ECG in Emergency Medicine and Acute Care

420 Pages·2004·22.46 MB·English

by  Theodore C. Chan

The Curtis Center
170 S Independence Mall W 300E
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ECG IN EMERGENCY MEDICINE AND ACUTE CARE ISBN 0-323-01811-4
Copyright © 2005,Elsevier Inc.
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NOTICE
Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and
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Library of Congress Cataloging-in-Publication Data
ECG in emergency medicine and acute care/[edited by] Theodore C. Chan—[et al.].—1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 0-323-01811-4
1. Electrocardiography. 2. Cardiovascular emergencies. I. Chan, Theodore C.
[DNLM: 1. Electrocardiography—methods. 2. Emergency Medicine—instrumentation.
WG 140 E1715 2005]
RC683.5.E5E246 2005
616.1’207547—dc22 2003071094
Acquisitions Editor:Todd Hummel
Developmental Editor:Carla Holloway
Publishing Services Manager:Frank Polizzano
Senior Project Manager:Natalie Ware
Design Coordinator:Karen O’Keefe Owens
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
I would like to thank Peter Rosen, my friend and mentor, for his inspiration and
encouragement. A lifetime of thanks is due to my parents, Eva and Lun Chan,
whose guidance and example set me on my path. Finally, I would like to thank my
wife, Diana, and our children, Taylor James and Lauren, for their understanding,
flexibility, support, and love, which have helped me keep perspective on what is
truly important in life.
TCC
I would like to thank my wife, King, for her support, guidance, love, and patience;
my children, Lauren, Anne, Chip, and Katherine, for their love; my parents, Joann
and Bill Brady, for all they’ve done and continue to do; the Emergency Medicine
Residents at the University of Virginia, for their devotion to our patients and
Emergency Medicine; and to my co-editors, for their support, understanding,
guidance, and, most of all, their friendship.
WJB
To my parents, Tom and Ruth Harrigan, thank you for being all that you are,
which is more than you know. To Noreen, thank you so much for selflessly giving
the time, support, and patience necessary to complete this project. To Quinn and
Kelly, thank you for being the perfect answer to what is important.
RAH
I would like to dedicate this book to the family of Emergency Medicine practition-
ers, residents, and students who strive to provide the highest quality care to our
patients with cardiovascular disease.
JPO
I would like to add my thanks to my coeditors whose labor and erudition have
helped to keep me educated, and whose efforts will translate into much improved
care of patients who rely on our knowledge.
PR
v
Editors
Theodore C. Chan, MD, FACEP, FAAEM Joseph P. Ornato, MD, FACP, FACC, FACEP
Associate Professor of Clinical Medicine, Professor and Chairman,
Assistant Clinical Director, Department of Emergency Medicine,
Department of Emergency Medicine, Virginia Commonwealth University Medical Center,
University of California, San Diego, Richmond, Virginia
San Diego, California 75: Body Surface Mapping
8: Tachydysrhythmias, 10: P Wave, 11: PR Interval
and Segment, 16: U Wave, 27: Pacemakers: Normal Peter Rosen, MD, FAAEM
Function, 28: Pacemakers: Abnormal Function,
Senior Lecturer, Department of Medicine,
37: Myopericarditis, and 49: Toxicology Section:
Harvard University, Beth Israel/Deaconess Hospital,
Introduction
Boston, Massachusetts;
Visiting Professor,
William J. Brady, Jr., MD, FACEP, FAAEM
Department of Emergency Medicine,
Associate Professor and Vice Chair,
University of Arizona School of Medicine,
Department of Emergency Medicine,
Tucson, Arizona;
Associate Professor,
Attending Emergency Physician,
Department of Internal Medicine,
Beth Israel/Deaconess Hospital,
University of Virginia School of Medicine,
Boston, Massachusetts;
Charlottesville, Virginia;
Attending Emergency Physician,
Medical Director, Life Support Learning Center
St. John’s Hospital, Jackson, Wyoming
University of Virgina Health System,
Charlottesville, Virginia
7: Bradydysrhythmias, 13: ST Segment, 14: T Wave,
20: Atrioventricular Block, 25: Preexcitation Syndromes,
34: Acute Myocardial Infarction: Confounding Patterns,
40: Benign Early Repolarization, 47: Long QT Syndromes,
and 71: The Prehospital 12-Lead Electrocardiogram
Richard A. Harrigan, MD, FAAEM
Associate Professor of Emergency Medicine,
Temple University Hospital and School of Medicine,
Philadelphia, Pennsylvania
6: Dysrhythmias at Normal Rates, 9: Abnormal Axis,
12: QRS Complex, 15: QT Interval, 20: Atrioventricular
Block, 30: Atrioventricular Dissociation, 55: Tricyclic
Antidepressant Agents, and 62: Pneumothorax
vi
Contributors
Douglas S. Ander, MD Steven L. Bernstein, MD
Associate Professor, Assistant Professor, Department of Emergency Medicine,
Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York;
Emory University School of Medicine, Attending Physician, Department of Emergency Medicine,
Atlanta, Georgia Montefiore Medical Center,
38: Myocarditis Bronx, New York
64: Neurologic and Neuromuscular Conditions,
Tom P. Aufderheide, MD, FACEP 65: Rheumatologic/Immunologic Disorders
Professor of Emergency Medicine,
Department of Emergency Medicine, Thomas P. Bleck, MD, FCCM
Medical College of Wisconsin, Louise Nerancy Eminent Scholar in Neurology and
Milwaukee, Wisconsin Professor of Neurology, Neurological Surgery, and
71: The Prehospital 12-Lead Electrocardiogram, Internal Medicine,
73: QT Dispersion, and 74: Electrocardiographic Department of Neurology,
Predictive Instruments University of Virginia, Charlottesville, Virginia;
Director, Neuroscience Intensive Care Unit,
Alexander B. Baer, MD University of Virginia,
Clinical Instructor, Department of Emergency Medicine, Charlottesville, Virginia
University of Virginia Health System, 64: Neurologic and Neuromuscular Conditions
Charlottesville, Virginia
56: Other Sodium Channel Blocking Agents Ioliene Boenau, MD
Assistant Director,
James Dave Barry, MD Emergency Medicine Residency Program,
Faculty Emergency Medicine Physician, Eastern Virginia Medical School,
Emergency Department, Brooke Army Medical Center, Norfolk, Virginia
San Antonio, Texas; Staff Emergency Medicine Physician, 29: Sick Sinus Syndrome
San Antonio Uniformed Services Health Education
Consortium Emergency Medicine Residency, Michael J. Bono, MD, FACEP
San Antonio, Texas Associate Professor of Emergency Medicine,
51: Beta-Adrenergic Blocking Agents Department of Emergency Medicine,
Eastern Virginia Medical School,
Todd J. Berger, MD Norfolk, Virginia; Associate Program Director,
Assistant Professor, Assistant Residency Director, Emergency Medicine Residency Program,
Department of Emergency Medicine, Department of Emergency Medicine,
Emory University, Atlanta, Georgia; Eastern University Medical School,
Attending Physician, Norfolk, Virginia
Department of Emergency Medicine, 36: Cardiomyopathy
Grady Memorial Hospital,
Atlanta, Georgia Kenneth J. Bramwell, MD
66: Acute Rheumatic Fever Director, Pediatric Emergency Medicine,
Emergency Medicine of Idaho,
James D. Bergin, MD St. Luke’s Regional Medical Center,
Associate Professor of Medicine, Boise, Idaho
Department of Medicine, 5: The Pediatric Electrocardiogram
University of Virginia,
Charlottesville, Virginia
44: Cardiac Transplant
vii
viii CONTRIBUTORS
Joseph S. Bushra, MD Brian F. Erling, MD
Adjunct Assistant Professor, Chief Resident, Department of Emergency Medicine,
Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
Temple University School of Medicine, 1: Standard 12-Lead Electrocardiogram: Principles and
Philadelphia, Pennsylvania; Attending Physician, Techniques, 31: Waveform Genesis in Acute Coronary
Department of Emergency Medicine, Syndrome, and 46: Cardiac Trauma
The Lankenau Hospital, Wynnewood, Pennsylvania
2: The Normal Electrocardiogram and Its Timothy C. Evans, MD
Interpretation Associate Professor of Emergency Medicine,
Program Director,
Taylor Y. Cardall, MD Department of Emergency Medicine,
Emergency Physician, Department of Emergency Medicine, Virginia Commonwealth University Medical Center,
Scottsdale Healthcare, Scottsdale, Arizona Medical College of Virginia, Richmond, Virginia
27: Pacemakers: Normal Function, and 28: Pacemakers: 35: Ventricular Hypertrophy
Abnormal Function
Jeffrey D. Ferguson, MD, NREMT-P
Leslie S. Carroll, MD, ABMT Department of Emergency Medicine,
Assistant Professor, Department of Emergency Medicine, University of Virginia Health System,
Temple University, Philadelphia, Pennsylvania Charlottesville, Virginia;
54: Antipsychotic Agents and Lithium Charlottesville-Albemarle Rescue Squad,
Charlottesville, Virginia
Richard F. Clark, MD 71: The Prehospital 12-Lead Electrocardiogram
Professor, Department of Medicine,
University of California, San Diego, Renee Yvette Friday, MD, MPH, FAAP, FACC
San Diego, California; Assistant Professor of Pediatrics,
Director, Division of Medicine Toxicology, Department of Pediatric Cardiology,
University of California, San Diego Medical Center, University of Texas Medical Branch Galveston,
San Diego, California; Medical Director, Galveston, Texas
California Poison Control System, San Diego Division, 48: Congenital Heart Disease
San Diego, California
53: Other Cardioactive Agents J. Lee Garvey, MD
Medical Director, Chest Pain Evaluation Center,
M. Todd Clever, MD Department of Emergency Medicine,
Medical College of Wisconsin, Carolinas Medical Center,
Milwaukee, Wisconsin Charlotte, North Carolina
71: The Prehospital 12-Lead Electrocardiogram 70: Serial Electrocardiography and ST Segment
Trend Monitoring
Francis L. Counselman, MD, FACEP
EVMS Distinguished Professor of Emergency Medicine, Paolo M. Gazoni, MD
Department of Emergency Medicine, Assistant Professor,
Eastern Virginia Medical School, Norfolk, Virginia; Department of Emergency Medicine, Virginia
Chairman and Program Director, Commonwealth University Health System,
Department of Emergency Medicine, Richmond, Virginia
Eastern Virginia Medical School, Norfolk, Virginia 35: Ventricular Hypertrophy
43: Pericardial Effusion
Christopher R. George, MD
Wendy M. Curulla, MD Senior Resident, Department of Emergency Medicine,
Instructor, Department of Emergency Medicine, Medical College of Wisconsin,
Eastern Virginia Medical School, Norfolk, Virginia Milwaukee, Wisconsin
29: Sick Sinus Syndrome 74: Electrocardiographic Predictive Instruments
Kurt R. Daniel, DO Chris A. Ghaemmaghami, MD
Chief Resident, Department of Internal Medicine, Associate Professor of Emergency Medicine and
Wake Forest University, Winston-Salem, North Carolina Internal Medicine,
59: Pulmonary Embolism Department of Emergency Medicine,
University of Virginia, Charlottesville, Virginia
60: Chronic Obstructive Pulmonary Disease
CONTRIBUTORS ix
W. Brian Gibler, MD Attending Physician,
Professor and Chairman, Department of Emergency Medicine, Lourdes Medical Center of Burlington County,
University of Cincinnati College of Medicine, Willingboro, New Jersey
Cincinnati, Ohio; 30: Atrioventricular Dissociation
Director, Center for Emergency Care,
University Hospital, Cincinnati, Ohio Timothy G. Janz, MD, FACEP, FCCP
Foreword Professor, Department of Emergency Medicine,
Wright State University School of Medicine,
Melody C. Graves, DO Dayton, Ohio
Senior Resident, Department of Emergency Medicine, 33: Acute Coronary Syndromes: Regional Issues
Medical College of Wisconsin, Milwaukee, Wisconsin
73: QT Dispersion Sharone Jensen, MD
Attending Physician, Our Lady of Lourdes Medical Center,
Glenn C. Hamilton, MD Camden, New Jersey
Professor and Chair, Department of Emergency Medicine, 26: Ventricular Tachycardia and Ventricular Fibrillation
Wright State University School of Medicine,
Dayton, Ohio David J. Karras, MD
33: Acute Coronary Syndromes: Regional Issues Associate Professor of Emergency Medicine, Associate
Chair for Academic Affairs and Director of Research,
Richard J. Harper, MS, MD Department of Emergency Medicine,
Assistant Professor, Department of Emergency Medicine, Temple University School of Medicine,
Oregon Health and Sciences University, Portland, Oregon; Philadelphia, Pennsylvania
Chief of Emergency Medicine, 67: Miscellaneous Infectious Syndromes: Lyme Carditis,
Emergency Medicine Service, Portland-VAMC, Human Immunodeficiency Virus-Associated, and
Chagas Disease
Portland, Oregon
4: Electrode Misplacement and Artifact, 41: Ventricular
Varnada A. Karriem-Norwood, MD
Aneurysm, and 42: Valvular Disorders
Assistant Professor of Emergency Medicine,
Katherine L. Heilpern, MD Assistant Medical Director, Grady Emergency Care Center,
Department of Emergency Medicine, Emory University,
Associate Professor and Vice Chair for Academic Affairs,
Atlanta, Georgia; Assistant Medical Director,
Department of Emergency Medicine,
Emergency Care Center, Grady Memorial Hospital,
Emory University School of Medicine,
Atlanta, Georgia
Atlanta, Georgia
39: Endocarditis
38: Myocarditis, 39: Endocarditis, and 66: Acute
Rheumatic Fever
A. Antoine Kazzi, MD, FAAEM
Robert S. Hoffman, MD Vice Chair and Associate Professor of Clinical
Associate Professor, Emergency Medicine,
Departments of Emergency Medicine and Medicine, Department of Emergency Medicine,
New York University School of Medicine, University of California, Irvine, Orange, California
New York, New York; 24: Other Supraventricular Tachydysrhythmias
Director, New York City Poison Center,
Department of Health and Mental Hygiene, Mark A. Kirk, MD
New York, New York Director, Medical Toxicology Fellowship,
57: Cocaine and Other Sympathomimetics Department of Emergency Medicine, University of Virginia,
Charlottesville, Virginia
Christopher P. Holstege, MD 50: Digitalis
Director, Division of Medical Toxicology,
Assistant Professor, Department of Emergency Medicine, Jeffrey A. Kline, MD
University of Virginia, Charlottesville, Virginia Director of Research, Department of Emergency Medicine,
50: Digitalis, and 56: Other Sodium Channel Carolinas Medical Center, Charlotte, North Carolina;
Blocking Agents Associate Professor, Department of Emergency Medicine,
University of North Carolina, Chapel Hill,
Lawrence Isaacs, MD, FACEP, FAAEM North Carolina
Assistant Professor (Adjunct) of Emergency Medicine, 59: Pulmonary Embolism
Department of Emergency Medicine,
Temple University School of Medicine,
Philadelphia, Pennsylvania;
x CONTRIBUTORS
Michael C. Kontos, MD Moss Mendelson, MD
Associate Director, Acute Cardiac Care, Assistant Professor, Associate Professor, Department of Emergency Medicine,
Departments of Internal Medicine (Division of Cardiology), Eastern Virginia Medical School, Norfolk, Virginia
Emergency Medicine, and Radiology, 45: Dextrocardia
Virginia Commonwealth University, Richmond, Virginia
72: The Electrocardiogram and Stress Testing Steven R. Offerman, MD
Assistant Professor, Division of Emergency Medicine and
Brian Korotzer, MD Clinical Toxicology,
Assistant Chief, Department of Internal Medicine, University of California Davis,
Kaiser Permanente, Bellflower, California; Sacramento, California
Assistant Clinical Professor of Medicine, 52: Calcium Channel Antagonists
David Geffen School of Medicine at UCLA,
Los Angeles, California Sonal M. Patel, MD
61: Pulmonary Hypertension Clinical Fellow, Department of Gastroenterology,
Beth Israel Deaconess Medical Center,
John R. Lindbergh, MD Boston, Massachusettes
Assistant Professor of Emergency Medicine, 68: Electrocardiographic Manifestations of
Emergency Department, University of Virginia, Gastrointestinal Diseases
Charlottesville, Virginia; Emergency Physician,
Emergency Department, Martha Jefferson Hospital, Andrew D. Perron, MD, FACEP, FACSM
Charlottesville, Virginia Residency Program Director,
25: Preexcitation Syndromes Department of Emergency Medicine,
Maine Medical Center, Portland, Maine
Binh T. Ly, MD 1: Standard 12-Lead Electrocardiogram: Principles and
Assistant Clinical Professor, Techniques, and 31: Waveform Genesis in Acute
Department of Emergency Medicine, Coronary Syndrome
University of California,San Diego Medical Center,
San Diego, California Jesse M. Pines, MD, MBA
52: Calcium Channel Antagonists Lecturer, Department of Emergency Medicine,
University of Pennsylvania School of Medicine,
Marcus L. Martin, MD Philadelphia, Pennsylvania
Professor and Chair, 47: Long QT Syndromes
Department of Emergency Medicine,
University of Virginia, Charlottesville, Virginia Sridevi R. Pitta, MBBS
40: Benign Early Repolarization Department of Emergency Medicine,
Department of Internal Medicine,
John Matjucha, MD Wayne State University, Detroit, Michigan
Department of Emergency Medicine, 69: Additional Lead Electrocardiograms
Newark Beth Israel Medical Center,
Newark, New Jersey Marc L. Pollack, MD, PhD
65: Rheumatologic/Immunologic Disorders Research Director, Department of Emergency Medicine,
York Hospital, York, Pennsylvania
Amal Mattu, MD 34: Acute Myocardial Infarction: Confounding Patterns
Co-Director, Emergency Medicine/Internal Medicine
Combined Residency, Director of Academic Development, Christopher F. Richards, MD
Emergency Medicine Residency, Associate Professor, Department of Emergency Medicine,
University of Maryland School of Medicine, Oregon Health and Sciences University, Portland, Oregon;
Baltimore, Maryland Chief, Acute Clinical Care,
21: Intraventricular Conduction Abnormalities Department of Emergency Medicine,
Oregon Health and Sciences University,
Nancy L. McDaniel, MD Portland, Oregon
Associate Professor of Pediatric Cardiology, 4: Electrode Misplacement and Artifact, and
Department of Pediatrics, University of Virginia, 42: Valvular Disorders
Charlottesville, Virginia
Robert L. Rogers, MD
48: Congenital Heart Disease
Assistant Professor and Program Director,
Bryon K. McNeil, MD Emergency Medicine/Internal Medicine Combined Residency,
University of Maryland School of Medicine,
Attending Physician, Emergency Department,
Baltimore, Maryland
Christi Regional Medical Center, Wichita, Kansas
21: Intraventricular Conduction Abnormalities
62: Pneumothorax
CONTRIBUTORS xi
Pamela A. Ross, MD Jacob W. Ufberg, MD
Assistant Professor, Clinical, Assistant Residency Program Director,
Departments of Emergency Medicine and Pediatrics, Department of Emergency Medicine,
University of Virginia Health System, Temple University School of Medicine,
Charlottesville, Virginia Philadelphia, Pennsylvania
48: Congenital Heart Disease 17: Bradycardia and Escape Rhythms, 18: Sinus
Pause/Sinus Arrest, and 19: Sinoatrial Exit Block
Joshua G. Schier, MD
Assistant Professor, Department of Emergency Medicine, Edward Ullman, MD
Emory University School of Medicine, Attending Physician, Department of Emergency Medicine,
Atlanta, Georgia; Beth Israel Deaconess Medical Center,
Medical Toxicology Attending, Boston, Massachusetts
Emory/CDC Medical Toxicology Fellowship, 68: Electrocardiographic Manifestations of
Georgia Poison Control Center, Atlanta, Georgia Gastrointestinal Diseases
57: Cocaine and Other Sympathomimetics
Michael J. Urban, MD
Aaron B. Schneir, MD Senior Resident, Department of Emergency Medicine,
Assistant Professor, Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
University of California, San Diego Medical Center, 71: The Prehospital 12-Lead Electrocardiogram
San Diego, California
53: Other Cardioactive Agents Robert A. VerNooy, MD
Electrophysiology Fellow,
George M. Shumaik, MD Department of Internal Medicine,
Clinical Professor of Medicine, Cardiovascular Division,
Department of Emergency Medicine, University of Virginia Health System,
University of California, San Diego School of Medicine, Charlottesville, Virginia
San Diego, California; 44: Cardiac Transplant
Medical Director, Department of Emergency Medicine,
University of California, San Diego Medical Center, Gary M. Vilke, MD
San Diego, California Associate Professor of Clinical Medicine,
58: Electrolyte Abnormalities Department of Emergency Medicine,
University of California,San Diego Medical Center,
Stephen W. Smith, MD, FACEP San Diego, California
Associate Professor of Emergency Medicine, 3: Variants of Normal
Department of Emergency Medicine,
University of Minnesota School of Medicine, Robert P. Wahl, MD
Minneapolis, Minnesota Assistant Professor (Clinical Educator),
32: Acute Coronary Syndromes: Acute Myocardial Department of Emergency Medicine,
Infarction and Ischemia Wayne State University/Detroit Medical Center,
Detroit, Michigan;
Teresa L. Smith, MD Emergency Medicine Residency Program Director,
Clinical Assistant Professor, Department of Emergency Medicine,
Michigan State University College of Human Medicine, Wayne State University/Detroit Medical Center,
Kalamazoo, Michigan; Detroit, Michigan
Medical Director, Adult Neurology, 69: Additional Lead Electrocardiograms
Bronson Methodist Hospital, Kalamazoo, Michigan
64: Neurologic and Neuromuscular Conditions David A. Wald, DO
Director of Undergraduate Medical Education,
Sarah A. Stahmer, MD Assistant Professor of Emergency Medicine,
Associate Professor, Department of Emergency Medicine, Department of Emergency Medicine,
Robert Wood Johnson/UMDNJ Medical School, Temple University School of Medicine,
Camden, New Jersey; Philadelphia, Pennsylvania; Attending Physician,
Program Director, Department of Emergency Medicine, Department of Emergency Medicine,
Cooper Hospital/University Medical Center, Temple University Hospital,
Camden, New Jersey Philadelphia, Pennsylvania
26: Ventricular Tachycardia and Ventricular Fibrillation 63: Endocrine and Metabolic Disorders
xii CONTRIBUTORS
Christopher J. Ware, MD Keith Wrenn, MD
Department of Emergency Medicine, Professor and Program Director,
Temple University School of Medicine, Department of Emergency Medicine,
Philadelphia, Pennsylvania Vanderbilt University School of Medicine,
17: Bradycardia and Escape Rhythms Nashville, Tennessee
22: Atrial Fibrillation and Atrial Flutter, and
Wayne Whitwam, MD 23: Wandering Atrial Pacemaker and Multifocal
Atrial Tachycardia
Fellow, Division of Cardiology,
Department of Emergency Medicine,
Jeffrey S. Young, MD, FACS
Wayne State University School of Medicine,
Detroit, Michigan; Associate Professor of Surgery and Health
Fellow, Division of Cardiology, Evaluation Sciences,
Department of Internal Medicine, Harper Hospital, Department of Surgery,
Detroit, Michigan University of Virginia Health System,
Charlottesville, Virginia;
32: Acute Coronary Syndromes: Acute Myocardial
Infarction and Ischemia Director, Trauma Center,
Department of Surgery,
Saralyn R. Williams, MD, FACMT, FACEP University of Virginia Health System,
Charlottesville, Virginia
Associate Clinical Professor of Medicine,
Department of Medicine, 46: Cardiac Trauma
University of California, San Diego,
San Diego, California Robert J. Zalenski, MD, MA
51: Beta-Adrenergic Blocking Agents Professor, Department of Emergency Medicine,
Wayne State University School of Medicine,
Hubert Wong, MD, RDMS, FACEP Detroit, Michigan;
Attending Physician, Department of Medicine,
Director of Emergency Ultrasound,
John D. Dingell Veterans Hospital,
Department of Emergency Medicine,
Urgent Care Center,
Loma Linda University Medical Center,
Detroit, Michigan
Loma Linda, California
69: Additional Lead Electrocardiograms
24: Other Supraventricular Tachydysrhythmias