Cardiology: ECGs and Cross-cover Intern Lecture Series

Posted by e-Medical PPT Thursday, September 6, 2012
Description of cardiac chest pain - typical
Pain is creshendo in nature (not sudden and severe as occurs with PE or aortic dissection)
“pressure-like” or “tightness” or “heaviness” or “indigestion” or “discomfort” in the chest
Located substernally radiating to the left arm, neck, jaw, or shoulder (see next slide).
Pain due to acute coronary syndrome lasts in general > 10 minutes.

Description of cardiac chest pain - atypical
While many people are familiar with the classic description of cardiac chest pain, many atypical presentations of cardiac pain may occur.
These include:
Sharp or burning pain instead of pressure-like.
Radiation to the shoulders, right chest/arm, or back.
Describing the feeling as a “discomfort”, not pain.

Myocardial ischemia: Physical Examination
The physical examination during active ischemia is helpful, however it is difficult to examine a person during ischemia since it may last only a few minutes (except in ACS).
Findings on exam may or may not include:
An S4 heart sound (ischemia impairs relaxation)
A murmur of MR (due to papillary muscle dysfunction)

ECG findings
Examine the ECG for ischemic changes including new ST depression, T wave inversions, or ST elevations
If the patient is actively having chest pain and the pain is due to myocardial ischemia, a majority of the time there will be some new ischemic ECG finding

Differential diagnosis
Atrial fibrillation/flutter (afib/aflutter)
Ventricular tachycardia (VT)
PSVT (AVNRT or AVRT)  less common on-call
    - Narrow-complex tachycardia. Caused by a re-entrant circuit  can be broken with AV nodal blockade
    - Hook up to a 12-lead ECG machine and give adenosine 6 mg IV followed by saline flush. Can repeat once, then give 12 mg IV once if unsuccessful.
    - Alternatively can do carotid massage (if no carotid bruit present)

Atrial fibrillation/Atrial flutter
Afib/flutter is a common rhythm which you will encounter on multiple occasions throughout your residency.
On-call management consists of:
Hemodynamic stabilization including HR control
Assessment of the etiology

Ventricular tachycardia (VT)
Non-sustained VT (NSVT) is very very common in patients with systolic CHF and usually is not serious when occurring on-call.
Sustained VT (usually defined as at least 30 seconds) is life threatening and requires immediate attention.

NSVT is easy to take care of overnight
Look at the strip to verify monomorphic VT and not polymorphic VT (Torsades)
Check recent electrolytes to be sure potassium and magnesium is not low. Order K+ and Mg2+ if not checked within 12 hours and replace appropriately.
Note: Describe NSVT by number of beats and rate..
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