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Introduction Introduction
Garret Pachtinger,
VMD, DACVECC Jus7ne
A.
Lee,
DVM,
DACVECC,
DABT
COO, VETgirl CEO,
VETgirl
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Introduction Objec7ves
• Why
perform
an
ECG?
Marc
Kraus,
DVM,
DACVIM,
ECVIM
• Best
way
to
interpret
ECGs
– Calculate
heart
rate
– Chamber
enlargements
• Treatment
– Supraventricular
arrhythmias
– Ventricular
arrhythmias
– Brady-‐arrhythmias
3
Genera7on of the PQRST
Systema7c
Approach
to
ECGs
• Is
there
a
P
wave
for
every
QRS
complex?
• The
relaFonship
of
the
P
wave
and
QRS
complexes
– Is
there
a
P
wave
in
front
of
every
QRS
complex
– Is
there
a
QRS
complex
following
every
P
wave?
• Are
the
QRS
complexes:
– Supraventricular
or
– Ventricular
50mm/s 10mm/mV
4
6
limb
leads
together
form
the
Right
Bundle
Branch
Block
hexaxial
lead
system
of
the
frontal
plane
DOG CAT
Normal conduction Abnormal conduction
Heart
rate
Puppy:70-‐220
120-‐240bpm
Adult:
70-‐180
P
wave
Amplitude
Max:
0.4mV
Max
:
0.2mV
Normal rate Abnormal rate Bundle branch blocks Sick sinus
P
wave
DuraFon
Max
0.04s
Max
:
0.04s
Left/Right syndrome
Ectopic
focus
is
firing
from
the
atria
or
within
the
AV
node:
• Atrial
premature
(ectopic)
complex
(APC)
Rapid VT (160-380 bpm) “Slow” VT (40-150 bpm) – QRS
complex
looks
90%
like
a
normal
beat
– P’
(arrow)
wave
may
be
buried
in
preceding
T
wave,
could
be
upright
or
negaFve
(any
morphology)
Idioventricular P - P’ P - P’ P - P
Polymorphic VT
rhythm or accelerated
Monomorphic VT Image copyright Marc Kraus©
ventricular rhythm
5
First
and
Second
Degree
AVB
What
is
this?
I
II ? ? ?
200 220 200 240
III
50 mm/sec
Fig K
6
Atrial
Tachycardia
Bradycardia-‐associated
syncope
in
boxers
variable
AV
conduc7on
with
ventricular
tachycardia
Ventricular tachycardia
? ? ?
Fusion beat
VPC VPC VPC VPC
Image copyright Marc Kraus©
P P P P P? P
25 mm/s 5 mm/mV
Third degree AV block:
• No P waves are associated wit the QRS
• QRS wide and bizarre: ventricular escape beat (NOT premature, but late beats)
• HR of escape rhythm very slow : 30 bpm
• Tx: pacemaker
7
Does
this
need
treatment?
Is
this
scary?
What
is
the
rate?
50mm/s, 10 mm/mV
Polymorphic VT at 550 bpm; risk to degenerate into ventricular fibrillation Monomorphic ventricular tachycardia: RR interval =10 mm; 3000/10= 300 bpm
Yes – needs antiarrhythmic treatment !
P P P
VPC VPC
440 440
460 460
50mm/s 10mm/mV
Ventricular fibrillation
8
Treatment
of
ventricular
tachycardia
If
lidocaine
does
not
work
for
life
–threatening
VT!
• Goal:
• Ask
yourself
is
it
really
VT?
– Reduce
risk
of
sudden
death
– Reduce
symptoms:
syncope,
episodic
weakness
– Ddx:
SVT
with
a
bundle
branch
block
paqern
• VT
during
a
cath
procedure:
Valvuloplasty
Sotalol
(2
to
3
mg/kg
PO
q
12h)
• Thyroid
storm
(cat)
• Combined
beta
blocker
with
K
channel
blocker
• Esmolol
IV:
• efficacious
in
most
Boxers
(Meurs
et
al.
JAVMA
2002)
– 50
-‐
100
µg/kg
IV
bolus
(max
500
µg/kg)
• pro-‐arrhythmic
effects
as
monotherapy
in
German
– CRI
at
50-‐200
µg/kg/min
(costly!)
shepherds
(Gelzer
et
al
JVC
2010)
– CombinaFon
of
esmolol
with
lidocaine
– If
esmolol
is
combined
with
procainamide:
• Dobermans:
If
severe
systolic
• Severe reduction in cardiac output
dysfuncFon:
– FracFonal
shortening<15%
• Propranolol:
beta-‐blocking
effects
of
sotalol
may
– Dog
&
cat:
0.01-‐0.1
mg/kg
slow
IV
bolus
be
too
negaFve
inotrope
9
What
is
missing?
Electrical
Alternans
Alternating amplitude of
QRS complexes
Atrial
standsFll
with
slow
juncFonal
rhythm:
50
bpm
• No
P
waves
• QRS
narrow
• Atrial
pathology
or
hyperkalemia
Atrial
Fibrilla7on
Is
this
atrial
fibrilla7on?
10
What
is
this
rhythm?
Atrial
Fibrilla7on
(AF)
What
is
this
species?
• AF
is
the
most
common
SVTarrhythmia
• Atrial
enlargement
– secondary
cardiomyopathy
– volume
overload
(CVD,
DCM,
PDA,
VSD)
Rate
Control
Treatment
of
AF
Rate
control
vs
conversion
Doberman
with
AF
and
DCM
Before
• Rate
control
=
slowing
of
ventricular
response
Treatment:
HR
225
bpm!
– If
significant
cardiac
pathology
(and
CHF)
– If
the
average
heart
rate
by
24h
Holter
is
>
140
bpm
– Cats
with
AF
Treatment:
Digoxin
alone
• Conversion
to
sinus
rhythm
HR
180
bpm!
– VERY
difficult
to
achieve
and
maintain
– Giant
breed
dog
with
no
or
minimal
cardiac
abnormaliFes
Digoxin
and
DilFazem
– Recent
onset
AF
HR
100
bpm!
Atrial
Tachycardia
Conversion
to
sinus
rhythm
(lone
AF)
variable
AV
conduc7on
• DC
cardioversion
:
– “Synchronizing”
defibrillator
required
– General
anesthesia
– Risk
of
recurrence
of
AF
• Amiodarone:
– Loading
dose
for
7-‐10days:
400
mg
SID
– Maintenance
:
200
mg/kg
SID
– success
rate??
11
Atrial
flu^er
AFL
Atrial
Flu^er
• ECG
characterisFcs:
• Reentry
circuit
– regular
saw
tooth
shaped
undulaFon
• Loop
is
typically
in
– rapid,
ventricular
response
counter
clockwise
– rapid
rhythm,
but
conducFon
can
be
variable
direcFon
(humans)
– Rarely,
1:1
AV
conducFon
can
occur
and
may
be
• Loop
consists:
lethal.
– Tricuspid
valve
annulus
– Atrial
septum
– Crista
terminalis
Courtesy Blaufuss
medical
WPW
Preexcita7on
during
sinus
rhythm
• Short
PR
interval
(40ms)
• Terminal
forces
of
V1
nega7ve:
• Delta
wave
suspected
loca7on
of
pathway:
RA-‐RV
• Wolf
Parkinson
White
Syndrome
Delta wave
PR
Blaufuss medical
QUESTIONS
?
Thank you to!
• For ECG images:
Dr. Anna Gelzer,
DACVIM
(Cardiology),
ECVIM
(Cardiology)
12
#CPRwheel
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