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Monday, 22 October 2012

Serum Potassium and The Heart

This 84yr old lady attends to see your CHD nurse, for her annual BP/CHD review.

She mentions in passing, that hasn't been feeling too well recently with non-specific symptoms of malaise, intermittent palpitations and muscle weakness.

Her BP (on medication) is 142/74. Her pulse is regular.

In view of her mentioning palpitations, the CHD nurse decides to do an ECG:


What would you like to know?

Please hashtag (#ECGclass) any questions you'd like to ask .

This lady takes the following medication:
Lisinopril 20mg (for Hypertension)
Furosemide, Bisoprolol and Sprinolactone (for her mild-moderate LVSD).
She also takes Simvastatin, Calcium, and Alendronic acid.

The CHD nurse takes blood, as planned, for U&E's eGFR, LFTS, bone profile and FBC.
(Her last blood tests were almost a year ago, but were all in normal range, other than eGFR which was mildly reduced at 52).

It's 5pm and the duty GP is out on a late visit, so the CHD nurse asks your Nurse Practitioner to take a look.
The NP examines her thoroughly and finds no abnormalities of the CVS/RS/abdomen, but urinalysis reveals slightly cloudy urine, with leucocytes, protein and a trace of blood. There are no Nitrites  - but is is late in the day.
The NP decides her symptoms are consistent with a UTI, and prescribes her some empirical Trimethoprim. She sends the lady home and puts the ECG in the duty doctors paper tray to view on his return.

On his return at 5.30 pm the duty GP resumes surgery, which is now running late. He finally gets to his paperwork at 7pm. and notices the ECG with a brief explanatory note from the Nurse Practitioner.

He notes the slight tachycardia (which seems to fit with a possible infection), and tallish complexes - possibly compatible with her thin bony stature and hypertension.

But,  oh dear......the duty GP has not been attending #ECGclass on Twitter.  :(

He is not concerned, and continues with the rest of his paperwork.

What are you thinking now?

Mid-morning the next day, the lady's daughter calls requesting to bring her mother straight down. She seems far more unwell today and the daughter is very worried about her.

She doesn't look at all well so a repeat ECG is done on arrival:

What are you thinking now?

The routine U&E's are now back from yesterday. Her eGFR is stable but poor at 42
But her serum Potassium returned at 6.6 . 
(The out of hours labs had called the on-call GP, but the lady could not be contacted at home as she had gone to spend the night with her daughter).  

She tells the GP today she started to feel a lot worse after the starting the Trimethoprim. She also admitting to taking some ibuprofen, which a friend had given her for low back pain.

Hyperkalaemia

Hyperkalaemia often gives no symptoms, and is picked up incidentally. It may give very vague non-specific symptoms, such as malaise, palpitations, or general weakness. 

Two of the most common causes of are:

1. Renal Disease (check: U&E's and eGFR)
2. Medication (check : ACE/ARB/s/Potassium sparing diuretics - spironolactone and amiloride, NSAIDS, Trimethoprim)

ECG changes
The Serum Potassium concentration, at which the various ECG changes takes place is inconsistent, but as a general guide:

K= 6.0-7.0 mmol/l : (see first ECG above)
  • Smaller flattened p waves (sometimes lost altogether)
  • Tall tented T waves 
K = 7.0-8.0 mmol/l: (see second ECG above)
  • Widening of the QRS complex 
  • Widening T waves (incorporating the ST segment)
  • ECG can develop a sinusoidal shape
K > 8.0 mmol/l : 
  • Lengthening of the PR interval and, 
  • Ultimately,  Atrial arrest 
Severe Hyperkalaemia is a medical emergency.

The broad QRS-T complexes classically show an "unfolded Z shape" (Imagine a stretchy Z shape - turned on its side and pulled out). Seen most clearly in V3-V5 in the second example above.

Lesson of the week:
Always monitor your patient's electrolytes (especially in the elderly)  if on combinations of the above medication. Hyperkalaemia is most likely to arise in polypharmacy for Hypertension, or Heart Failure, on a background of CKD. 
In the case above, the addition of Trimethoprim may well have tipped the balance, and exacerbated the problem. 

Hypokalaemia

Whilst we are on with Potassium levels, it may be a timely opportunity to mention the effects of low serum potassium on the ECG. 

Possible Causes of Hypokalaemia Include : 
  • Inadequate dietary intake, 
  • excessive loss (eg diarrhoea/xs perspiration or persistent vomiting) or 
  • excessive loss in urine (e.g. As a result of diabetic ketoacidosis, Thiazide or loop diuretics)





=  The "U" wave of low serum Potassium, is seen after the QRS complex:




                                    
The end :)
Thank you!
H.

#ECGclass Case 14

#ECGclass Case 14


This 84yr old lady attends to see your CHD nurse, for her annual BP/CHD review.

She mentions in passing, that hasn't been feeling too well recently with non-specific symptoms of malaise, intermittent palpitations and muscle weakness.

Her BP (on medication) is 142/74. Her pulse is regular.

In view of her mentioning palpitations, the CHD nurse decides to do an ECG:
   


What would you like to know?

Please hashtag (#ECGclass) any questions you'd like to ask .


This lady takes the following medication:
Lisinopril 20mg (for Hypertension)
Furosemide, Bisoprolol and Sprinolactone (for her mild-moderate LVSD).
She also takes Simvastatin, Calcium, and Alendronic acid.

The CHD nurse takes blood, as planned, for U&E's eGFR, LFTS, bone profile and FBC.
(Her last blood tests were almost a year ago, but were all in normal range, other than eGFR which was mildly reduced at 52).

It's 5pm and the duty GP is out on a late visit, so the CHD nurse asks your Nurse Practitioner to take a look.
The NP examines her thoroughly and finds no abnormalities of the CVS/RS/abdomen, but urinalysis reveals slightly cloudy urine, with leucocytes, protein and a trace of blood. There are no Nitrites  - but is is late in the day.
The NP decides her symptoms are consistent with a UTI, and prescribes her some empirical Trimethoprim. She sends the lady home and puts the ECG in the duty doctors paper tray to view on his return.

On his return at 5.30 pm the duty GP resumes surgery, which is now running late. He finally gets to his paperwork at 7pm. and notices the ECG with a brief explanatory note from the Nurse Practitioner.

He notes the slight tachycardia (which seems to fit with a possible infection), and tallish complexes - possibly compatible with her thin bony stature and hypertension.

But,  oh dear......the duty GP has not been attending #ECGclass on Twitter.  :(

He is not concerned, and continues with the rest of his paperwork.


Mid-morning the next day, the lady's daughter calls requesting to bring her mother straight down. She seems far more unwell today and the daughter is very worried about her. She has no chest pains, but more palpitations. On arrival, she doesn't look at all well, she's very pale and clammy.


What are you thinking now?

When you've had a go,  you'll find the full discussion on the next blog!


Monday, 15 October 2012

The Cardiac Axis - For 4 yr olds

This weeks #ECGclass is by Special request :-)


Twitter Challenge :
An anaesthetist recently asked “Please can you explain how to calculate the cardiac Axis.......ideally, as if explaining to a 4yr old. ”

O.K. Here goes.


To calculate the Cardiac Axis you will need:

  • ·       A piece of paper
  • ·       A small piece of card
  • ·       A pair of scissors (always ask an adult first)
  • ·       Some glue
  • ·       Some sticky back plastic
  • ·       Some ‘copy and paste’ facility (or a pen)


Step 1
Copy the picture below and stick it on a small piece of card:
(Please ask an adult to help you with the cutting)




Cover it with sticky-back plastic, and Keep this with you at all times in your wallet or pocket. 

Now, wherever you go in the world, and whatever crises confront you, you will ALWAYS be able to calculate a cardiac axis.


Step 2

Imagine the picture above is an intersection of railway lines. (Imagine joining all the lines so that they make a star in the centre).

There are 6 Train Stations, called aVR, aVL, AvF, I, II and III.
The station lines have arrows on them, pointing towards the station.
(Ignore the other lines for the time being, and ignore the numbers).

The trains can only travel in straight lines.


Now remember 3 golden rules:


1If a train travels towards a station – it makes an upward shape (known as positive deflection) which looks like this:




2.   If a train travels away from a station – it makes a downward shape (known as a negative deflection) which looks like this:



3.    So, what do you think happens, if a train crosses the track at right angles?

Yes, that’s right – It makes a more ‘flat’ pattern, such as this:

This is known as ‘isoelectric’. 




Step 3


Take any old ECG. Such as this one: 






Step 4

The best bit about calculating a cardiac axis, is that you can completely ignore V1-V6 (these aren’t real “Stations”!). 
So cover them up and forget them.

So now we can focus solely on the Stations I, II, III, AvR, AvL and AvF:






Step 5 

The Nitty Gritty

For any axis, the first thing to do, is to identify the most isoelectric lead.

Remembering the 3 golden rules, which of the Stations in the example above, do you think is the one most likely to have a train crossing it at right angles?
(Clue: It’s the lead with the most isoelectric pattern).

Answer: In the ECG above, the most isoelectric lead is Station aVL.

So we KNOW for sure, that the train is crossing aVL at right angles!

Step 6

Now take a look at the Intersection picture you copied and put in your pocket. 

Whichever train track crosses the AvL track at right angles, is the one the train is travelling on.

The line at right angles to the aVL line is station II line.
So the train is travelling along line II!

So far so good?

BUT at the moment we don’t know in which direction the train is travelling.
Is it travelling towards the Station II, or away from it??

To know the answer to this question, take a look at the pattern made in Lead II on your ECG.
If it’s POSITIVE then we know the train is travelling towards Lead II. If it’s NEGATIVE, then it’s travelling away from it.

In the example above, Lead II shows a POSITIVE deflection.
SO THE TRAIN IS TRAVELLING TOWARDS LEAD II

Step 7

Now you get to look at the ‘numbers’ on the intersection picture.
Look at the number associated with station II.
It is +60 degrees.


Now substitute the word ‘Train’ for ‘Cardiac impulse’
                            ‘Station’ for ‘Limb Lead’

And what do you get:

THE CARDIAC AXIS ON THIS ECG IS +60 DEGREES

Tah Dah!
And there you have it. The cardiac Axis for 4yr olds. :-)




Summary  (For the Grown ups)

THE CARDIAC AXIS 

  • 1.     First identify the most isoelectric limb lead on the ECG.
  • 2.     Using the axis diagram – identify the lead which crosses the most isoelectric lead, at right angles. This lead represents the pathway of the cardiac impulse.
  • 3.     Look back at this lead on the ECG, to see if the deflection is positive or negative (to know which direction the cardiac impulse is travelling. i.e. Is it travelling towards, or away, from that lead?)
  • 4.     Read off the corresponding axis ('x' degrees) from the diagram.

This process, calculates the axis to the nearest 30 degrees. This is accurate enough for most  situations.

If desired, the accuracy of the axis estimate, can be further improved by  +/- 15 degrees. 
To do this, note which axis leads lay on either side of the impulse lead (see axis diagram) . then take a look at these leads on the ECG. Whether they are positive or negative will determine which of the neighboring axis, the impulse is between. Add +/- 15degrees accordingly. 


A Normal Axis lies between +90 and -30 degrees.

An axis between -30 and -90 degrees is a LEFT Axis deviation (LAD).
Common causes of LAD: LVH, left anterior fascicular block, inferior myocardial infarction. Can be normal variant in obese or stocky.

An axis between +90 and +180 degrees is a RIGHT axis deviation (RAD).
Common causes of RAD: RVH, chronic lung disease, anterolateral myocardial infarction, left posterior hemiblock, pulmonary embolus. 
Can be normal in children or tall, thin adults.


Thus:

(image courtesy of  medicine-on-line.com)






So here are three more for you to try at home!

What is the cardiac axis of the following 3 ECG’s:

Q1




Q2  

   

Q3







Answers:
(Sorry - my IT skills don't enable me to write the answers upside down)

Q1.
 Lead aVR is the most isoelectric. So impulse is travelling towards, or away from, lead III.
 Lead III deflection is NEGATIVE, so impulse must be travelling AWAY from lead III.
 The opposite direction to Lead III  means Axis =  -60 degrees 
 This is Left Axis Deviation. 
(Typical ECG pattern of LAD is "Left to Leave" - imagine the QRS complex deflections in leads I and III are repelling away from - or leaving - each other!).

Q2.
Lead II is the most isoelectric. So impulse is travelling towards, or away from,  lead aVL.
Lead aVL deflection is NEGATIVE, so impulse is travelling AWAY from lead aVL.
The opposite direction to aVL means Axis =  +150 degrees
This is Right Axis deviation.
(Typical ECG pattern of RAD is "Right to Return" - i.e the QRS complex deflections in leads I and II are trying to reach inwards towards each other - trying to kiss and make up perhaps?!)


Q3
Lead II is the most isoelectric. So impulse is travelling towards or away from lead aVL.
Lead aVL is POSITIVE, so impulse is travelling TOWARDS aVL .
The same direction as aVL means Axis =  -30 degrees
This is an axis within NORMAL limits.  (slightly leftward, but not significantly so)
At a glance, if just eye-balling the ECG, you may have thought that this pattern looked a little like LAD (" Left to Leave" pattern as seen in Q1), but for this to be significant,  lead II should also be predominantly negative. 


Well done.  And thanks so much for all your positive feedback. :-)
See you next week! 


Heather.