Wednesday, 4 February 2015

ECG of the Week - 2nd February 2015 - Interpretation

This ECG is from a 74 yr old female who presented with central chest pain for the last 90 minutes.
Check out the comments on our original post here.




Click to enlarge
Rate:
  • ~100 bpm
Rhythm:
  • Regular
  • Sinus rhythm
Axis:
  • Normal
Intervals:
  • PR - Normal (140ms)
  • QRS - Normal (60ms)
  • QT - 360ms (QTc Bazette 470 ms)
Segments:

  • ST Elevation leads I (1mm), aVR (<1mm), aVL (2mm), V1 (2mm), V2 (4mm), V3 (4mm), V4 (3mm), V5 (2.5mm), V6 (2mm)
  • ST Depression leads II, III, aVF


Interpretation:

  • Antero-lateral STEMI

What are the contraindications to thrombolysis ?

If you work in a metropolitan or tertiary center you probably send all your STEMI's for urgent angiography but it remote and rural centers thrombolysis must be considered.

The following list is taken from the Australian Resuscitation Council Guideline 14.3 'Acute Coronary Syndromes: Reperfusion Strategy'.


Contraindications to thrombolysis in STEMI
ARC Guideline 14.3
Click to enlarge


What agents can you use and how are they given ?


  • Streptokinase 1.5 million units iv over 60 minutes
  • Alteplase initial iv bolus plus variable dose infusion over 90 minutes
  • Reteplase 10 units iv over 2 minutes followed 30 minutes later by a further 10 units iv over 2 minutes
  • Tenecteplase 30-50mg iv bolus depending on patient's weight


What are the complications of thrombolysis for STEMI ?

  • Haemorrhage ~10%
  • Intracranial haemorrhage ~0.8%
  • Allergic reaction / anaphylaxis
  • Hypotension
  • Myocardial rupture if thrombolysis given >12 onset ischaemia
  • Re-perfusion arrhythmias
  • Re-occlusion / Re-infarction
  • Bone pain with streptokinase


References / Further Reading

Life in the Fast Lane

Medscape


Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Dunn R. The Emergency Medicine Manual. 5th Edition. Venom Publishing 2010.