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ECG Abnormalities_Part 21

Saturday, July 21, 2012

69 year old female with a past history of breast cancer presents with dyspnea on exertion and dizziness. Her vital signs are BP 80/40, HR 120, RR 24, and oxygen saturation 88% on room air. Physical exam revealed crepitations at the left lung base, distant heart sounds, and elevated jugular venous pressures especially with inspiration. Her ECG is given below. Also provided is a simultaneous recording of her arterial line pressue tracing and inspirometer.
What are the abnormal ECG findings?
What is the diagnosis?

ANSWER

The ECG findings are:
1) Sinus tachycardia
2) Low voltage
3) PAC (2nd beat from the last on rhythm strip)
4) Poor R wave progression

Diagnosis is cardiac tamponade. Malignancy is the most common cause for a pericardial effusion resulting in increased intrapericardial pressures causing the right atrium and right ventricle to collapse in diastole.This results in hypotension and tachycardia and can be life threatening. The ECG findings of cardiac tamponade include low voltage on the ECG and "electricle alternans" where each QRS complex alternates from normal voltage to low voltage.Arterial line pressue tracing shows her systolic blood pressure dramtically drop with inspiration.This phenomenon which occurs in cardiac tamponade is called "pulsus paradoxus" and can be measured non-invasively using a blood pressure cuff.

ECG Abnormalities_Part 20

Monday, June 25, 2012

A 65 year old male patient with end-stage COPD gets admitted to the ICU with respiratory failure. He was found to have the below ECG:

What are the ECG findings?
What is the treatment for this heart rhythm disorder?

ANSWER

The ECG findings include: 1) Multifocal atrial tachycardia (three distinct P wave morphologies) 2) Incomplete right bundle branch block 3) Poor R wave progression 4) PVCs

Multifocal atrial tachycardia (aka MAT) is an irregularly irregular, tachycaric rhythm in which many foci in the atium chaotically fire acting as the pacemaker of the heart instead of the sinus node. The atrial rate is not as fast as in atrial flutter or atrial fibrillation, so normal AV synchrony can occur. When the rhythm has 3 distinct P wave morphologies and the heart rate is not fast, the term "wandering atrial pacemaker" or WAP is used.

 The treatment of multifocal atrial tachycardia is aimed at the underlying cause. In this case it would be to treat the COPD exacerbation and respiratory failure. The only medication that has been used to treat MAT is verapamil with only marginal success. No anticoagulation is needed for MAT in contrast to atrial flutter/fibrillation since the atrium are contracting well, but simply originating in different areas.

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