Clue: Arterial trace gives it away.
12/29/2011
Interpret this - EKG...Monitor printout
1 week old, s/p Arterial Switch Operation. 6 hrs postop.
Clue: Arterial trace gives it away.
Clue: Arterial trace gives it away.
Narrow Complex Tachycardia/SVT - 3 types of responses to Adenosine
Response 1 - Adenosine terminates SVT to sinus rhythm
Response 2 - Adenosine terminates SVT to sinus rhythm; but, SVT returns
Response 3 - Adenosine decreases ventricular response, enabling the correct diagnosis of Atrial Flutter (This narrow complex tachycardia was not SVT)
Thus, if Adenosine does not treat it. It helps to uncover the correct diagnosis! It is important to record EKG strip during Adenosine administration so that the type of response can be carefully analyzed and documented.
Response 2 - Adenosine terminates SVT to sinus rhythm; but, SVT returns
Response 3 - Adenosine decreases ventricular response, enabling the correct diagnosis of Atrial Flutter (This narrow complex tachycardia was not SVT)
Thus, if Adenosine does not treat it. It helps to uncover the correct diagnosis! It is important to record EKG strip during Adenosine administration so that the type of response can be carefully analyzed and documented.
12/24/2011
EKG - Interpret this
8-day old, 31 week gestation baby. Recovering from Respiratory distress syndrome.
Consulted for episodes of bradycardia.
12/12/2011
EKG: Dextrocardia
Panel 1: EKG recorded with standard lead placements
Panel 2: EKG recorded with reversed lead placement (Illustrates why this should not be done)
It is good exercise to compare the two EKGs and identify how reversing lead positions change the morphology of the complexes.
Panel 2: EKG recorded with reversed lead placement (Illustrates why this should not be done)
It is good exercise to compare the two EKGs and identify how reversing lead positions change the morphology of the complexes.
12/09/2011
12/06/2011
12/05/2011
12/04/2011
Anatomy: Left Aortic Arch with Right Descending Aorta
Left Aortic Arch with Right Descending Aorta: Possible type
(From Esophagography in anomalies of the aortic arch system by A.C. Klinkhamer. 1969. Williams & Wilkins Company, Baltimore, MD)
See related posting
(From Esophagography in anomalies of the aortic arch system by A.C. Klinkhamer. 1969. Williams & Wilkins Company, Baltimore, MD)
See related posting
12/02/2011
Vascular Ring - General Rules
From Moss & Adams(Vol. 1) 7th ed. 2008.
Chapter: Aortic Arch Anomalies by Dr. Paul Weinberg.
1) Arch sidedness: Retroesophageal or Isolated vessel always is the vessel on opposite side from the arch.
2) Vascular Ring: Easier to recognize the existence of vascular ring if all components of the ring are patent. The following rule is helpful when the ring is completed by an atretic ligament on one side i.e. Presence of one of the 3 Ds on the opposite side from the aortic arch indicates presence of a vascular ring. (3Ds are Diverticulum, Dimple or Descending aorta).
Chapter: Aortic Arch Anomalies by Dr. Paul Weinberg.
1) Arch sidedness: Retroesophageal or Isolated vessel always is the vessel on opposite side from the arch.
2) Vascular Ring: Easier to recognize the existence of vascular ring if all components of the ring are patent. The following rule is helpful when the ring is completed by an atretic ligament on one side i.e. Presence of one of the 3 Ds on the opposite side from the aortic arch indicates presence of a vascular ring. (3Ds are Diverticulum, Dimple or Descending aorta).
12/01/2011
11/30/2011
ICU: What's wrong with this picture...
6-mo old. s/p Complete AVSD repair. Immediate postop. Just arrived from operating room.
Hint: The anomaly is the relationship between LA pressure and PA pressure.
Panel 1 - Has a problem/mistake. (Pardon the shaken image)
Panel 2 - The problem/mistake has been rectified.
Hint: The anomaly is the relationship between LA pressure and PA pressure.
Panel 1 - Has a problem/mistake. (Pardon the shaken image)
Panel 2 - The problem/mistake has been rectified.
11/29/2011
ICU: Pulsus Alternans
What is the significance of Pulsus Alternans?
6 mo old baby girl, s/p VSD closure, Repair of Cleft mitral valve. Postop. ICU stay. Residual VSD with Pulmonary hypertension. Pulsus alternans is noted in the PA line pressure traces.
Panel 1 - DDD pacing
Panel 2 - Pacing Off
Panel 3 - AAI pacing
Panel 4 - VVI pacing
6 mo old baby girl, s/p VSD closure, Repair of Cleft mitral valve. Postop. ICU stay. Residual VSD with Pulmonary hypertension. Pulsus alternans is noted in the PA line pressure traces.
Panel 1 - DDD pacing
Panel 2 - Pacing Off
Panel 3 - AAI pacing
Panel 4 - VVI pacing
ICU: Arterial Pressure Trace Distortion
(From Cardiovascular Dynamics by Robert F. Rushmer. 3rd Ed. 1970. W.B. Saunders Company)
11/19/2011
Quiz, EKG: What is the rhythm? Junctional vs. Low Atrial rhythm?
11 yr old boy. s/p Repair of Sinus venosus ASD. Started with AAI pacing at 80 bpm in the operating room. You set out to determine the underlying rhythm. The following strips are availabe for analysis. Second-from-the-last panel has atrial lead electrogram in V1. (Click on the images to enlarge).
Last panel image is from Principles of Clinical Electrocardiography by Mervin J. Goldman. Lange Medical Publications. 11th ed. 1982.
11/09/2011
ICU: Pericardial Tamponade
Beware of the importance of looking "all-around" when you are doing a "quick" echo when a baby is unstable, in the immediate postoperative period. (Poor image quality is part of the deal!)
The first two panels show no significant effusion. However, in the lower-most panel - angled more posteriorly - there is a localized collection of clot compressing right atrium and part of right ventricle. This was not recognized due to poor images. Chest was opened to cannulate for ECMO! Clot was noted in the pericardial space, compressing right atrium (Lower-most panel). Hemodynamic status improved when the clot was removed. ECMO was not necessary.
Newborn, s/p Arterial switch operation. 3 hrs postop.
The first two panels show no significant effusion. However, in the lower-most panel - angled more posteriorly - there is a localized collection of clot compressing right atrium and part of right ventricle. This was not recognized due to poor images. Chest was opened to cannulate for ECMO! Clot was noted in the pericardial space, compressing right atrium (Lower-most panel). Hemodynamic status improved when the clot was removed. ECMO was not necessary.
Newborn, s/p Arterial switch operation. 3 hrs postop.
11/06/2011
EKG: Nomogram / Table: Cycle Length to Heart Rate Table
L = Cycle length (seconds)
R = Heart rate
In pediatrics, it is useful remember the cycle length range of 200-300 ms (0.2 to 0.3 seconds) where most of pediatric arrhythmias occur.
R = Heart rate
In pediatrics, it is useful remember the cycle length range of 200-300 ms (0.2 to 0.3 seconds) where most of pediatric arrhythmias occur.
EKG - Normal values, Basics
Kirschoff's Law: Algebraic sum of all the potential differences in a closed circuit equals zero. Based on this law, I + II + III = 0.
But, Einthoven reversed the polarity of II. Instead of connecting RA - LL, he connected it LL - RA. Therefore, the formula becomes I - II + III = 0.
When this equation is solved, it becomes Einthoven's equation: II = I + III.
(To verify, take the net amplitude of QRS complexes respective leads from any EKG and do the calculations)
Relationship between Augmented unipolar limb leads (aVR, aVL, aVF) & Standard bipolar leads (I, II, III):
aVR = (I + II)/2
aVL = (I - III)/2
aVF = (II + III)/2
From Principles of clincal electrocardiography by Mervin J. Goldman. 11th ed. 1982. Lange Medical Publications.
11/02/2011
Cath Lab: Artifacts in Pressure Traces...Underdamped waveform
Both panels below have LV pressure trace recorded in the same patient.
Upper panel has artifact (Underdamping of the trace)
This artifact is corrected in the lower panel.
What is the mechanism of this artifact (Underdamping)?
What are the methods that can be used to correct such artifact?
Upper panel has artifact (Underdamping of the trace)
This artifact is corrected in the lower panel.
What is the mechanism of this artifact (Underdamping)?
What are the methods that can be used to correct such artifact?
10/31/2011
EKG - Quiz
5-mo old, VSD closure, Repair of primum ASD and Cleft Mitral Valve. Postop. Day 4. H/O Junctional Ectopic Tachycardia - controlled with Amiodarone for the 2 days.
What is the rhythm?
What is the differential diagnosis?
How would you differentiate between Junctional Rhythm from Sinus rhythm with First degree AV block?
(Click on the image to enlarge)
Atrial lead is in V1.
A-paced at 150 bpm.
What is the rhythm?
What is the differential diagnosis?
How would you differentiate between Junctional Rhythm from Sinus rhythm with First degree AV block?
(Click on the image to enlarge)
Atrial lead is in V1.
A-paced at 150 bpm.
10/24/2011
EP: Quiz, Interpret this EKG recording
You are called to consult for irregular heart rate. A newborn who has recovered from severe sepsis was noted to have irregular heart rate on the day of discharge. Therefore, discharge was canceled and you were consulted. A PICC line was removed the day before. Baby is otherwise doing well. Here are the traces. There are no answers for these traces. Your differential diagnosis and discussion is what is expected.
10/23/2011
Quiz: EP - Apparent Malfunction of Pacemaker
1 yr old boy, s/p Mitral Valve replacement, Postop. AV block. Epicardial DDD pacemaker. HR range is set at 110-180 bpm.
First panel (24-hr trend) shows pacemaker heart rate decreased to ~110 bpm between 6pm & 10pm, when the patient was febrile.
Second panel shows EKG prior to drop in HR.
Third panel shows EKG during the low HR at ~110 bpm (with fever).
Fourth panel shows EKG after return of HR to higher level (after fever).
Fifth panel shows current EKG at the time of review (next day).
1) What are the possible reasons for the pacemaker not to respond appropriately during a time of need (fever)?
2) What further information is needed regarding pacemaker settings to determine the cause of this pacemaker behavior?
3) What change, if any need to be made in the pacemaker settings?
First panel (24-hr trend) shows pacemaker heart rate decreased to ~110 bpm between 6pm & 10pm, when the patient was febrile.
Second panel shows EKG prior to drop in HR.
Third panel shows EKG during the low HR at ~110 bpm (with fever).
Fourth panel shows EKG after return of HR to higher level (after fever).
Fifth panel shows current EKG at the time of review (next day).
1) What are the possible reasons for the pacemaker not to respond appropriately during a time of need (fever)?
2) What further information is needed regarding pacemaker settings to determine the cause of this pacemaker behavior?
3) What change, if any need to be made in the pacemaker settings?
10/20/2011
Pacemaker Timing Cycles - PPT
Click on the link below for a slide set on this subject:
Pacemaker Timing Cycles PPT Pacemaker Implantation Pacemaker Implantation Guidelines Pacemaker Implantation Surgery: SlideWorld Medical PPT Search Engine
Pacemaker Timing Cycles PPT Pacemaker Implantation Pacemaker Implantation Guidelines Pacemaker Implantation Surgery: SlideWorld Medical PPT Search Engine
10/13/2011
Wire shape for RPA and LPA
Image from Jim Lock's Cath Book 1987
(Diagnostic and Interventional Catheterization in Congenital Heart Disease.
James E. Lock, John F. Keane, Kenneth E. Fellows First edition 1987. Marinus Nijhoff Publishing, Boston, MA)
My first choice for LPA is just not to put any curves in the wire. But, you may need these wire shapes to enter "postop. LPAs".
(Diagnostic and Interventional Catheterization in Congenital Heart Disease.
James E. Lock, John F. Keane, Kenneth E. Fellows First edition 1987. Marinus Nijhoff Publishing, Boston, MA)
My first choice for LPA is just not to put any curves in the wire. But, you may need these wire shapes to enter "postop. LPAs".
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