Day 9: Medication and Electrolyte Effects; Miscellaneous Conditions
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Medication effects
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Digoxin (Day 9-01)
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Digoxin has a narrow therapeutic to toxic ratio, and is potent stimulator of arrhythmias.
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At therapeutic levels, digoxin frequently causes nonspecific ST changes with “scooping” of the ST segment and shortening of the QT interval.
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Digoxin causes SA nodal suppression and AV block.
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Digoxin can cause virtually any arrhythmia, but, because of its ability to enhance automaticity, ectopic arrhythmias are commonly encountered in digoxin toxicity.
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The commonest arrhythmia manifested by digoxin toxicity is multiform PVCs. (Day 9-02)
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The two most specific arrhythmias are accelerated junctional rhythm and atrial tachycardia with AV block. (Day 9-03) (Day 9-04)
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Sotalol and amiodarone (Day 9-05)
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These agents slow conduction in general and result in bradycardia and prolongation of the PR, QRS, and QT intervals.
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Sotalol also has significant beta blocking properties, which exacerbates the bradyarrhythmic effects.
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Sotalol can also prolong the QT interval and cause torsades de pointe.
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Quinidine and other Class IA agents (see long QT below)
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These agents are less frequently used than previously because of side effects, proarrhythmic potential, and possibly increased mortality.
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Quinidine prolongs the QRS duration and QT interval, and may cause torsades de pointe. (Day 6-11)
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Verapamil and diltiazem
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These agents can cause sinus bradycardia, varying amounts of AV block, and, in toxic doses, intraventricular conduction defects. (Day 9-06)
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Their effects are additive with beta blockers.
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DAY 9-01
DAY 9-02
DAY 9-03
DAY 9-04
DAY 9-05
DAY 9-06
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Electrolyte abnormalities
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Hypokalemia
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Hyperkalemia
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Hypocalcemia is manifested by prolongation of the QT interval; the ST segment is usually flat and the T wave is not distorted (see figure). (Day 9-13)
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Hypercalcemia is associated with a short QT interval.
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QT prolongation and U wave abnormalities
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A rough indicator of QT prolongation is that the QT interval should not exceed one half of the surrounding R-R interval.
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Congenital long QT syndromes
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There are at least five forms of congenital long QT syndromes, two of which are:
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Jervell and Lange-Nielsen syndrome is an autosomal recessive disorder associated with deafness.
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Romano-Ward is an autosomal dominant disorder.
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Acquired long QT syndromes
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Non-drug causes of long QT interval include ischemia, central nervous system (CNS) lesions, and significant bradyarrhythmias. (Day 9-14) (Day 9-15)
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Many drugs can prolong the QT interval, including the Class IA, IC, and III antiarrhythmic agents, erythromycin, some antihistamines, and some psychiatric drugs.
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U wave abnormalities
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Prominent U waves are seen with hypokalemia, digoxin, LVH, and amiodarone (see previous page)
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Negative U waves are encountered in hypertension (HTN), aortic and mitral disease, and ischemia.
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DAY 9-07
DAY 9-08
DAY 9-09
DAY 9-10
DAY 9-11
DAY 9-12
DAY 9-13
DAY 9-14
DAY 9-15
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Causes of tall R waves in V1
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Right ventricular hypertrophy (RVH) (Day 9-16)
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Posterior MI (Day 9-17)
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RBBB (Day 9-18)
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Wolff-Parkinson-White (WPW) (Day 9-19)
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Hypertrophic obstructive cardiomyopathy (HOCM) with asymmetric septal hypertrophy (ASH) (Day 9-20)
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Congenital dextrocardia (Day 9-21)
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Duchenne’s muscular dystrophy (Day 9-22)
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Causes of ST segment elevation
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CNS injury and the ECG
DAY 9-16
DAY 9-17
DAY 9-18
DAY 9-19
DAY 9-20
DAY 9-21
DAY 9-22
DAY 9-23
DAY 9-24
DAY 9-25
DAY 9-26
DAY 9-27
DAY 9-28
DAY 9-29
DAY 9-30
DAY 9-31
DAY 9-32
DAY 9-33
Sample Tracings
ECG 1
ECG 2
ECG 3
ECG 4
ECG 5
ECG 6
ECG 7
ECG 8
ECG 9
ECG 10
ECG 11
ECG 12
ECG 13
ECG 14
ECG 15
ECG 16
ECG 17
ECG 18
ECG 19
ECG 20
Medication and Electrolyte Effects; Miscellaneous Conditions
Interpretations of Sample Tracings
ECG 1
Atrial rate: 74
Ventricular rate: 74
Rhythm: Sinus rhythm with occasional premature atrial complexes (PACs)
P wave: Normal
PR interval: 200 msec
QRS complex:
Axis: 60°
Duration: 80 msec
Voltage: Normal
Morphology: Normal
ST segment: Nonspecific changes
T wave: Deeply inverted in V2 to V4
QT interval: 470 msec
U wave:
Diagnosis: Sinus rhythm with frequent PACs, and diffuse T wave inversion and QT prolongation. This patient had a combination of severe metabolic and acid-base disorders, including a pH of 7.24, pCO2 of 60 mm Hg, a serum calcium level of 6.6 mmol/l and a digoxin level of 2.6.
ECG 2
Atrial rate: 40
Ventricular rate: 40
Rhythm: Sinus bradycardia
P wave: Normal
PR interval: 280 msec
QRS complex:
Axis: -60°
Duration: 160 msec
Voltage: Normal

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