Electrocardiogram in Clinical Medicine

Electrocardiogram in Clinical Medicine

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Description

Offers a guide for a complete understanding of the disease and conditions most frequently revealed in ECGs recorded in the acute, critical, and emergency care settings


Electrocardiogram in Clinical Medicine offers an authoritative guide to ECG interpretation that contains a focus and perspective from each of the three primary areas of medical care: acute care, critical care and emergency care. It can be used as a companion with the book ECGs for the Emergency Physician I & II (by Mattu and Brady) or as a stand-alone text. These three books can be described as a cumulative EGG reference for the medical provider who uses the electrocardiogram on a regular basis.


Electrocardiogram in Clinical Medicine includes sections on all primary areas of ECG interpretation and application as well as sections that highlight use, devices and strategies. The medical content covers acute coronary syndromes and all related issues, other diseases of the myocardium, morphologic syndromes, toxicology and paediatrics; dysrhythmias will also be covered in detail. This important resource:


* Goes beyond pattern recognition in ECGs to offer a real understanding of the clinical syndromes evidenced in ECGs and implications for treatment


* Covers the indications, advantages and pitfalls of the use of ECGs for diagnosis in all acute care settings, from EMS to ED to Critical Care


* Examines the ECG in toxic, metabolic and environmental presentations; critical information for acute care clinicians who need to be able to differentiate ODs, poisoning and other environmental causes from MI or other cardiac events


* Facilitates clinical decision-making


Written for practicing ER, general medicine, family practice, hospitalist and ICU physicians and medical students, Electrocardiogram in Clinical Medicine is an important book for the accurate interpretation of EGG results.
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Product details

  • Paperback | 512 pages
  • 217 x 276 x 29mm | 1,270g
  • New York, United States
  • English
  • 1. Auflage
  • 1118754557
  • 9781118754559

Back cover copy

Offers a guide for a complete understanding of the disease and conditions most frequently revealed in ECGs recorded in the acute, critical, and emergency care settings

Electrocardiogram in Clinical Medicine offers an authoritative guide to ECG interpretation that contains a focus and perspective from each of the three primary areas of medical care: acute care, critical care and emergency care. It can be used as a companion with the book ECGs for the Emergency Physician I & II (by Mattu and Brady) or as a stand-alone text. These three books can be described as a cumulative EGG reference for the medical provider who uses the electrocardiogram on a regular basis.

Electrocardiogram in Clinical Medicine includes sections on all primary areas of ECG interpretation and application as well as sections that highlight use, devices and strategies. The medical content covers acute coronary syndromes and all related issues. Other diseases of the myocardium, morphologic syndromes, toxicology and paediatrics and dysrhythmias will also be covered in detail. This important resource: goes beyond pattern recognition in ECGs to offer a real understanding of the clinical syndromes evidenced in ECGs and implications for treatment covers the indications, advantages and pitfalls of the use of ECGs for diagnosis in all acute care settings, from EMS to ED to Critical Care examines the ECG in toxic, metabolic and environmental presentations; critical information for acute care clinicians who need to be able to differentiate ODs, poisoning and other environmental causes from MI or other cardiac events facilitates clinical decision-making

Written for practicing ER, general medicine, family practice, hospitalist and ICU physicians and medical students, Electrocardiogram in Clinical Medicine is an important book for the accurate interpretation of EGG results.
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Table of contents

List of Contributors xxi


Section I The ECG in Clinical Practice 1


1 The ECG in Clinical Medicine 3
Brian Kessen and Kelly Williamson


Introduction 3


The ECG as a Clinical Tool 3


Clinical Presentations and the ECG 4


Chest Pain 4


Dyspnea 5


Syncope 6


Toxicology 7


Electrolyte Abnormalities 7


Pacemakers 10


Conclusion 10


References 10


2 History of the Electrocardiogram 13
Trale Permar and Kelly Williamson


References 17


Section II ECG Changes in Myocardial Ischemia 19


1 The Cardiac Action Potential and Changes in the Setting of Acute Coronary Syndrome: How Ischemia and Infarction Impacts the ECG 21
Kirsti A. Campbell and Michael J. Lipinski


Introduction 21


Basic Electrophysiology 21


Action Potentials in Sodium-Dependent Depolarizers 21


Action Potential in Calcium-Dependent Depolarizers 24


Anatomy of the Electrical Conduction System 24


Biochemical Impact of Ischemia 25


ST-Segment Deviation 25


QRS Complex 30


T Waves 31


P Waves 31


U Waves 34


Myocardial Ischemia: Causes Other than Acute Coronary Syndrome 34


Conclusion 34


References 36


2 Ischemic Electrocardiographic Changes and Correlation with Regions of the Myocardium 37
Thibault Lhermusier and Michael J. Lipinski


Introduction 37


Coronary Anatomy 37


Definitions of STEMI and Non-ST Elevation ACS 38


Left Main Coronary Ischemia 39


Anterior STEMI 40


Wellens Syndrome 40


Inferior STEMI 41


Right Ventricular Infarction 41


Lateral STEMI 44


Posterior STEMI 44


Conduction Abnormalities in the Setting of Ischemia 46


Aneurysm of the Left Ventricle 49


ECG in Pharmacological and Mechanical Reperfusion 49


Conclusion 50


References 50


3 STEMI Mimics 53
Peter M. Pollak


Introduction 53


Myocarditis and Myopericarditis 53


Early Repolarization 55


Left Ventricular Hypertrophy 57


Prior Infarction and Ventricular Aneurysm 58


Vasospasm (Prinzmetal or Variant Angina) 58


Apical Ballooning Syndrome (Takotsubo Cardiomyopathy) 61


Brugada Pattern and Idiopathic Ventricular Fibrillation 62


Hyperkalemia 62


Post-Cardioversion/Shock 62


Hypothermia and Osborn Waves 62


Pulmonary Embolism 63


Other Causes of ST Elevation 63


Conclusion 65


References 65


4 Confounders of ST?Elevation Myocardial Infarction 69
Amy West Pollak


Introduction 69


Left Bundle Branch Block 69


LBBB and Ischemic Heart Disease 69


Left Ventricular Hypertrophy 71


Ventricular Paced Rhythm 71


Right Bundle Branch Block (RBBB) 73


References 73


5 The Prognostic Value of the Electrocardiogram in Acute Coronary Syndromes 75
Benjamin Shepple and Robert Gibson


Introduction 75


The ECG in Acute Coronary Syndromes 75


ST Elevation Myocardial Infarction (STEMI) 75


The ECG during Myocardial Injury 76


The ECG in Response to Therapy 80


ECG after Completion of Infarction 81


UA/NSTEMI 83


ST-Segment Depression 83


T-Wave Inversions 84


Initial Normal ECG 86


Arrhythmia and Conduction Disease 86


Ventricular Arrhythmias 86


Premature Ventricular Contractions 87


Ventricular Tachycardia 87


Ventricular Fibrillation 87


Supraventricular Tachycardia 89


AV Conduction Delay and Heart Block 90


Prolonged QTc Interval 91


Conclusion 92


References 92


6 ECG Tools: Alternate Lead Placement, Serial ECGs, and ECG Monitoring 97
Augustus E. Mealor, Yasir Akhtar, and Michael Ragosta


Introduction 97


Right-Sided Leads 97


Posterior ECG 99


Serial ECG Monitoring 101


STM-ECG 101


Serial ECG Monitoring 101


References 105


7 Electrocardiographic Changes of Ischemia during Stress Testing 107
Michael J. Lipinski and Victor F. Froelicher


Introduction 107


Exercise Physiology 108


Normal ECG Changes with Exercise 108


ECG Changes with Ischemia 109


Women 114


Diagnostic Scores 114


Termination of Exercise Testing 114


Exercise Testing and Acute Coronary Syndromes 117


Exercise Testing after Myocardial Infarction 117


Recommended Reading 120


Conclusions 120


References 120


Section III The Dysrhythmic ECG 123


1 Bradycardia 125
Andrew E. Darby


Introduction 125


Abnormalities of Sinus Node Function 125


Abnormalities of Atrioventricular Nodal Conduction 126


Indications for Cardiac Pacing 131


Conclusions 131


References 132


2 Atrioventricular (AV) Block 133
Mark Marinescu and Andrew E. Darby


First-Degree AV Block 133


Second-Degree AV Block 133


Third-Degree AV Block 137


Indications for Permanent Pacing 137


Conclusions 138


References 138


3 The Dysrhythmic ECG: Intraventricular Block 141
Andrew E. Darby


Introduction 141


Anatomy and Electrophysiology 141


Right Bundle Branch Block 141


Left Bundle Branch Block 143


Nonspecific Intraventricular Conduction Delay 145


Fascicular Block 145


References 146


4 Narrow QRS Complex Tachycardia 149
Augustus E. Mealor and Andrew E. Darby


Introduction 149


Approach to the ECG Diagnosis of NCT 150


The Regular Narrow Complex Tachycardias 151


Paroxysmal Supraventricular Tachycardia 154


The Irregular Narrow Complex Tachycardias 158


References 160


5 Wide QRS Complex Tachycardia 161
Andrew E. Darby


Ventricular Tachycardia 161


Ventricular Paced Rhythm 164


Diagnosis of Wide QRS Complex Tachycardia by Electrocardiogram 166


Conclusions 167


References 167


6 Non-Sinus Rhythms with Normal Rates 169
Will Dresen and Andrew E. Darby


Introduction 169


Ectopic Atrial Rhythm 169


Accelerated Idioventricular Rhythm (AIVR) 172


Conclusions 172


References 172


7 Rhythms of Cardiac Arrest 173
Erich Kiehl and Andrew E. Darby


Introduction 173


Torsade de Pointes 174


Preexcited Atrial Fibrillation 174


Pulseless Electrical Activity 177


Conclusions 179


References 179


8 Premature Atrial and Ventricular Complexes 181
Adrian I. Loeffler and Andrew E. Darby


Premature Atrial Contractions 181


Premature Ventricular Contractions 184


References 186


9 Nontraditional Rhythm Disorders: Dysrhythmias Related to Metabolic and Toxicologic Conditions 187
Andrew E. Darby


Introduction 187


Antiarrhythmic Drug Toxicity 188


Tricyclic Antidepressant Toxicity 190


Conclusions 191


References 192


10 Dysrhythmia-Related Syndromes 193
Michele Murphy and Andrew E. Darby


Introduction 193


Dysrhythmia-Related Syndromes - Primary Electrical Abnormalities 193


Wolff-Parkinson-White Syndrome 193


Dysrhythmia-Related Syndromes - Primary Cardiac Structural Conditions 197


Conclusions 199


References 200


Section IV The ECG in Cardinal Presentations and Scenarios 201


1 The Patient with Cardiac Arrest 203
Michael Cirone, Mitchell Lorenz, and Karis Tekwani


Introduction 203


Ventricular Fibrillation 203


Pulseless Ventricular Tachycardia 203


Asystole 205


Pulseless Electrical Activity 205


Conclusion 206


References 206


2 The Patient with Chest Pain 207
Paul Basel, Lane Thaut, and Nathan Olson


Introduction 207


Acute Coronary Syndrome 207


Pericarditis 213


References 215


3 The Patient with Dyspnea 219
Adriana Segura Olson, Anders Messersmith, and Matthew Robinson


Introduction 219


Pulmonary Embolism 219


Cor Pulmonale 220


Cardiomyopathy 220


Congestive Heart Failure 223


Pneumothorax 223


ASTHMA/COPD 224


Anaphylaxis/Kounis Syndrome 225


Metabolic 226


Summary 227


References 227


4 The Patient with Palpitations/Syncope 229
Natasha Wheaton, Emma Nash, and Jeffrey Brown


Supraventricular Tachycardia 229


Atrial Fibrillation 229


Multifocal Atrial Tachycardia 230


Conduction Blocks 232


Brugada Syndrome 233


Hypertrophic Cardiomyopathy 234


Wolf-Parkinson-White Syndrome 234


Long QT Syndrome 236


Arrhythmogenic Right Ventricular Dysplasia 237


References 237


5 The Patient with Preoperative Evaluation 239
Sarah Chuzi, Jane Wilcox, and Lisa B. Van Wagner


Introduction 239


Indications 239


Common ECG Abnormalities 239


Nonspecific ST-T Changes 244


Pathologic Q Waves 244


QT/QTc Prolongation 245


Conclusion 245


References 246


6 The Patient in Shock 249
Meagan R. Hunt and Nicholas D. Hartman


Introduction 249


Cardiogenic Shock 249


Obstructive Shock 252


Distributive Shock 252


Hypovolemic Shock 262


Summary 262


References 263


7 The Patient with Overdose 265
Ashley Pastore and Andrea Carlson


Introduction 265


Approach to the ECG in the Poisoned Patient 265


Classic Toxicology ECGs 267


Drug-Induced SVT 268


Brugada Pattern 268


Tricyclics Antidepressants 268


Calcium Channel Blockers 272


Conclusion 273


References 274


Section V The ECG in Poison, Electrolyte, Metabolic and Environmental Emergencies 275


1 ECG Diagnosis and Management of the Poisoned Patient 277
William F. Rushton and Christopher P. Holstege


Introduction 277


Cardiac Action Potential 277


Tachycardia in the Poisoned Patient 277


Bradycardia 278


QRS Prolongation 279


QT Prolongation 282


Conclusion 283


References 284


2 The Use of the ECG in the Poisoned Patient: The "Rule-out Ingestion" Strategy 287
Heather A. Borek and Lewis S. Hardison


Introduction 287


Background 287


Rate 287


Rhythm 289


Morphology of the Cardiac Action Potential and the ECG 290


QRS Interval Prolongation 290


QTc Interval Prolongation 292


Timing 293


The Undifferentiated Patient 294


Conclusion 294


References 295


3 The ECG and Electrolyte Abnormalities 297
Justin Rizer, Joshua D. King, and Nathan P. Charlton


Introduction 297


Calcium 297


Hypocalcemia 297


Hypercalcemia 298


Magnesium 298


Hypomagnesemia 299


Potassium 300


Hyperkalemia 300


Hypokalemia 303


References 305


4 The ECG and Metabolic Abnormalities 307
George F. Glass, Amita Sudhir, and Amit Anil Kumar Pandit


Introduction Metabolic Disturbances and the ECG 307


ECG Findings During Acute Complications of Diabetes Mellitus 307


Disturbances Due to Alterations of pH 309


Other Metabolic Conditions 311


References 311


5 The ECG in Environmental Urgencies and Emergencies 315
Heather T. Lounsbury and Seth O. Althoff


Introduction 315


Hypothermia 315


Lightning Strikes 319


Underwater Submersion 321


Heat Stroke 322


Conclusion 324


References 324


Section VI The ECG in Special Inpatient Groups 327


1 The ECG-Monitored Patient 329
Feras Khan


Introduction 329


Clinical Scenarios Requiring Telemetry/Electrocardiographic Monitoring 329


Conclusion 332


References 334


2 Electrocardiography in the Operating Room 335
Feras Khan


Introduction 335


Types of Monitoring 335


Risks for Arrhythmias in the OR 335


Postoperative Electrocardiographic Abnormalities 335


Initial Management and ECG Evaluation 335


Types of Arrhythmias 336


Specific Clinical Conditions 341


Conclusion 342


References 343


3 ECG in the ICU Patient: Identification and Treatment of Arrhythmias in the Intensive Care Unit 345
Feras Khan


Introduction 345


Common Dysrhythmias in the ICU 345


Other Common Electrocardiographic Findings 352


The Effect of Vasopressors on Cardiac Conduction 352


Consequences of Anti-Arrhythmic Medications 353


Arrhythmias Induced by Central Line Placement 354


Specific Clinical Conditions 354


Conclusion 357


References 357


4 The ECG in Patients with Implanted Cardiac Devices 359
Ali Farzad, Benjamin J. Lawner, and Tu Carol Nguyen


Basics of Pacemakers 359


Electrocardiographic Findings in Normally Functioning Pacemakers 360


Electrocardiographic Findings in Abnormally Functioning Pacemakers 361


Key Points: Electrocardiographic Clues to Pacemaker Malfunction 368


Electrocardiographic Diagnosis of Acute Myocardial Infarction in the Presence of a Paced Rhythm 368


Basics of the Implantable Cardioverter Defibrillator 370


Electrocardiographic Findings after Defibrillation 370


Basics of Left Ventricular Assist Devices 371


References 375


5 Electrocardiographic Manifestations of Cardiac Transplantation 377
Semhar Tewelde


Introduction 377


Cardiac Transplantation 377


Conclusion 80


Key Points 380


References 380


Section VII Electrocardiographic Differential Diagnosis 383


1 Abnormalities of the P Wave and PR Interval 385
Matthew Borloz


The Normal P Wave 385


The Abnormal P Wave 385


The Normal PR Interval 387


The Abnormal PR Interval 387


Conclusion 395


References 395


2 Differential Diagnosis of QRS Complex Abnormalities 397
Matthew Wilson, Michael Ybarra, and Munish Goyal


QRS Complex Abnormalities 397


The Large QRS Complex 397


The Small QRS Complex 398


The Wide QRS Complex 399


References 405


3 Differential Diagnosis of ST Segment Changes 407
Korin Hudson and Norine McGrath


Introduction 407


Describing ST-Segment Changes 407


Acute Coronary Syndrome and Related ST Segment Deviation 408


Nonischemic Causes of ST-Segment Changes 412


Benign Early Repolarization 414


Acute Myocarditis/Pericarditis 415


Ventricular Aneurysm 416


Digitalis 416


Hypothermia 417


Hyperkalemia 417


Brugada Syndrome 417


Tachycardia-Related STD 418


CNS Injury 418


Other Causes 418


References 419


4 ECG Differential Diagnosis of T Wave and QT Interval Abnormalities 421
Sanjay Shewakramani and Kari Gorder


The T Wave 421


Prominent T Waves 421


Benign Early Repolarization 422


T-Wave Inversions 422


The QT Interval 427


QT Prolongation 428


Congenital Long QT Syndrome 429


Short QT Interval 429


Congenital Short QT Syndrome 429


References 429


5 Bradycardia 433
B. Elizabeth Delasobera and Tress Goodwin


Bradycardia Basics 433


Bradycardia Rhythms 433


Rhythms That Can Be Slow 434


Slow Atrial Fibrillation 435


Slow Atrial Flutter 437


AV Blocks 437


First-Degree AV Block 438


Second-Degree AV Block: Mobitz Type 1 (Wenckebach) 438


Second-Degree AV Block: Mobitz Type 2 438


Third-Degree or Complete Heart Block 439


Conclusion 439


6 Rhythms Presenting with Normal Rate 441
Robert Katzer and Janet Smereck


Definitions and Clinical Considerations 441


Regular Rhythms 441


Irregular Rhythms 442


References 447


7 Narrow Complex Tachycardia 449
David J. Carlberg and Rahul Bhat


Introduction 449


Mechanisms for NCTs 449


Approach to NCT 450


Sinus Node Tachycardias 453


Atrial Tachycardias 453


Reentrant Tachycardia Involving the AV Node 457


Junctional Tachycardia 459


Conclusions 459


References 460


8 Wide Complex Tachycardia 461
Scott Young and Rachel Villacorta Lyew


Introduction to Wide Complex Tachycardia 461


Monomorphic WCT 461


Polymorphic WCTs 468


References 470


Index 473
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About William J. Brady

William J. Brady, MD, is Professor of Emergency Medicine and Medicine, University of Virginia, Charlottesville, VA, USA.
Michael J. Lipinski, MD, PhD, is Cardiovascular Associates of Charlottesville, Charlottesville, VA, USA.
Andrew E. Darby, MD, FHRS, is Associate Professor of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.
Michael C. Bond, MD, FACEP, FAAEM, is Associate Professor of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
Nathan P. Charlton, MD, is Associate Professor of Emergency Medicine, Division of Medical Toxicology, University of Virginia, Charlottesville, VA, USA.
Korin Hudson, MD, is Associate Professor of Emergency Medicine, MedStar Georgetown University Hospital, Georgetown University School of Medicine, Washington, DC, USA.
Kelly Williamson, MD, is Assistant Residency Program Director, Advocate Christ Medical Center Emergency Medicine Residency; and is Clinical Associate Professor of Emergency Medicine, University of Illinois at Chicago, Chicago, IL, USA.
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