Critical Decisions in Emergency and Acute Care Electrocardiography

497 Pages·2009·8.91 MB·English

by  William Brady

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Critical Decisions in Emergency and
Acute Care Electrocardiography
Critical Decisions in Emergency and Acute Care Electrocardiography.
Edited by William J. Brady and Jonathon D. Truwit © 2009 Blackwell
Publishing Ltd. ISBN: 978-1-405-15906-7
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Dr Brady’s dedication – To my wife, King, for her constant support, patience, and
guidance; and for my children, Lauren, Anne, Chip, and Katherine, for their love.
Dr Truwit’s dedication – To my wife Jeanne and my children, Jason, Matthew and
Lauren without whom I could not be personally or professionally fulfilled nor accom-
plish as much.
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Critical Decisions
in Emergency and
Acute Care
Electrocardiography
EDITED BY
William J. Brady | MD
Professor of Emergency Medicine and Medicine Ice Chair, Department of Emergency Medicine
Medical Director, Life Support Learning Center
University of Virginia Health System
Charlottesville, VA, USA
Jonathon D. Truwit | MD
Senior Associate Dean for Clinical Affairs
E. Cato Drash Professor of Medicine
Pulmonary and Critical Care Medicine
University of Virginia Health System
Charlottesville, VA, USA
A John Wiley & Sons, Ltd., Publication
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This edition first published 2009, © 2009 by Blackwell Publishing Ltd
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Library of Congress Cataloging-in-Publication Data
Critical decisions in emergency and acute care electrocardiography / edited by William Brady,
Jonathon Truwit.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-4051-5906-7
1. Electrocardiography. 2. Critical care medicine. I. Brady, William, 1960– II. Truwit,
Jonathon Dean.
[DNLM: 1. Electrocardiography. 2. Critical Care. 3. Decision Making. 4. Emergency
Medical Services. WG 140 C934 2009]
RC683.5.E5C75 2009
616.1′207547—dc22
2008030326
ISBN: 9781405159067
A catalogue record for this book is available from the British Library.
Set in 9/12pt Meridien by Graphicraft Limited, Hong Kong
Printed & bound in Singapore by Fabulous Printers Pte Ltd
1 2009
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Contents
Section Editors, vii 15 What ECG changes might myocardial ischemia cause
other than ST segment elevation or Q waves and what
Contributors, viii
are the differential diagnoses of these changes? 103
Preface, xi
16 What is a hyperacute T Wave? 115
Forewords, xii
17 What is the significance of Q waves? 122
Part 1 | The ECG in Clinical Practice, 1 18 What are the ECG indications for additional
electrocardiographic leads (including
1 What are the clinical applications of the ECG in electrocardiographic body-surface mapping) in chest
emergency and critical care? 3 pain patients? 128
2 What are the indications for the ECG in the pediatric 19 What further diagnostic adjuncts to the standard 12-lead
emergency department? 12 ECG may help to diagnose ACS? 138
3 What are the limitations of the ECG in clinical practice? 19 20 Is serial electrocardiography (serial ECGs and ST segment
4 Is the ECG indicated in stable, non-cardiac patients monitoring) of value in the ECG diagnosis of ACS? 148
admitted to the hospital? 24
21 What QRS complex abnormalities result in ST segment
5 What is the use of the ECG in preoperative assessment elevation that may mimic or obscure AMI? 155
and cardiovascular risk stratification? 28
22 What are the electrocardiographically silent areas of the
6 Which patients benefit from continuous heart? 167
electrocardiographic monitoring during
23 What is the value of the prehospital acquired 12-lead
hospitalization? 33
ECG? 176
24 What are the electrocardiographic indications for
Part 2 | The ECG in Cardinal Presentations, 39
reperfusion therapy? 182
7 How should the ECG be used in the syncope patient? 41
25 What are the ECG manifestations of reperfusion and
8 How should the ECG be used in the chest pain patient? 49 reocclusion? 195
9 How should the ECG be used in the dyspneic patient? 58 26 Does localization of the anatomic segment/identification
of the infarct-related artery affect early care? 204
10 How should the ECG be used in the patient with altered
mentation? 64 27 Can the ECG be used to predict cardiovascular risk and
11 How should the ECG be used in the patient during and acute complications in ACS? 216
following cardiac arrest? 69
12 What is the impact/proper role of the ECG in the Part 4 | The Dysrhythmic ECG, 231
undifferentiated cardiorespiratory failure patient? 75
28 Can the electrocardiogram determine the rhythm
diagnosis in narrow complex tachycardia? 233
Part 3 | The ECG in ACS, 83
29 Can the ECG guide treatment of narrow QRS
13 What is the role of the ECG in ACS? 85 tachycardia? 244
14 What pseudoinfarction patterns mimic ST elevation 30 How can the ECG guide the diagnosis and management
myocardial infarction? 92 of wide complex tachycardias? 251
v
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vi | Contents
31 Can the ECG guide management in the patient with Part 6 | The Toxicologic ECG, 395
bradydysrhythmias? 267
45 How useful is the ECG in the evaluation of the poisoned
32 What are the electrocardiographic indications for patient? 397
temporary cardiac pacing? 276
46 Can the ECG guide management in the critically ill,
33 Can the ECG accurately diagnose pacemaker poisoned patient? 402
malfunction and/or complication? 284
47 Do characteristics of the QRS complex in the poisoned
34 How can the ECG guide acute therapy in the Wolff patient correlate with outcome? 407
Parkinson White (WPW) patient? 295
48 What is the treatment for wide complex dysrhythmias in
35 What is the role of the ECG in PEA cardiac arrest the poisoned patient? 412
scenarios? 303
Part 7 | Electrocardiogaphic Differential
Part 5 | The ECG in Critical Care, 315 Diagnosis, 417
36 What is the role of the ECG in the critically ill, 49 What is the ECG differential diagnosis of ST segment
non-coronary patient? 317 elevation? 419
37 Can the ECG distinguish between coronary and 50 What is the ECG differential diagnosis of ST segment
non-coronary etiologies in the critically ill patient? 326 depression? 428
38 What is the role of the ECG in therapeutic considerations/ 51 What is the ECG differential diagnosis of the abnormal
medical management decisions in the critically ill T wave? 436
patient? 335
52 What is the ECG differential diagnosis of narrow
39 Can the ECG predict risk in the critically ill, non- complex tachycardia? 444
coronary patient? 345
53 What is the ECG differential diagnosis of wide complex
40 What is the proper role of the ECG in the evaluation of tachycardia? 452
patients with suspected PE? 354
54 What is the ECG differential diagnosis of
41 What is the role and impact of the ECG in the patient bradycardia? 461
with hyperkalemia? 362
55 What is the ECG differential diagnosis of the abnormally
42 What is the role and impact of the ECG in the patient wide or large QRS complex? 469
with electrolyte abnormalities other than hyperkalemia?
56 What is the ECG differential diagnosis of a prolonged
371
QT interval? 479
43 What is the role of the ECG in the hypothermic
patient? 378
44 What are the non-ACS “deadly” ECG presentations?
384
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Section Editors
Ellen C. Keeley, MD Ajeet Vinayak, MD
Associate Professor of Internal Medicine, Department of Assistant Professor of Medicine, Pulmonary and Clinical Care Division,
Internal Medicine, Division of Cardiology, University of Virginia, Department of Medicine, University of Virginia, Charlottesville, VA, USA
Charlottesville, VA, USA
Christopher P. Holstege, MD
Andrew Perron, MD Associate Professor, Department of Emergency Medicine; Director,
Program Director, Department of Emergency Medicine, Maine Medical Division of Medical Toxicology, University of Virginia School of
Center, Portland, ME, USA Medicine, Charlottesville, VA, USA
Stephen W. Smith, MD Theodore C. Chan, MD
Faculty Emergency Physician, Hennepin County Medical Center, Professor and Medical Director, Department of Emergency Medicine,
Associate Professor of Emergency Medicine, University of Minnesota University of California, San Diego, CA, USA
School of Medicine, Minneapolis, MN, USA
Richard A. Harrigan, MD
Amal Mattu, MD, FAAEM, FACEP Professor, Department of Emergency Medicine, Temple University,
Director, Emergency Medicine Residency Associate Professor, Philadephia, PA, USA
Department of Emergency Medicine, University of Maryland School of
Medicine, Baltimore, MD, USA
vii
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Contributors
Michael Abraham, MD Mark D. Connelly, MD
Attending Physician, Department of Emergency Medicine, Upper Emergency Medicine Department, Regions Hospital, St Paul. MN, USA
Chesapeake Medical Center, Bel Air, MD, USA
Andrew Darby, MD
Khaled Bachour, MD Cardiology Fellow, Department of Medicine, Division of Cardiovascular
Fellow, Division of Cardiology, Department of Internal Medicine, Medicine, University of Virginia, Charlottesville, VA, USA
Harper Hospital, Wayne State University School of Medicine,
Detroit, MI, USA John Ferguson, MB ChB, MD
Assistant Professor of Internal Medicine, Department of Medicine,
Billie Barker, MD, USA Division of Cardiovascular Medicine, University of Virginia,
Pulmonary & Critical Care Fellow, Department of Internal Medicine, Charlottesville, VA, USA
Division of Pulmonary & Critical Care, University of Virginia,
Charlottesville, VA, USA Lisa M. Filippone, MD
Assistant Professor of Emergency Medicine, Department of Emergency
Stefan C. Bertog, MD Medicine, UMDNJ-Robert Wood Johnson Medical School, Camden, NJ,
Interventional Cardiology Veterans Administration Medical Center, USA
University of Minnesota, Minneapolis, MN, USA
Carl A. Germann, MD
Michael A. Bohrn, MD, FAAEM, FACEP Attending Phsyician, Department of Emergency Medicine, Maine
Associate Residency Program Director, Clinical Assistant Professor, Medical Center, Portland, ME, USA
Department of Emergency Medicine, York Hospital, York, PA, USA
Chris Ghaemmaghami
Michael C. Bond, MD, FAAEM Associate Professor, Vice Chair of Academics, and Program Director,
Assistant Residency Program Director, Assistant Professor, Department Department of Emergency Medicine, University of Virginia,
of Emergency Medicine, University of Maryland School of Medicine, Charlottesville, VA, USA
Baltimore, MD, USA
Daniel Grinnan, MD
Christopher T. Bowe, MD, FACEP Assistant Professor of Medicine, Department of Internal Medicine,
Associate Residency Program Director, Assistant Professor, Emergency Division of Pulmonary & Critical Care, Virginia Commonwealth
Medicine, Department of Emergency Medicine, Maine Medical Center, University, Richmond, VA, USA
Portland, ME, USA
Richard A. Harrigan, MD
David Burt, MD Professor, Department of Emergency Medicine, Temple University,
Assistant Professor, Medical Director, Chest Pain Center, Department of Philadelphia, PA, USA
Emergency Medicine, University of Virginia, Charlottesville, VA, USA
Adam Helms, MD
Claire C. Caldwell, MD Chief Medical Resident, Department of Internal Medicine, University of
Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Virginia, Charlottesville, VA, USA
Medical School, Camden, NJ, USA
Steve Herndon MD
Clay A. Cauthen, MD, MA Pulmonary & Critical Care Fellow, Department of Internal Medicine,
Chief Medical Resident, Department of Internal Medicine, University of Division of Pulmonary & Critical Care, University of Virginia,
Virginia, Charlottesville, VA, USA Charlottesville, VA, USA
Theodore C. Chan, MD D. Kyle Hogarth, MD
Professor and Medical Director, Department of Emergency Medicine, Assistant Professor of Medicine, Department of Internal Medicine, Division
University of California, San Diego, CA, USA of Pulmonary & Critical Care, University of Chicago, Chicargo, IL, USA
Nathan P. Charlton, MD Joel S. Holger, MD
Medical Toxicology Fellow, Division of Medical Toxicology, Department Assistant Professor of Emergency Medicine, University of Minnesota
of Emergency Medicine, University of Virginia School of Medicine, Medical School, Senior Staff Physician, Regions Hospital, St Paul, MN,
Charlottesville, VA, USA USA
viii
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Contributors | ix
Benjamin Holland MD Robert O’Connor, MD, MPH
Medical Resident, Department of Internal Medicine, University of Professor and Chair, Department of Emergency Medicine, University of
Virginia, Charlottesville, VA, USA Virginia, Charlottesville, VA, USA
Christopher P. Holstege, MD Daniel T. O’Laughlin, MD, FACEP
Associate Professor, Departments of Emergency Medicine & Pediatrics; Emergency Medicine Faculty, Abbott Northwestern Hospital, Assistant
Director, Division of Medical Toxicology, University of Virginia School Professor of Emergency Medicine, University of Minnesota School of
of Medicine, Charlottesville, VA, USA Medicine, Minneapolis, MN, USA
Colin G. Kaide, MD, FACEP, FAAEM, UHM Michael Osmundson, MD, MBA, FACEP
Associate Professor of Emergency Medicine, Specialist in Hyperbaric Associate Clinical Professor, Mercer University School of Medicine,
Medicine and Wound Care, Department of Emergency Medicine, Savannah, GA, USA
The Ohio State University, Columbus, OH, USA
Rajan A.G. Patel, MD
Ellen C. Keeley, MD
Cardiology Fellow, Department of Medicine, Division of Cardiovascular
Associate Professor of Internal Medicine, Department of Medicine,
Medicine, University of Virginia, Charlottesville, VA, USA
Division of Cardiovascular Medicine, University of Virginia,
Charlottesville, VA, USA
Tamas R. Peredy, MD
Medical Director, Northern New England Poison Center, Maine Medical
Vipin Khetarpal, MD
Center, Portland, ME, USA
Fellow in Cardiology, Division of Cardiology, Department of Internal
Medicine, Harper Hospital Wayne State University School of Medicine,
Andrew Perron, MD
Detroit, MI, USA
Program Director, Department of Emergency Medicine, Maine Medical
Michael Christopher Kurz, MD, MS-HES Center, Portland, ME, USA
Assistant Professor, Department of Emergency Medicine, Virginal
Peter M. Pollak, MD
Commonwealth University Medical Center, Richmond, VA, USA
Internal Medicine Resident, Department of Medicine, University of
David M. Larson, MD Virginia, Charlottesville, VA, USA
Clinical Associate Professor, University of Minnesota Medical School,
St Paul, MN, USA Michael Ragosta, MD
Associate Professor of Internal Medicine, Department of Medicine,
David T. Lawrence, DO Division of Cardiovascular Medicine, University of Virginia,
Assistant Professor, Department of Emergency Medicine, Division of Charlottesville, VA, USA
Medical Toxicology, University of Virginia School of Medicine,
Charlottesville, VA, USA Kevin C. Reed, MD, FACEP, FAAEM
Assistant Clinical Professor, Department of Emergency Medicine,
Stephen D. Lee, MD Georgetown University, Attending Physician, Department of
Emergency Medicine Resident, Department of Emergency Medicine, Emergency Medicine, Washington Hospital Center, Washington,
University of Virginia School of Medicine, Charlottesville, VA, USA DC, USA
Joseph E. Levitt, MD Christopher M. Rembold, MD
Assistant Professor of Medicine, Department of Internal Medicine, Professor of Internal Medicine, Department of Medicine, Division
Division of Pulmonary & Critical Care, Stanford University Medical of Cardiovascular Medicine, University of Virginia, Charlottesville,
Center, Stanford, CA, USA VA, USA
D. Scott Lim, MD
John R. Saucier, MD, FACEP
Assistant Professor of Pediatrics, Department of Pediatrics, University of
Attending Physician, Maine Medical Center, Portland, ME; Assistant
Virginia, Charlottesville, VA, USA
Professor of Emergency Medicine, Department of Emergency Medicine;
Clinical Assistant Professor in Surgery, University of Vermont, College
Michael J. Lipinski, MD
of Medicine, Burlington, VT, USA
Resident in Medicine, Department of Medicine, University of Virginia,
Charlottesville, VA, USA
Jason T. Schaffer, MD, FAAEM
Amal Mattu, MD, FAAEM, FACEP Assistant Clinical Professor of Emergency Medicine, Department of
Emergency Medicine, Indiana University School of Medicine,
Director, Emergency Medicine Residency, Associate Professor,
Indianapolis, IN, USA
Department of Emergency Medicine, University of Maryland School of
Medicine, Baltimore, MD, USA
Joseph Shiber, MD, FAAEM, FACEP
Michael A. McCulloch, MD Associate Professor of Emergency Medicine, University of Central Florida
Pediatric Resident, Department of Pediatrics, University of Virginia, School of Medicine, Research Director, Florida Hospital Emergency
Charlottesville, VA, USA Medicine Residency, Orlando, FL, USA
Franklin R. McGuire, MD Allan G. Simpson, MD
Assistant Professor of Medicine, Department of Internal Medicine, Associate Professor of Internal Medicine, Department of Medicine,
Division of Pulmonary & Critical Care, University of South Carolina, Division of Cardiovascular Medicine, University of Virginia,
Colombia, SC, USA Charlottesville, VA, USA