2024 ECGs for Acute, Critical and Emergency Care 2nd Volume 1

ECGs for Acute, Critical and Emergency Care 2nd Volume 1 Năm xuất bản: 2024 Nhà xuất bản: Wiley Blackwell Số trang: 168 (file pdf 179 trang) Link amazon: https://www.amazon.com/ECGs-Acute-Critical-Emergency-Anniversary-ebook/dp/B0CRK7ZLP7/

and Emergency Care

Second Edition, Volume 1

20th Anniversary Edition

Amal Mattu, MD

Professor and Vice Chair of Academic Affairs

Department of Emergency Medicine, University of Maryland School of Medicine

Baltimore, Maryland, USA

William J Brady, MD

Professor, Vice Chair for Faculty Affairs and The David A Harrison Distinguished Educator, Department of Emergency

Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, United States

and

Medical Director, Albemarle County Fire Rescue, Charlottesville, Virginia, USA

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Library of Congress Cataloging- in- Publication Data

Names: Mattu, Amal, author | Brady, William, 1960– author

Title: ECGs for acute, critical and emergency care : 20th anniversary /

Amal Mattu, William J Brady

Other titles: ECGs for the emergency physician 2 | Electrocardiography for

acute, critical and emergency care

Description: Second edition | Hoboken, NJ : Wiley-Blackwell, 2024 |

Preceded by ECGs for the emergency physician 2 / Amal Mattu, William

Brady 2008 | Includes bibliographical references and index

Identifiers: LCCN 2023037647 (print) | LCCN 2023037648 (ebook) | ISBN

9781119986164 (paperback) | ISBN 9781119986171 (Adobe PDF) | ISBN

9781119986188 (epub)

Subjects: MESH: Electrocardiography–methods | Heart Diseases–diagnostic

imaging | Emergencies | Emergency Medical Services

Classification: LCC RC683.5.E5 (print) | LCC RC683.5.E5 (ebook) | NLM WG

140 | DDC 616.1/207547–dc23/eng/20231128

LC record available at https://lccn.loc.gov/2023037647

LC ebook record available at https://lccn.loc.gov/2023037648

Cover Design: Wiley

Cover Image: Courtesy of Amal Mattu

Set in 9/13pt Frutiger by Straive, Pondicherry, India

ALGrawany

Preface vi

Dedications viii

Part 1 Case histories 3

ECG interpretations and comments 53

Part 2 Case histories 83

ECG interpretations and comments 133

Appendix A: Differential Diagnoses 159

Appendix B: Commonly used abbreviations 161

Index 162

and reference textbook for acute, critical, and emergency care physicians written by two specialists practicing and teaching

acute, critical, and emergency care

Drs Mattu and Brady have created an ECG text that facilitates self- instruction in learning the basics, as well as the

complexities, of ECG interpretation They know that ECG interpretation requires knowledge, insight, and practice They

know “the eye does not see what the mind does not know.” In order to accomplish this goal of teaching ECG interpretation,

they have divided their book into two parts In Part I, as the authors state, are the “bread and butter” ECGs of clinical care

These are the ECG findings that form the core knowledge necessary for accurate ECG interpretation In Part II, they teach

recognition of more subtle ECG abnormalities, which when mastered, allow the practitioner to approach expert status

The beauty of this text lies in the combination of a collection of ECGs with the authors’ insights and expert observations

This book has great utility as a reference text, a bound ECG teaching file, a board review aide or a resident in emergency

medicine’s best friend for learning the art of advanced ECG interpretation Its greatest value, however, is for all of us who

want to be both challenged and taught by 200 great electrocardiograms and their interpretations

May the forces be with you

Emergency and other acute care physicians must be experts in the use and interpretation of the 12- lead electrocardiogram

(ECG) We have prepared this text with this basic, though highly important, thought in mind This text represents our effort

to further the art and science of electrocardiography as practiced by emergency physicians and other acute/critical care

clinicians

A significant number of the patients managed in the emergency department (ED) and other clinical settings present with

chest pain, cardiovascular instability, or complaints related to the cardiovascular system The known benefits of early, accurate

diagnosis and rapid, appropriate treatment of cardiovascular emergencies have only reinforced the importance of physician

competence in electrocardiographic interpretation The physician is charged with the responsibility of rapid, accurate

diagno-sis followed by appropriate therapy delivered expeditiously This evaluation does not infrequently involve the performance of

the 12- lead ECG For example, the patient with chest pain presenting with STEMI must be rapidly and accurately evaluated

so that appropriate therapy is offered in a prompt – and correct – fashion Another example includes the hemodynamically

unstable patient with atrioventricular block who must be cared for in a rapid manner In these instances as well as numerous

other scenarios, resuscitative and other therapies are significantly guided by information obtained from the ECG

The ECG is used frequently in the ED and other acute care settings; numerous presentations may require a 12- lead ECG For

instance, the most frequent indication for ECG performance in the ED is the presence of chest pain; other complaints

fre-quently involving ECG analysis include dyspnea and syncope Physicians obtain an ECG in the ED in the evaluation of

sus-pected acute coronary syndrome, pulmonary embolism, and intentional medication overdose, among other situations; the

ECG also plays a major role in various diagnostic strategies, such as the “rule- out myocardial infarction” protocol.1

Regardless of the cause, the physician must be an expert in the interpretation of the 12- lead ECG Interpretation of the ECG

is as much an art as it is a science Accurate ECG interpretation requires a sound knowledge of the ECG, both the objective

criteria necessary for various diagnoses of those patients encountered in the ED as well as a thorough grasp of the various

electrocardiographic waveforms and their meaning in the individual patient And, importantly, the physician must understand

the vital concept of interpreting the ECG within the context of the patient’s presentation (i.e clinical correlation suggested)

We have prepared this text for the physician who manages patients not only in the ED but also in other clinical care settings –

whether it be in the office, the hospital ward, critical care unit, the out- of- hospital arena, or other patient- care locale We

have used actual ECGs from patients treated in our EDs; a brief but accurate history has also been provided in each instance

In certain cases, the history may provide a clue to the diagnosis; yet in other situations, the clinical information will have no

relationship to the final diagnosis – as is the case in the ED We have made an effort to choose the most appropriate ECG for

each patient, but as occurs in “real ED,” some of the ECGs are imperfect: the evaluation is hindered by artifact, incomplete

electrocardiographic sampling, etc We have also provided the ECGs in a random fashion, much the way actual patients

present to the ED We have endeavored to reproduce the reality of the ED when the reader uses this text to expand his or her

knowledge of the 12- lead ECG and how it relates to patient care

ALGrawany

interpretation This ECG text has been constructed in two basic sections The first half of the text contains ECGs that we feel

represent the “bread and butter” of emergency electrocardiography – the core material with which we feel that the acute

care physician must be thoroughly familiar These ECGs were chosen because they represent common electrocardiographic

diagnoses that all emergency physicians should know This section is prepared primarily for the physician- in- training (for

example the emergency medicine resident), though practicing physicians and senior medical students will also benefit from

reviewing the material The second half of the text is composed of ECGs that are more challenging Electrocardiographic

diagnoses are more difficult to establish and will often be based on subtle findings In some cases, the ECGs in this section

were chosen not necessarily because of the related level of difficulty but because of subtle teaching points found, which are

likely to be quite challenging for the physician- in- training

It is also crucial to understand that this text is not intended for the “beginner in ECG interpretation.” The text, in essence

an electrocardiographic teaching file, is intended for the physician who already possesses a basic understanding of

elec-trocardiography, yet desires additional practice and review – a review which is highly clinically pertinent The

electrocardiog-raphy beginner is advised to begin by reading through one of the many outstanding books that have previously been written

for novice students prior to studying this teaching file

One last point must also be stressed to the reader of this text Diagnostic criteria for various electrocardiographic diagnoses

vary somewhat amongst authors Therefore, in an effort to standardize the interpretations used in this text, we chose to use

the following two references as the “gold standard” for electrocardiographic interpretations: Chou’s Electrocardiography in

Clinical Practice: Adult and Pediatric, 6th ed, and The Complete Guide to ECGs, 5th ed.2,3

Medical Center and University of Maryland Medical Center in Baltimore for their ECG contributions; to the faculty and

residents of the University of Maryland Emergency Medicine Residency Program for providing the main inspiration for this

work; to Wiley-Blackwell for supporting and believing in this work; to Dr Bill Brady for his mentorship, friendship, and

com-mitment to teaching and education; and to emergency physicians around the world – may your dedication to learning

con-tinue to strengthen our specialty and improve patient care

Amal Mattu, MD

I would like to thank my wife, King, for her love, support, wise counsel, and patience – none of these efforts would be

possible without her; my “all- grown- up” children, Lauren, an internal medicine physician; Anne, a cardiology nurse; Chip,

a  firefighter- EMT; and Katherine, an ED nurse for not only being wonderful but also for “being there” for others; the

Emergency Medicine residents, faculty, and nurses (past, present, and future) at the University of Virginia, for their hard work,

astronomical dedication, and expertise – all directed at our patients in the emergency department; the firefighter- EMTs of

Albemarle County Fire Rescue for all that they do, every day; and my co- author, Dr Amal Mattu, for his dedicated effort on

this book in particular and his dedication to Emergency Medicine education in general – a true gentleman, talented clinician,

and distinguished scholar . . . and good friend

William J Brady, MD

ALGrawany

1

ECGs for Acute, Critical and Emergency Care, Second Edition Amal Mattu and William J Brady.

© 2024 John Wiley & Sons Ltd Published 2024 by John Wiley & Sons Ltd.

**All leads at half standard**

62 45 year old man with severe lightheadedness

ECGs for Acute, Critical and Emergency Care, Second Edition Amal Mattu and William J Brady.

© 2024 John Wiley & Sons Ltd Published 2024 by John Wiley & Sons Ltd.

1 Sinus rhythm (SR), rate 60, normal ECG SR is generally defined as having an atrial rate of 60–100/minute and a P- wave

axis +15 to +75 degrees Sinus beats can be identified by upright P- waves in leads I, II, and aVF; and inverted P- waves in lead aVR If the P- waves do not meet these criteria It implies an ectopic atrial origin for the P- waves The PR- interval should

be >0·12 seconds; a shorter PR- interval suggests either a low ectopic atrial origin, an atrioventricular (AV) junctional origin,

or the presence of a pre- excitation syndrome (for example Wolff–Parkinson–White (WPW) syndrome) The normal ECG often will demonstrate inverted T- waves in leads aVR and V1 Inverted T- waves in lead III are often normal as well

2 SR with sinus arrhythmia, rate 66, early repolarization (ER) Sinus arrhythmia is defined as sinus rhythm with

slight variation (>0·16 seconds) in the sinus cycles This produces mild irregularity in the rhythm and usually occurs at lower heart rates (<70/minute) ER is a normal variant often found in young healthy adults, especially men Patients will have ST- segment elevation in many leads, although not in aVR or V1 The absence of reciprocal ST- segment changes

Early repolarization – note the diffuse ST- segment elevation which is more prominent in the precordial leads (leads V2, V3,

and V5) when compared to the limb leads (I and II) The J point is elevated with elevation of the ST- segment maintaining the

morphology of the ST- segment The morphology of the elevated ST- segment is concave (small arrow), a feature which is

highly suggestive of a non- AMI cause of ST- segment elevation The J point is frequently notched or irregular (large arrow)