CREIGHTON/MARICOPA EMERGENCY MEDICINE RESIDENCY
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AV Blocks

3/10/2017

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Amal Mattu gives us a very simple way to distinguish the type of advanced AV block by looking at the PR intervals.
  • PR interval gradually increasing = Mobitz I
  • PR interval fixed = Mobitz II
  • PR interval appears random = 3rd Degree Block

You may also find this link to LITFL on SVT vs VT most informative.
Copa Cardiogram # 80
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Bonus! Who needs the Cath Lab?

2/18/2017

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Join in the conversation between Scott Weingart and Steve Smith as they discuss who should go to the cath lab on Dr. Scott Weingart's EMCRIT two part podcast or check out the pdf cheat sheet from Dr. Smith on which patients should go to the cath lab and when to engage you cardiologist for consult.
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who-to-pci-by-smith-and-weingart.pdf
File Size: 2458 kb
File Type: pdf
Download File

cheatsheet-edited_pci_cards_consult.pdf
File Size: 151 kb
File Type: pdf
Download File

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Download Dr. Smith's Subtle STEMI App from iTunes
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Arrhythmogenic Right Ventricular Hypertrophy

2/15/2017

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This is an autosomal dominant disease with variable penetration that is second only to HCM in causing sudden cardiac death in otherwise healthy young people.  Dr. Burns presents basic ECG findings of ARVH as well as discussing other diagnostic studies and treatment.  Highlights below.
  • Epsilon wave: positive deflection buried in end of QRS complex, occasionally resembling greek letter epsilon on its side.
  • T wave inversions in V1-3
  • Prolonged S wave upstroke of 55ms in V1-3
  • Wide QRS in V 1-3
  • Paroxysmal VTach with LBBB morphology
Copa Cardiogram #79
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Left Ventricular Hypertrophy

2/3/2017

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 What exactly are the electrical criteria for LVH?  Dr. Burns walks us through it on LITFL.  Not a copa cardiogram, this one's on the house!
Sokolov-Lyon Criteria
  • S wave depth V1 + tallest R wave in V5 or V6 >35mm
Should be accompanied by:
  • Increased R wave peak time (>50ms in V5 or V6)
  • ST depression and T wave inversion in the left side leads (strain pattern)
Cornell Criteria (Sn 42%, specificity 95%)
  • R wave in aVL + S wave in V3
  • >20mm in females
  • >28mm in males
(Dr. Loli's favorite criteria to use)
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Heart Block

1/24/2017

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Dr. Mattu walks us through a three step method to make identifying heart blocks easy. Just ask three qestions
1) What is the atrium doing? (regular, irregular rate?)
2) What is the ventricle doing? (morphology and thus location? rate?)
3) How are the two related? (Look at PR interval, is it regular? long then dropped QRS, longer, longer then drop? or randomly related? 1st, 2nd, 3rd degree blocks).
Copa Cardiogram #77
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Accelerated Idioventricular Rhythm (AIVR)

1/3/2017

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Commonly seen after ventricular reperfusion, and generally self limiting, this rhythm is important to recognize as managment with antiarrhythmics is not indicated (and may make the situation worse).  It is a result of a ventricular rhythm that is faster than the atrial rhythm and will generally resolve once the atrial rhythm exceeds the ventricular pacemaker.  Focus on recognizing the underlying causes, treating the cause and not the rhythm, or being watchfully patient as the case may require.  Follow the link to LITFL to learn more.

ECG Features
  • Regular rhythm.
  • Rate 50-110 bpm. (<50 is likely ventricular escape, > 110 is VT)
  • Three or more ventricular complexes.
  • QRS complexes >120ms.
  • Fusion and capture beats.

Copa Cardiogram #76
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Left Posterior Fascicular Block

12/5/2016

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The posterior fascicle is much large and less susceptible to injury.  As such it is not likely to occur in isolation, and more commonly seen with some AV node dysfunction as a Bifascicular block (LPFB + RBBB).  Dr, Burns walks us through some of expected ECG findings and also reminds that you should not dx LPFB without first considering more worrisome causes of right axis deviation: PE, TCA overdose, lateral MI, or RVH.  Check out his post on LITFL.
Conduction goes down functioning anterior fascicle, from endocardium to epicardium (initial small voltage) to remaining myocardium from the anterior/superior LV towards the inferior/posterior LV resulting in the following changes:
  • Right axis deviation (> +90 degrees)
  • Small R waves with deep S waves in leads I and aVL
  • Small Q waves with tall R waves in inferior leads (II, III, aVF)
This altered conduction takes longer than usual and the delay can be seen on ECG:
  • QRS duration normal or slightly prolonged (80-110ms)
  • Prolonged R wave peak time in aVF
  • Increased QRS voltage in the limb leads
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​Remember it's probably NOT LPFB if you see:
  • No evidence of right ventricular hypertrophy
  • No evidence of any other cause for right axis deviation
  • PE
  • TCA overdose
  • Lateral MI






Copa Cardiogram #73
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Left Anterior Fascicular Block

11/2/2016

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It helps to remember how the current is conducted.  The posterior fascicle originates inferiorly and posteriorly on the endocardium.  Thus the initial flow of current in LV will be rightward and down, as current moves to the epicardium.  Additionally, depolarization of the right ventricle is progressing normally.  As depolarization progresses, it moves from inferior, posterior to anterior, superior giving you the  patter noted below.  Check out LITFL's page on LAFB.
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  • Left axis deviation
  • Small q waves with tall R waves in leads I and aVL
  • Small r waves with deep S waves in leads II, III, aVF
  • QRS duration is normal or slightly prolonged (80-110 ms)
  • Prolonged R wave peak time in aVL > 45 ms (measure from start of Q to peak of R)
  • Increased QRS voltage in the limb leads

Dr. Burns also provides a beautiful pearl that in LAFB you might see LVH voltage criteria in aVL (R wave height > 11 mm), but there will be no LV strain pattern.
Copa Cardiogram #66
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Pediatric ECGs

10/31/2016

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There are several key differences in pediatric ECGs that would otherwise cause alarm in an adult ECG.  Also check out life in the fast lane's page on pediatric ECGs

Axis:  Rightward axis
  • Large R wave in V1-V2, small S in V5-V6
Q waves
  • Narrow, sharp in inferior and lateral leads
Intervals
  • PR short without aberrant conduction
  • QRS <80ms prior to age 8
  • QT 490ms may be normal up to 6 mo old
T-Waves
  • Inverted V1-V3
  • usually through age 8, but may persist as 'Juvenile T wave abnormality'
Copa Cardiogram #65
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Really, no really, wide QRS complexes

10/15/2016

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Dr. Mattu reminds us of our differential for really wide QRS complexes, also quick approach to TCA overdose treatment.
Wide QRS
  • Ventricular ectopy
  • Paced Beats
  • BBB
  • WPW syndrome
  • Non Specific IVCD
  • Medication toxicity (NaCB)
  • Metabolic
Tips to identifying TCA on ECG
  • Wide complex tachy, esp if QRS >200ms
  • Right Axis Deviation
    • Tall R in aVR
  • New onset seizures
Copa Cardiogram #62
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    Author

    Our thanks to Dr. Tim Davie for assembling the Copa Cardiogram each week.  Please follow this link to get to spreadsheet of all Copa Cardiograms.

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©2020
Department of Emergency Medicine
Maricopa Medical Center
Phoenix, AZ 85008
602-344-5808 - tel
602-344-5907 - fax
copapride@gmail.com
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  • Home
  • Program
    • Program Director's Message
    • Benefits
    • Clinical Sites >
      • Valleywise Health
      • Arizona Burn Center
      • Phoenix Children's Hospital
      • Banner University Medical Center – Phoenix
      • Toxicology - BUMCP
      • Mayo Clinic Arizona
      • Banner Cardon Children's Medical Center
    • Curriculum >
      • Curriculum
      • Electives
    • Diversity + Inclusion
    • Faculty >
      • Department Chair
      • Faculty Bios
      • Faculty Alumni
      • Program Coordinators
    • Residents >
      • Class of 2021
      • Class of 2022
      • Class of 2023
      • Alumni
    • Students >
      • Adult EM Rotation
      • Ultrasound Rotation
      • Applying to Rotate
      • Applying to the Program
      • Interviews
    • Research
    • Vision & Principles
    • Ultrasound >
      • Ultrasound Director
      • Ultrasound Fellowship
      • Education (internal link)
      • Admin (internal link)
    • Admin Fellowship