ECG IN EMERGENCY

Adi Sulistyanto
 OBJECTIVES
1. Review ECG Interpretation

2. Review Cardiac Arrest Management

3. Know when to start and stop resuscitation

ECGs and strips
 What?
 Elektrokardiogramm (Jerman)

 Noninvasive transthoracic graphic

 Is a test that records the electrical activity

of the heart.
 Indication
 Chest Pain
 Palpitation
 Syncope
 Any suspected cardiac patient

Cardiac monitoring for critically ill patients

 What types of pathology can we
identify and study from EKGs?

 Arrhythmias
 Myocardial ischemia and infarction
 Pericarditis
 Chamber hypertrophy
 Electrolyte disturbances (i.e.
hyperkalemia, hypokalemia)
 Drug toxicity (i.e. digoxin and drugs which
prolong the QT interval)
TREAT THE PATIENT
NOT THE ECG
Lead Position
Anatomic Groups
(Summary)
The Normal Conduction System
 BASIC ECG
INTERPRETATION
Simple, quick method in
emergencies
 Step 1: Heart Rate
 Step 2: Rhytm
 Step 3: P waves
 Step 4: PR Interval
 Step 5: QRS Complex
Waveforms and Intervals
 Determining the Heart Rate
 Rule of 300

 6 Second Rule
 The Rule of 300
It may be easiest to memorize the following table:

# of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
What is the heart rate?

www.uptodate.com

(300 / ~ 4) = ~ 75 bpm
 6 Second Rule

Count the number of complexes on a 6 second

strip and multiply them by 10

This method works well for irregular rhythms.

 P Waves
 Are they present?
 Occuring regularly?
 Is there P Waves for each QRS?
 Normal appearance?
 Do all P waves look similar?
 PR Interval
 0.12 – 0.20 seconds

 Constant
 QRS Complex
 Narrow (<0.12 seconds)?

 Wide (>0.12 seconds)?

 Similar?
FOUR LETHAL RHYTMS
The most common cause of a flatline tracing
on ECG is a detached lead or
malfunctioning equipment, not asystole;
therefore, always confirm asystole in more
than one lead!

 Never shock asystole (no matter what you

see on TV).
 Asystole interventions :
1. ABCs, O2, IV access, cardiac monitor,
pulse oximetry
2. CPR.
3. Consider possible causes.
4. Consider immediate transcutaneous
pacing (Class IIb).
5. Epinephrine 1 mg IV push q 3–5 minutes.
 Pulseless Electrical Activity
 Any normally perfusing rhythm in which
there is no detectable pulse.
 Possible Causes of Asystole &
PEA
 6 H & 5T
Hypovolemia Toxins
Hypoxia Tamponade
Hydrogen Tension
Hypo/Hyperkalemia Pneumothorax
Hypoglycemia Thrombosis
Hypothermia Trauma
 Defibrillation should take precedence over establishing
IV access, intubation, or the administration of any drug!
 ABCs
 Initiate and continue CPR until defibrillator is attached.
 Defibrillate (shock), 120-200 J (biphasic) or 360J
(monophasic).
 Epinephrine 1 mg IV q 3–5 minutes or vasopressin 40 U
IV × 1.
 Amiodarone 300 mg IV for VF/pulseless VT, repeat 150
mg
 Lidocaine 1 to 1.5 mg/kg repeat 0.5-0.75 mg/kg until max
3 mg/kg
 Causes of cardiac arrest
 In Adults:
Ventricular Fibrilation (65-85%)
SHOCK EARLY !
Chances decrease 7-10% each minute
 In Children
Respiratory insufficiency (60%)
VF (<10%)
 Stopping resuscitation
 ROSC
 Exhaustion
 Apparent signs of death
 Depending on local regulation and
physician medical judgement
 Death In Medicine
1. Clinical Death:
Cessation of respiration and heart beat

2. Brain death ( Biological death):

Permanent cessation of electrical activity
in the brain
Specific criteria from different
organizations
 Brain death criteria
 Prerequisite:
Structural CNS disease, no complicating
medical condition/toxins, and core
temperature > 32 C
 Cardinal findings:
1. Coma or unresponsiveness
2. Absence of brainstem reflexes
3. Positive apnea testing
The end