB
✤ Complete – 3rd degree HB and bifasicular block (usually RBBB and
LAD)
Trifasicular block (incomplete)
Trifasicular block
✤ Incomplete trifascicular block may progress to complete heart
block.
✤ Patients who present with a syncopal episode and have an
ECG showing incomplete trifascicular block should be
admitted for a cardiology review as they may be having
episodes of complete heart block. Therefore, some of these
patients will require a pacemaker.
VT or SVT with aberrant
conduction???
VT or SVT with aberrant
conduction???
✤ 3 possibilities:
✤ VT
✤ SVT with aberrant conduction due to bundle branch block
✤ SVT with aberrant conduction due to the Wolff-Parkinson-White
syndrome
VT or SVT with aberrant
conduction???
✤ While it is not always possible to differentiate VT from SVT with
aberrant conduction it is important to try. SVT is amenable to AV nodal
blockers. But someone in VT can suffer haemodynamic collapse if AV
blockers given...
✤ Unfortunately, the electrocardiographic differentiation of VT from SVT
with aberrancy is not always possible. However, there are several
electrocardiographic features that increase the likelihood of VT:
More likely to be VT...
✤ Absence of typical RBBB or LBBB morphology
✤ Extreme axis deviation (“northwest axis”)
✤ Very broad complexes (>160ms)
✤ AV dissociation (P and QRS complexes at different rates)
More likely to be VT...
✤ Capture beats — occur when the sinoatrial node transiently ‘captures’
the ventricles, in the midst of AV dissociation, to produce a QRS
complex of normal duration.
✤ Fusion beats — occur when a sinus and ventricular beat coincides to
produce a hybrid complex.
More likely to be VT...
✤ Brugada’s sign – The distance from the onset of the QRS complex to
the nadir of the S-wave is > 100ms
✤ Josephson’s sign – Notching near the nadir of the S-wave
More likely to be VT...
✤ Positive or negative concordance throughout the chest leads, i.e.
leads V1-6 show entirely positive (R) or entirely negative (QS)
complexes, with no RS complexes seen.
✤ RSR’ complexes with a taller left rabbit ear. This is the most specific
finding in favour of VT. This is in contrast to RBBB, where the right
rabbit ear is taller.
VT
RBB
B
The likelihood of VT is also
increased if:
✤ Age > 35 (positive predictive value of 85%)
✤ Structural heart disease
✤ Ischaemic heart disease
✤ Previous MI
✤ Congestive heart failure
✤ Cardiomyopathy
✤ Family history of sudden cardiac death (suggesting conditions such as HOCM,
congenital long QT syndrome, Brugada syndrome or arrhythmogenic right
ventricular dysplasia that are associated with episodes of VT)
The likelihood of SVT with
aberrancy is increased if:
✤ Previous ECGs show a bundle branch block pattern with identical
morphology to the broad complex tachycardia.
✤ Previous ECGs show evidence of WPW (short PR < 120ms, broad
QRS, delta wave).
✤ The patient has a history of paroxysmal tachycardias that have been
successfully terminated with adenosine or vagal manoeuvres.
✤ HOWEVER - IF IN DOUBT TREAT AS VT
Quiz Answers Q1
✤ 55 year old man presents with central crushing chest pain.
✤ Comment on the ECG and what is you treatment plan?
Quiz Answers Q1
Quiz Answers Q1
✤ NSR
✤ Widespread ST depression
✤ Elevation in aVR --> LMCA lesion!!
✤ D/W Papworth for ?PPCI, ACS Rx etc…
Quiz Answers Q2
✤ 78 year old diabetic man. Previous MI. Presents with sudden onset
SOB and an odd feeling in chest.
✤ Comment on the ECG and what is you treatment plan?
Quiz Answers Q2
Quiz Answers Q2
✤ Paced rhythm - Broad complexes
✤ Positive Scarbossa Criteria
✤ > 5mm ST elevation in III, aVF
✤ < 1mm ST depression V2, V3
✤ 1mm ST elevation aVL
✤ Needs PPCI
Quiz Answers Q3
✤ 45 year old male. Brought in by wife after an episode of severe
indigestion last night. Now symptoms free. Insists he’s fine and wants
to go home. Thinks his wife is worrying unnecessarily.
✤ Obs fine. Bloods normal. Trop 12.
✤ Comment on the ECG and what is your management plan?
Quiz Answers Q3
Quiz Answers Q3
✤ Wellens’ type 1 - deep symmetrical TWI anteriorly.
✤ Likely has a severe LAD stenosis and should be investigated urgently.
✤ Refer medics for urgent angiography.
Quiz Answers Q4
✤ 78 year old lady who presents with ischaemic chest pain.
✤ Comment on the ECG.
✤ How can you confirm your diagnosis and what is your management
plan?
Quiz Answers Q4
Quiz Answers Q4
✤ Likely posterior MI (borderline inferior MI also)
✤ Anterior ST depression with a dominant R wave.
✤ Confirm with posterior leads
✤ Treat as per AMI - PPCI
Quiz Answers Q5
✤ 20 year old student. Brought in after collapse.
✤ Went to feel lightheaded and then blacked out for a few seconds.
✤ Not happened before. Now feels fine and wants to go home.
✤ Comment on his ECG and what would you tell him?
Quiz Answers Q5
Quiz Answers Q5
✤ Brugada syndrome type 1
✤ Risk of sudden death. Need admission for an ICD...
Quiz Answers Q6
✤ VT OR SVT?
Quiz Answers Q6
Quiz Answers Q6
✤ Probably SVT with aberrant conduction.
Advanced ecgs
Advanced ecgs
Advanced ecgs
Advanced ecgs

Mais conteúdo relacionado

Mais procurados

ECG Interpretation by USAMA ELSAYED
ECG Interpretation by USAMA ELSAYEDECG Interpretation by USAMA ELSAYED
ECG Interpretation by USAMA ELSAYEDusama elsayed
 
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythmsECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythmsMichael-Joseph Agbayani
 
The Basics of ECG Interpretation
The Basics of ECG InterpretationThe Basics of ECG Interpretation
The Basics of ECG Interpretationmeducationdotnet
 
Idiopathic Ventricular Tachycardia (VT)
Idiopathic Ventricular Tachycardia (VT)Idiopathic Ventricular Tachycardia (VT)
Idiopathic Ventricular Tachycardia (VT)M Usman Javed
 
Choice of guiding catheters in PCI
Choice of guiding catheters in PCIChoice of guiding catheters in PCI
Choice of guiding catheters in PCISatyam Rajvanshi
 
Coronary anatomy and angiographic views
Coronary anatomy and angiographic viewsCoronary anatomy and angiographic views
Coronary anatomy and angiographic viewsthanigai arasu
 
Approach to bradyarrythmias1
Approach to bradyarrythmias1Approach to bradyarrythmias1
Approach to bradyarrythmias1Bhargav Kiran
 
Ventricular arrhythmias
Ventricular arrhythmiasVentricular arrhythmias
Ventricular arrhythmiasarnab ghosh
 
ECG LOCALISATION OF CULPRIT ARTERY IN STEMI
ECG LOCALISATION OF CULPRIT ARTERY IN STEMIECG LOCALISATION OF CULPRIT ARTERY IN STEMI
ECG LOCALISATION OF CULPRIT ARTERY IN STEMIPraveen Nagula
 
Myocardial infarction (MI) ecg localisation
Myocardial infarction (MI) ecg localisationMyocardial infarction (MI) ecg localisation
Myocardial infarction (MI) ecg localisationMalleswara rao Dangeti
 

Mais procurados (20)

Narrow QRS Tachycardia
Narrow QRS TachycardiaNarrow QRS Tachycardia
Narrow QRS Tachycardia
 
ECG Interpretation by USAMA ELSAYED
ECG Interpretation by USAMA ELSAYEDECG Interpretation by USAMA ELSAYED
ECG Interpretation by USAMA ELSAYED
 
CATH MEET PDA
CATH MEET PDACATH MEET PDA
CATH MEET PDA
 
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythmsECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
 
ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE
ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE
ECHO ASSESSMENT OF ASD FOR DEVICE CLOSURE
 
Asd device closure
Asd device closureAsd device closure
Asd device closure
 
The Basics of ECG Interpretation
The Basics of ECG InterpretationThe Basics of ECG Interpretation
The Basics of ECG Interpretation
 
WIDE QRS TACHYCARDIA
WIDE  QRS TACHYCARDIAWIDE  QRS TACHYCARDIA
WIDE QRS TACHYCARDIA
 
approach to wide complex tachycardia
approach to wide complex tachycardia approach to wide complex tachycardia
approach to wide complex tachycardia
 
Ecg quiz @ SEMICON 1018
Ecg quiz @ SEMICON 1018Ecg quiz @ SEMICON 1018
Ecg quiz @ SEMICON 1018
 
Idiopathic Ventricular Tachycardia (VT)
Idiopathic Ventricular Tachycardia (VT)Idiopathic Ventricular Tachycardia (VT)
Idiopathic Ventricular Tachycardia (VT)
 
Choice of guiding catheters in PCI
Choice of guiding catheters in PCIChoice of guiding catheters in PCI
Choice of guiding catheters in PCI
 
Bradyarrhythmias
BradyarrhythmiasBradyarrhythmias
Bradyarrhythmias
 
ECG: Ventricular Premature Beats
ECG: Ventricular Premature BeatsECG: Ventricular Premature Beats
ECG: Ventricular Premature Beats
 
Coronary anatomy and angiographic views
Coronary anatomy and angiographic viewsCoronary anatomy and angiographic views
Coronary anatomy and angiographic views
 
ECG emergencies
ECG emergenciesECG emergencies
ECG emergencies
 
Approach to bradyarrythmias1
Approach to bradyarrythmias1Approach to bradyarrythmias1
Approach to bradyarrythmias1
 
Ventricular arrhythmias
Ventricular arrhythmiasVentricular arrhythmias
Ventricular arrhythmias
 
ECG LOCALISATION OF CULPRIT ARTERY IN STEMI
ECG LOCALISATION OF CULPRIT ARTERY IN STEMIECG LOCALISATION OF CULPRIT ARTERY IN STEMI
ECG LOCALISATION OF CULPRIT ARTERY IN STEMI
 
Myocardial infarction (MI) ecg localisation
Myocardial infarction (MI) ecg localisationMyocardial infarction (MI) ecg localisation
Myocardial infarction (MI) ecg localisation
 

Destaque

CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...
CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...
CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...Ist. Superiore Marini-Gioia - Enzo Exposyto
 
Understanding How The Sales Funnel & Inbound Marketing Generate Leads
Understanding How The Sales Funnel & Inbound Marketing Generate LeadsUnderstanding How The Sales Funnel & Inbound Marketing Generate Leads
Understanding How The Sales Funnel & Inbound Marketing Generate LeadsKennedy Andersson AB
 
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...Cactus
 
Evans - Branding in Perspective - Self-Branding for Professional Success
Evans  - Branding in Perspective - Self-Branding for Professional SuccessEvans  - Branding in Perspective - Self-Branding for Professional Success
Evans - Branding in Perspective - Self-Branding for Professional SuccessDr. Joel Evans
 
Nasty people in organizations and society
Nasty people in organizations and societyNasty people in organizations and society
Nasty people in organizations and societySeth Spain
 
Hollywood Quotes that stress the importance of Customer Feedback
Hollywood Quotes that stress the importance of Customer FeedbackHollywood Quotes that stress the importance of Customer Feedback
Hollywood Quotes that stress the importance of Customer FeedbackCloudcherry
 
KS2 Arithmetic practise - Great to start each lesson.
KS2 Arithmetic practise - Great to start each lesson. KS2 Arithmetic practise - Great to start each lesson.
KS2 Arithmetic practise - Great to start each lesson. Nathan Williams
 
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swift
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swiftみんなで Swift 復習会での談笑用スライド – 6th #minna_de_swift
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swiftTomohiro Kumagai
 
Intelligent Personal Assistants, Search & SEO
Intelligent Personal Assistants, Search & SEOIntelligent Personal Assistants, Search & SEO
Intelligent Personal Assistants, Search & SEOTom Anthony
 
The Technical Debt Trap - Michael "Doc" Norton
The Technical Debt Trap - Michael "Doc" NortonThe Technical Debt Trap - Michael "Doc" Norton
The Technical Debt Trap - Michael "Doc" NortonLeanDog
 
Hopeless? WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless Diagnosis
Hopeless?  WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless DiagnosisHopeless?  WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless Diagnosis
Hopeless? WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless DiagnosisCharles Pixley - LION
 
Modelo educativo 2017 SEP
Modelo educativo 2017 SEPModelo educativo 2017 SEP
Modelo educativo 2017 SEPArturo Llaca
 
HAPPYWEEK 210 - 2017.03.13.
HAPPYWEEK 210 - 2017.03.13.HAPPYWEEK 210 - 2017.03.13.
HAPPYWEEK 210 - 2017.03.13.Jiří Černák
 
Row Pattern Matching in SQL:2016
Row Pattern Matching in SQL:2016Row Pattern Matching in SQL:2016
Row Pattern Matching in SQL:2016Markus Winand
 
Channel Marketing Scorecard
Channel Marketing ScorecardChannel Marketing Scorecard
Channel Marketing ScorecardAveretek
 

Destaque (20)

CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...
CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...
CUBICA: dal GRAFICO all'EQUAZIONE - PRIMO e TERZO METODO - ESEMPIO 4ac - CALC...
 
Understanding How The Sales Funnel & Inbound Marketing Generate Leads
Understanding How The Sales Funnel & Inbound Marketing Generate LeadsUnderstanding How The Sales Funnel & Inbound Marketing Generate Leads
Understanding How The Sales Funnel & Inbound Marketing Generate Leads
 
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...
Retail Brand Ambassadors: How To Foster Loyalty and Engagement Through Social...
 
Evans - Branding in Perspective - Self-Branding for Professional Success
Evans  - Branding in Perspective - Self-Branding for Professional SuccessEvans  - Branding in Perspective - Self-Branding for Professional Success
Evans - Branding in Perspective - Self-Branding for Professional Success
 
Nasty people in organizations and society
Nasty people in organizations and societyNasty people in organizations and society
Nasty people in organizations and society
 
Hollywood Quotes that stress the importance of Customer Feedback
Hollywood Quotes that stress the importance of Customer FeedbackHollywood Quotes that stress the importance of Customer Feedback
Hollywood Quotes that stress the importance of Customer Feedback
 
KS2 Arithmetic practise - Great to start each lesson.
KS2 Arithmetic practise - Great to start each lesson. KS2 Arithmetic practise - Great to start each lesson.
KS2 Arithmetic practise - Great to start each lesson.
 
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swift
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swiftみんなで Swift 復習会での談笑用スライド – 6th #minna_de_swift
みんなで Swift 復習会での談笑用スライド – 6th #minna_de_swift
 
Intelligent Personal Assistants, Search & SEO
Intelligent Personal Assistants, Search & SEOIntelligent Personal Assistants, Search & SEO
Intelligent Personal Assistants, Search & SEO
 
Genesis
GenesisGenesis
Genesis
 
The Technical Debt Trap - Michael "Doc" Norton
The Technical Debt Trap - Michael "Doc" NortonThe Technical Debt Trap - Michael "Doc" Norton
The Technical Debt Trap - Michael "Doc" Norton
 
Cluster Analysis for Dummies
Cluster Analysis for DummiesCluster Analysis for Dummies
Cluster Analysis for Dummies
 
Hopeless? WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless Diagnosis
Hopeless?  WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless DiagnosisHopeless?  WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless Diagnosis
Hopeless? WHO SAID SO AND DO YOU AGREE 714 x - Defy A Hopeless Diagnosis
 
IIJmio meeting 14 IIJmioタイプAとSIMフリー端末について
IIJmio meeting 14 IIJmioタイプAとSIMフリー端末についてIIJmio meeting 14 IIJmioタイプAとSIMフリー端末について
IIJmio meeting 14 IIJmioタイプAとSIMフリー端末について
 
Modelo educativo 2017 SEP
Modelo educativo 2017 SEPModelo educativo 2017 SEP
Modelo educativo 2017 SEP
 
Elaboracion de metas
Elaboracion de metasElaboracion de metas
Elaboracion de metas
 
HAPPYWEEK 210 - 2017.03.13.
HAPPYWEEK 210 - 2017.03.13.HAPPYWEEK 210 - 2017.03.13.
HAPPYWEEK 210 - 2017.03.13.
 
Row Pattern Matching in SQL:2016
Row Pattern Matching in SQL:2016Row Pattern Matching in SQL:2016
Row Pattern Matching in SQL:2016
 
WCAG 2.1 Mobile Accessibility
WCAG 2.1 Mobile AccessibilityWCAG 2.1 Mobile Accessibility
WCAG 2.1 Mobile Accessibility
 
Channel Marketing Scorecard
Channel Marketing ScorecardChannel Marketing Scorecard
Channel Marketing Scorecard
 

Semelhante a Advanced ecgs

STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?
STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?
STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?Haitham Habtar
 
Atypical stemi patterns and stemi equivalents
Atypical stemi patterns and stemi equivalentsAtypical stemi patterns and stemi equivalents
Atypical stemi patterns and stemi equivalentsDr Varun Patel
 
STEMI equivalents
STEMI  equivalentsSTEMI  equivalents
STEMI equivalentsantonhenry
 
St segment elevations
St  segment elevationsSt  segment elevations
St segment elevationsRamesh Babu
 
STEMI EQUIVALENT 1.pptx
STEMI EQUIVALENT 1.pptxSTEMI EQUIVALENT 1.pptx
STEMI EQUIVALENT 1.pptxHadinurJufri
 
Acute coronary syndrome presentation with bivalirudin
Acute coronary syndrome presentation with bivalirudinAcute coronary syndrome presentation with bivalirudin
Acute coronary syndrome presentation with bivalirudinRaleifoot Chisolm
 
Conduction Disorders
Conduction DisordersConduction Disorders
Conduction DisordersEneutron
 
ECG Quiz
ECG QuizECG Quiz
ECG Quiztmit2
 
BUNDLE BRANCH BLOCK WITH AMI latest.pptx
BUNDLE BRANCH BLOCK WITH AMI latest.pptxBUNDLE BRANCH BLOCK WITH AMI latest.pptx
BUNDLE BRANCH BLOCK WITH AMI latest.pptxSiti Syahida
 
ecg_systemic_approach_12-lead_compressed.pdf
ecg_systemic_approach_12-lead_compressed.pdfecg_systemic_approach_12-lead_compressed.pdf
ecg_systemic_approach_12-lead_compressed.pdfjiregnaetichadako
 
Myocardial infarction [autosaved]
Myocardial infarction [autosaved]Myocardial infarction [autosaved]
Myocardial infarction [autosaved]sruthiMeenaxshiSR
 
Understanding Medicine - Complete ECG Guide by Dr. Sam Gharbi
Understanding Medicine - Complete ECG Guide by Dr. Sam GharbiUnderstanding Medicine - Complete ECG Guide by Dr. Sam Gharbi
Understanding Medicine - Complete ECG Guide by Dr. Sam GharbiSam Gharbi
 

Semelhante a Advanced ecgs (20)

Stemi equivalents
Stemi equivalentsStemi equivalents
Stemi equivalents
 
Stemi equivalents
Stemi equivalentsStemi equivalents
Stemi equivalents
 
STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?
STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?
STEMI Mimic WHAT IS IT AND HOW TO IDENTIFY IT ?
 
Ecg challenges
Ecg challengesEcg challenges
Ecg challenges
 
Atypical stemi patterns and stemi equivalents
Atypical stemi patterns and stemi equivalentsAtypical stemi patterns and stemi equivalents
Atypical stemi patterns and stemi equivalents
 
ECG for the intensivists
ECG for the intensivistsECG for the intensivists
ECG for the intensivists
 
Ecg part 2
Ecg part 2Ecg part 2
Ecg part 2
 
STEMI equivalents
STEMI  equivalentsSTEMI  equivalents
STEMI equivalents
 
St segment elevations
St  segment elevationsSt  segment elevations
St segment elevations
 
Myocardial infarction
Myocardial infarction Myocardial infarction
Myocardial infarction
 
STEMI EQUIVALENT 1.pptx
STEMI EQUIVALENT 1.pptxSTEMI EQUIVALENT 1.pptx
STEMI EQUIVALENT 1.pptx
 
Acute coronary syndrome presentation with bivalirudin
Acute coronary syndrome presentation with bivalirudinAcute coronary syndrome presentation with bivalirudin
Acute coronary syndrome presentation with bivalirudin
 
Conduction Disorders
Conduction DisordersConduction Disorders
Conduction Disorders
 
ECG Quiz
ECG QuizECG Quiz
ECG Quiz
 
Ecg example
Ecg exampleEcg example
Ecg example
 
BUNDLE BRANCH BLOCK WITH AMI latest.pptx
BUNDLE BRANCH BLOCK WITH AMI latest.pptxBUNDLE BRANCH BLOCK WITH AMI latest.pptx
BUNDLE BRANCH BLOCK WITH AMI latest.pptx
 
Imitators
ImitatorsImitators
Imitators
 
ecg_systemic_approach_12-lead_compressed.pdf
ecg_systemic_approach_12-lead_compressed.pdfecg_systemic_approach_12-lead_compressed.pdf
ecg_systemic_approach_12-lead_compressed.pdf
 
Myocardial infarction [autosaved]
Myocardial infarction [autosaved]Myocardial infarction [autosaved]
Myocardial infarction [autosaved]
 
Understanding Medicine - Complete ECG Guide by Dr. Sam Gharbi
Understanding Medicine - Complete ECG Guide by Dr. Sam GharbiUnderstanding Medicine - Complete ECG Guide by Dr. Sam Gharbi
Understanding Medicine - Complete ECG Guide by Dr. Sam Gharbi
 

Mais de Bishan Rajapakse

Intern o-week -wellbeing 2023.pdf
Intern o-week -wellbeing 2023.pdfIntern o-week -wellbeing 2023.pdf
Intern o-week -wellbeing 2023.pdfBishan Rajapakse
 
Mahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxMahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxBishan Rajapakse
 
Balancing personal and professional lives (27-9-22).pptx
Balancing personal and professional lives (27-9-22).pptxBalancing personal and professional lives (27-9-22).pptx
Balancing personal and professional lives (27-9-22).pptxBishan Rajapakse
 
Re-framing Failure into success - EM Fellowship OSCE
Re-framing Failure into success - EM Fellowship OSCERe-framing Failure into success - EM Fellowship OSCE
Re-framing Failure into success - EM Fellowship OSCEBishan Rajapakse
 
Shellharbour Mentorship program 2022 - Aug.potx
Shellharbour Mentorship program 2022 - Aug.potxShellharbour Mentorship program 2022 - Aug.potx
Shellharbour Mentorship program 2022 - Aug.potxBishan Rajapakse
 
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptx
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptxPhase 3 Med Student Orientation SHH ED - 22-07-22.pptx
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptxBishan Rajapakse
 
Barriers to Engagement in Wellbeing-4.pptx
Barriers to Engagement in Wellbeing-4.pptxBarriers to Engagement in Wellbeing-4.pptx
Barriers to Engagement in Wellbeing-4.pptxBishan Rajapakse
 
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes Makoni
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes MakoniEm consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes Makoni
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes MakoniBishan Rajapakse
 
Shellharbour mentorship program 2021
Shellharbour mentorship program 2021Shellharbour mentorship program 2021
Shellharbour mentorship program 2021Bishan Rajapakse
 
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)Bishan Rajapakse
 
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)Bishan Rajapakse
 
Wellbeing and mentorship - SRMO Orientation Feb 2020
Wellbeing and mentorship - SRMO Orientation Feb 2020Wellbeing and mentorship - SRMO Orientation Feb 2020
Wellbeing and mentorship - SRMO Orientation Feb 2020Bishan Rajapakse
 
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCare
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCarePrioritizing Wellbeing - #ACEM19 #HumanityInHealthCare
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCareBishan Rajapakse
 
1. the road less travelled prioritising wellbeing3
1. the road less travelled   prioritising wellbeing31. the road less travelled   prioritising wellbeing3
1. the road less travelled prioritising wellbeing3Bishan Rajapakse
 
Defining sepsis - Journal Club (Jason Wu)
Defining sepsis - Journal Club  (Jason Wu)Defining sepsis - Journal Club  (Jason Wu)
Defining sepsis - Journal Club (Jason Wu)Bishan Rajapakse
 
The emergency and intensive care management of OP poisoning
The emergency and intensive care management of OP poisoning The emergency and intensive care management of OP poisoning
The emergency and intensive care management of OP poisoning Bishan Rajapakse
 
Fever in travellers (25-6-14)
Fever in travellers (25-6-14)Fever in travellers (25-6-14)
Fever in travellers (25-6-14)Bishan Rajapakse
 
Airway management in the Emergency Department for Trainees
Airway management in the Emergency Department for TraineesAirway management in the Emergency Department for Trainees
Airway management in the Emergency Department for TraineesBishan Rajapakse
 
Opthalmology in the ED - Dr Andrew White (June 2013)
Opthalmology in the ED - Dr Andrew White (June 2013)Opthalmology in the ED - Dr Andrew White (June 2013)
Opthalmology in the ED - Dr Andrew White (June 2013)Bishan Rajapakse
 
Rhabdomyolysis -Registar teaching (9-10-12)b
Rhabdomyolysis -Registar teaching (9-10-12)bRhabdomyolysis -Registar teaching (9-10-12)b
Rhabdomyolysis -Registar teaching (9-10-12)bBishan Rajapakse
 

Mais de Bishan Rajapakse (20)

Intern o-week -wellbeing 2023.pdf
Intern o-week -wellbeing 2023.pdfIntern o-week -wellbeing 2023.pdf
Intern o-week -wellbeing 2023.pdf
 
Mahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptxMahsa - presentation on Sepsis 8-4-22.pptx
Mahsa - presentation on Sepsis 8-4-22.pptx
 
Balancing personal and professional lives (27-9-22).pptx
Balancing personal and professional lives (27-9-22).pptxBalancing personal and professional lives (27-9-22).pptx
Balancing personal and professional lives (27-9-22).pptx
 
Re-framing Failure into success - EM Fellowship OSCE
Re-framing Failure into success - EM Fellowship OSCERe-framing Failure into success - EM Fellowship OSCE
Re-framing Failure into success - EM Fellowship OSCE
 
Shellharbour Mentorship program 2022 - Aug.potx
Shellharbour Mentorship program 2022 - Aug.potxShellharbour Mentorship program 2022 - Aug.potx
Shellharbour Mentorship program 2022 - Aug.potx
 
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptx
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptxPhase 3 Med Student Orientation SHH ED - 22-07-22.pptx
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptx
 
Barriers to Engagement in Wellbeing-4.pptx
Barriers to Engagement in Wellbeing-4.pptxBarriers to Engagement in Wellbeing-4.pptx
Barriers to Engagement in Wellbeing-4.pptx
 
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes Makoni
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes MakoniEm consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes Makoni
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes Makoni
 
Shellharbour mentorship program 2021
Shellharbour mentorship program 2021Shellharbour mentorship program 2021
Shellharbour mentorship program 2021
 
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
 
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)
Shellharbour Emergency Rotation - orientation talk (P3 Med Student UOW 2020)
 
Wellbeing and mentorship - SRMO Orientation Feb 2020
Wellbeing and mentorship - SRMO Orientation Feb 2020Wellbeing and mentorship - SRMO Orientation Feb 2020
Wellbeing and mentorship - SRMO Orientation Feb 2020
 
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCare
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCarePrioritizing Wellbeing - #ACEM19 #HumanityInHealthCare
Prioritizing Wellbeing - #ACEM19 #HumanityInHealthCare
 
1. the road less travelled prioritising wellbeing3
1. the road less travelled   prioritising wellbeing31. the road less travelled   prioritising wellbeing3
1. the road less travelled prioritising wellbeing3
 
Defining sepsis - Journal Club (Jason Wu)
Defining sepsis - Journal Club  (Jason Wu)Defining sepsis - Journal Club  (Jason Wu)
Defining sepsis - Journal Club (Jason Wu)
 
The emergency and intensive care management of OP poisoning
The emergency and intensive care management of OP poisoning The emergency and intensive care management of OP poisoning
The emergency and intensive care management of OP poisoning
 
Fever in travellers (25-6-14)
Fever in travellers (25-6-14)Fever in travellers (25-6-14)
Fever in travellers (25-6-14)
 
Airway management in the Emergency Department for Trainees
Airway management in the Emergency Department for TraineesAirway management in the Emergency Department for Trainees
Airway management in the Emergency Department for Trainees
 
Opthalmology in the ED - Dr Andrew White (June 2013)
Opthalmology in the ED - Dr Andrew White (June 2013)Opthalmology in the ED - Dr Andrew White (June 2013)
Opthalmology in the ED - Dr Andrew White (June 2013)
 
Rhabdomyolysis -Registar teaching (9-10-12)b
Rhabdomyolysis -Registar teaching (9-10-12)bRhabdomyolysis -Registar teaching (9-10-12)b
Rhabdomyolysis -Registar teaching (9-10-12)b
 

Último

Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)Ahmad Thanin
 
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTION
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTIONANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTION
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTIONojaswinihemane
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...JakeMatthews12
 
SGK PHÙ PHỔI CẤP ĐHYHN .pdf
SGK PHÙ PHỔI CẤP ĐHYHN                   .pdfSGK PHÙ PHỔI CẤP ĐHYHN                   .pdf
SGK PHÙ PHỔI CẤP ĐHYHN .pdfHongBiThi1
 
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKLaryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKQuick MedTalk
 
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxsiddharthroy26587
 
(IDE)and(IVD),QMS,21 CFR part820 , 801)
(IDE)and(IVD),QMS,21 CFR part820  , 801)(IDE)and(IVD),QMS,21 CFR part820  , 801)
(IDE)and(IVD),QMS,21 CFR part820 , 801)chahattyagi200
 
TARGET DELINEATION IN CERVIX CANCER BY DR KANHU
TARGET DELINEATION IN CERVIX CANCER BY DR KANHUTARGET DELINEATION IN CERVIX CANCER BY DR KANHU
TARGET DELINEATION IN CERVIX CANCER BY DR KANHUKanhu Charan
 
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Dr. Dheeraj Kumar
 
Problems associated with the production of recombinant protein.pdf
Problems associated with the production of recombinant protein.pdfProblems associated with the production of recombinant protein.pdf
Problems associated with the production of recombinant protein.pdfNetHelix
 
Ovarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxOvarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxSizan Thapa
 
clean rooms and its classification .pptx
clean rooms and its classification .pptxclean rooms and its classification .pptx
clean rooms and its classification .pptxushakiranmai4
 
airway management recorded for S2.pptx
airway management  recorded  for S2.pptxairway management  recorded  for S2.pptx
airway management recorded for S2.pptxnakera38
 
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdf
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdfEMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdf
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdfMayuriGamit2
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedSBL DIGITAL
 
bleeding disorders 1 Dr.Nannika Pradhan
bleeding disorders 1  Dr.Nannika Pradhanbleeding disorders 1  Dr.Nannika Pradhan
bleeding disorders 1 Dr.Nannika Pradhanthesalberry
 
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptxCholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptxRajendra Dev Bhatt
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisAshishMaletha2
 
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedDerma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedSBL DIGITAL
 

Último (20)

Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)Methicillin-resistant Staphylococcus Aureus (MRSA)
Methicillin-resistant Staphylococcus Aureus (MRSA)
 
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTION
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTIONANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTION
ANTIPERSPIRANTS AND DEODORANTS : MECHANISM OF ACTION
 
The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...The Art and the Science of UK General Practice A historical review and timeli...
The Art and the Science of UK General Practice A historical review and timeli...
 
SGK PHÙ PHỔI CẤP ĐHYHN .pdf
SGK PHÙ PHỔI CẤP ĐHYHN                   .pdfSGK PHÙ PHỔI CẤP ĐHYHN                   .pdf
SGK PHÙ PHỔI CẤP ĐHYHN .pdf
 
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALKLaryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
Laryngeal papillomatosis .pdf ENT BY QUICKMEDTALK
 
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptxANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
ANATOMY OF THE CEREBRUM WITH CLINICAL ANATOMY.pptx
 
(IDE)and(IVD),QMS,21 CFR part820 , 801)
(IDE)and(IVD),QMS,21 CFR part820  , 801)(IDE)and(IVD),QMS,21 CFR part820  , 801)
(IDE)and(IVD),QMS,21 CFR part820 , 801)
 
TARGET DELINEATION IN CERVIX CANCER BY DR KANHU
TARGET DELINEATION IN CERVIX CANCER BY DR KANHUTARGET DELINEATION IN CERVIX CANCER BY DR KANHU
TARGET DELINEATION IN CERVIX CANCER BY DR KANHU
 
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
Range of Secondary Electrons and Electron Build-Up: Impact on Scatter in Homo...
 
Problems associated with the production of recombinant protein.pdf
Problems associated with the production of recombinant protein.pdfProblems associated with the production of recombinant protein.pdf
Problems associated with the production of recombinant protein.pdf
 
Ovarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptxOvarian tumors Lecture notes for MBBS.pptx
Ovarian tumors Lecture notes for MBBS.pptx
 
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
Evolving Concepts in the Pathogenesis of Inflammatory Dermatologic Disorders ...
 
clean rooms and its classification .pptx
clean rooms and its classification .pptxclean rooms and its classification .pptx
clean rooms and its classification .pptx
 
airway management recorded for S2.pptx
airway management  recorded  for S2.pptxairway management  recorded  for S2.pptx
airway management recorded for S2.pptx
 
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdf
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdfEMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdf
EMBRYOLOGY AND FOETAL DEVELOPMENT-mayu.pdf
 
Ortho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limitedOrtho Products Franchise-solace biotech limited
Ortho Products Franchise-solace biotech limited
 
bleeding disorders 1 Dr.Nannika Pradhan
bleeding disorders 1  Dr.Nannika Pradhanbleeding disorders 1  Dr.Nannika Pradhan
bleeding disorders 1 Dr.Nannika Pradhan
 
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptxCholesterol Biosynthesis  and catabolism for MBBS, Lab. MEd. BDS.pptx
Cholesterol Biosynthesis and catabolism for MBBS, Lab. MEd. BDS.pptx
 
Basic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth AnalysisBasic of Thyroid Hormone:- An In-depth Analysis
Basic of Thyroid Hormone:- An In-depth Analysis
 
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech LimitedDerma Pharmaceutical Franchise Company - Solace Biotech Limited
Derma Pharmaceutical Franchise Company - Solace Biotech Limited
 

Advanced ecgs

  • 2. Quiz Q1 ✤ 55 year old man presents with central crushing chest pain. ✤ Comment on the ECG and what is you treatment plan?
  • 4. Quiz Q2 ✤ 78 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest. ✤ Comment on the ECG and what is you treatment plan?
  • 6. Quiz Q3 ✤ 45 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily. ✤ Obs fine. Bloods normal. Trop negative. ✤ Comment on the ECG and what is your management plan?
  • 8. Quiz Q4 ✤ 78 year old lady who presents with ischaemic chest pain. ✤ Comment on the ECG. ✤ How can you confirm your diagnosis and what is your management plan?
  • 10. Quiz Q5 ✤ 20 year old student. Brought in after collapse. ✤ Went to feel lightheaded and then blacked out for a few seconds. ✤ Not happened before. Now feels fine and wants to go home. ✤ Comment on his ECG and what would you tell him?
  • 12. Quiz Q6 ✤ VT OR SVT?
  • 15. Elevation in aVR ✤ Single lead - significant? ✤ Yes. STE in aVR implies lesion of the left main coronary artery
  • 16. Elevation in aVR ✤ STE in aVR itself of more than 1.5 mm carries a 75% specificity of LMCA and ~75% mortality! ✤ STE in aVR + avL -- 90% specificity AMI ✤ STE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion but ✤ STE in aVR > V1 -- more suggestive of LMCA ✤ The significance of STE in aVR is dubious in the presence of BBB.
  • 17. Sgarbossa Criteria ✤ Or how to detect AMI in LBBB ✤ ST elevation ≥1 mm in a lead with upward (concordant) QRS complex - 5 points ✤ ST depression ≥1 mm in lead V1, V2, or V3 (concordant) - 3 points ✤ ST elevation ≥5 mm in a lead with downward (discordant) QRS complex - 2 points ✤ ≥3 points = specificity of 98% and sensitivity of 20% (10 paper meta-analysis of 614 patients)
  • 19. Sgarbossa Criteria ✤ Only one lead required BUT the significance of elevation in aVR is no longer certain. ✤ Serial / old ECG’s can also help
  • 20. Wellens’ Syndrome ✤ Wellens’ syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting with ischaemic chest pain) that is highly specific for critical stenosis of the left anterior descending artery. ✤ Patients may be pain free by the time the ECG is taken and have normally or minimally elevated cardiac enzymes; however, they are at extremely high risk for extensive anterior wall MI within the next 2-3 weeks. ✤ Type 1 Wellens’ T-waves are deeply and symmetrically inverted ✤ Type 2 Wellens’ T-waves are biphasic, with the initial deflection positive and the terminal deflection negative
  • 23. Wellen’s Syndrome ✤ Wellen's criteria is not dependent on ST changes, just the T inversion! ✤ VERY worrying...Signifies critical LAD stenosis! ✤ 100% of 180 patients with the pattern having >50% stenosis of the left anterior descending coronary artery (mean = 85%), with complete or near complete occlusion in almost 60%. ✤ Likely to need a cath lab rather than medical therapy... ✤ Should be investigated urgently even if now asymptomatic! ✤ BUT - young children and especially female up to 40 years, may have normal variant of T inversion (the juvenile pattern).
  • 25. Posterior MI ✤ Be wary in any patient with infero-lateral ischaemia. ✤ Posterior MI is suggested by the following changes in V1-3: ✤ Horizontal ST depression ✤ Tall, broad R waves (>30ms) ✤ Upright T waves ✤ Dominant R wave (R/S ratio > 1) in V2
  • 26. Posterior MI ✤ Posterior Leads: ✤ V7 – Left posterior axillary line, in the same horizontal plane as V6. ✤ V8 – Tip of the left scapula, in the same horizontal plane as V6. ✤ V9 – Left paraspinal region, in the same horizontal plane as V6.
  • 28. Posterior MI ✤ The degree of ST elevation seen in V7-9 is typically modest – note that only 0.5 mm of ST elevation is required to make the diagnosis of posterior MI!
  • 31. Brugada Syndrome ✤ 25 year old Asian male has had a collapse. Now feels fine and wants to go home...
  • 32. Brugada Syndrome ✤ Brugada syndrome is an ECG abnormality with a high incidence of sudden cardiac death in structurally normal hearts... ✤ Sodium channel mutation (at least 60 different types described so far) ✤ Diagnosis depends upon ECG criteria (which may be transient and clinical criteria (VF, VT, syncope, FHx sudden cardiac death <45) ✤ Definitive treatment = ICD
  • 33. Brugada Syndrome ✤ May be unmasked / augmented by the following: ✤ Fever ✤ Ischaemia ✤ Multiple Drugs: Sodium channel blockers (eg Flecainide, Propafenone), Calcium channel blockers, Alpha agonists, Beta Blockers, Nitrates, Cholinergic stimulation, Cocaine, Alcohol ✤ Hypokalaemia ✤ Hypothermia ✤ Post DC cardioversion
  • 34. Brugada Syndrome - Type 1 Type 1: Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave (don’t confuse with RBBB which should have ST depression)
  • 35. Brugada Syndrome - Type 2 Type 2 has >2mm of saddleback shaped ST elevation.
  • 36. Brugada Syndrome - Type 3 Brugada type 3 can have either type 1 or type 2 morphology, but with <2mm of ST segment elevation.
  • 37. Brugada Syndrome ✤ Do they need admitting? ✤ Type 1 ECG and symptomatic = YES! ✤ If undiagnosed - 10% mortality per year... ✤ Asymptomatic patients with a type 1 ECG pattern and all type 2 + 3 ECG patterns can probably go home and have outpatient electrophysiology...
  • 38. Brugada Syndrome ✤ ...however, EPS is far from a gold standard, with a negative predictive value of less than 50% and some studies suggest that we might be getting a little over-excited about this relatively recently described ECG finding (1992). ✤ One study followed 98 asymptomatic japanese patients with a type 1 ECG found incidentally for 7.8 years and found them to have no greater mortality than the rest of a 14000 strong cohort. This highlights the importance of the clinical criteria required for diagnosis listed above.
  • 39. Trifasicular block ✤ Disease in all 3 conduction fasicles (RBB, LAF, LPF) ✤ May be complete or incomplete: ✤ Incomplete (or Impending) – RBBB, LAD, 1st degree HB ✤ Complete – 3rd degree HB and bifasicular block (usually RBBB and LAD)
  • 41. Trifasicular block ✤ Incomplete trifascicular block may progress to complete heart block. ✤ Patients who present with a syncopal episode and have an ECG showing incomplete trifascicular block should be admitted for a cardiology review as they may be having episodes of complete heart block. Therefore, some of these patients will require a pacemaker.
  • 42. VT or SVT with aberrant conduction???
  • 43. VT or SVT with aberrant conduction??? ✤ 3 possibilities: ✤ VT ✤ SVT with aberrant conduction due to bundle branch block ✤ SVT with aberrant conduction due to the Wolff-Parkinson-White syndrome
  • 44. VT or SVT with aberrant conduction??? ✤ While it is not always possible to differentiate VT from SVT with aberrant conduction it is important to try. SVT is amenable to AV nodal blockers. But someone in VT can suffer haemodynamic collapse if AV blockers given... ✤ Unfortunately, the electrocardiographic differentiation of VT from SVT with aberrancy is not always possible. However, there are several electrocardiographic features that increase the likelihood of VT:
  • 45. More likely to be VT... ✤ Absence of typical RBBB or LBBB morphology ✤ Extreme axis deviation (“northwest axis”) ✤ Very broad complexes (>160ms) ✤ AV dissociation (P and QRS complexes at different rates)
  • 46. More likely to be VT... ✤ Capture beats — occur when the sinoatrial node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration. ✤ Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.
  • 47. More likely to be VT... ✤ Brugada’s sign – The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms ✤ Josephson’s sign – Notching near the nadir of the S-wave
  • 48. More likely to be VT... ✤ Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen. ✤ RSR’ complexes with a taller left rabbit ear. This is the most specific finding in favour of VT. This is in contrast to RBBB, where the right rabbit ear is taller. VT RBB B
  • 49. The likelihood of VT is also increased if: ✤ Age > 35 (positive predictive value of 85%) ✤ Structural heart disease ✤ Ischaemic heart disease ✤ Previous MI ✤ Congestive heart failure ✤ Cardiomyopathy ✤ Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT)
  • 50. The likelihood of SVT with aberrancy is increased if: ✤ Previous ECGs show a bundle branch block pattern with identical morphology to the broad complex tachycardia. ✤ Previous ECGs show evidence of WPW (short PR < 120ms, broad QRS, delta wave). ✤ The patient has a history of paroxysmal tachycardias that have been successfully terminated with adenosine or vagal manoeuvres. ✤ HOWEVER - IF IN DOUBT TREAT AS VT
  • 51. Quiz Answers Q1 ✤ 55 year old man presents with central crushing chest pain. ✤ Comment on the ECG and what is you treatment plan?
  • 53. Quiz Answers Q1 ✤ NSR ✤ Widespread ST depression ✤ Elevation in aVR --> LMCA lesion!! ✤ D/W Papworth for ?PPCI, ACS Rx etc…
  • 54. Quiz Answers Q2 ✤ 78 year old diabetic man. Previous MI. Presents with sudden onset SOB and an odd feeling in chest. ✤ Comment on the ECG and what is you treatment plan?
  • 56. Quiz Answers Q2 ✤ Paced rhythm - Broad complexes ✤ Positive Scarbossa Criteria ✤ > 5mm ST elevation in III, aVF ✤ < 1mm ST depression V2, V3 ✤ 1mm ST elevation aVL ✤ Needs PPCI
  • 57. Quiz Answers Q3 ✤ 45 year old male. Brought in by wife after an episode of severe indigestion last night. Now symptoms free. Insists he’s fine and wants to go home. Thinks his wife is worrying unnecessarily. ✤ Obs fine. Bloods normal. Trop 12. ✤ Comment on the ECG and what is your management plan?
  • 59. Quiz Answers Q3 ✤ Wellens’ type 1 - deep symmetrical TWI anteriorly. ✤ Likely has a severe LAD stenosis and should be investigated urgently. ✤ Refer medics for urgent angiography.
  • 60. Quiz Answers Q4 ✤ 78 year old lady who presents with ischaemic chest pain. ✤ Comment on the ECG. ✤ How can you confirm your diagnosis and what is your management plan?
  • 62. Quiz Answers Q4 ✤ Likely posterior MI (borderline inferior MI also) ✤ Anterior ST depression with a dominant R wave. ✤ Confirm with posterior leads ✤ Treat as per AMI - PPCI
  • 63. Quiz Answers Q5 ✤ 20 year old student. Brought in after collapse. ✤ Went to feel lightheaded and then blacked out for a few seconds. ✤ Not happened before. Now feels fine and wants to go home. ✤ Comment on his ECG and what would you tell him?
  • 65. Quiz Answers Q5 ✤ Brugada syndrome type 1 ✤ Risk of sudden death. Need admission for an ICD...
  • 66. Quiz Answers Q6 ✤ VT OR SVT?
  • 68. Quiz Answers Q6 ✤ Probably SVT with aberrant conduction.