Professional Documents
Culture Documents
Objectives
Be able to interpret ECGs using a systematic approach Be able to interpret ABGs and ACT upon the findings Be able to recognise key features of CXR and AXR Be a competent FY1
ECGs
Systematic approach,
Clinical scenarios
Systematic approach 1.
1. Name & DOB, date & time, chest pain?
How do you calculate rate? Rhythm: p-waves & their relation to QRS complexes Axis: use lead I & II. Check this using lead III
3. The most obvious abnormality is
Axis
Left axis Normal tall thin
LVH Anterior fascicular block (when alone) Left heart strain e.g. LVH, HTN + RBBB bifascicular block (bad news)
Systematic approach 2.
P waves shape, PR interval, regular/irregular?
ST segment
Elevation infarction (high take off follows a deep Swave. Diffuse elevation pericarditis) Depression ischaemia Make sure its in consecutive leads!! Anterior LAD Lateral Left circumflex Inferior Right circumflex
Hypertrophy:
RVH R axis dev, tall R in V1, deep S V6 +/- Twi inferior
& anterior LVH L axis dev, Tall Sw in V1, deep Rw V1 +/- Twi laterally Causes??
Summary
Use the systematic approach every time and you wont
miss anything
Cases:
1. 32 year old female, treated for pyelonephritis. Develops chest pain & tachycardia.
ABGs
5 stage approach to interpreting ABGs: 1.Assess oxygenation
>10kPa Is the patient hypoxic? Are they on supplementary O2
2.Determine the pH
>7.45 alkalaemia <7.35 acidaemia
ABGs
4.Determine the metabolic component
HC03
<22 mmol-1 Metabolic Acidosis >26mmol-1 Metabolic Alkalosis
What is compensation?
Stick to basics
Acidosis Respiratory Metabolic Co2 high HCO3 or base excess low Alkalosis Co2 low HCO3 or base excess high
ACID-BASE disorders
Respiratory Acidosis
Respiratory distress Pneumothorax PE COPD Life-threatening Asthma Neuro-muscular disease
ACID-BASE disorders
Respiratory Alkalosis
Hyperventilation Pregnancy Pain Thyrotoxicosis Anxiety Pneumonia
ACID-BASE disorders
Metabolic Acidosis
DKA Renal Failure Salicylate poisoning Drug-induced Refeeding syndrome
ACID-BASE Disorders
Metabolic Alkalosis
Vomiting Diuresis Hypokalemia hyperaldestronsim
Scenario 1
75 yr old man on surgical ward 2/7 after a laparotomy
for a perforated sigmoid colon secondary to diverticular disease. Nurse calls you
Obs:
Pulse 110bpm Bp 72/45 Fio2 92% oa Urine output 50mls in past 6hrs
ABG
Oxygenated at 40%
PH 7.12
paCO2 4.5kPa paO2 8.2kPa
HCO3 12mmol
BE -15mmol
What is this?
What are you going to do next?
Scenario 2
62 yr old admitted MAU with 1/7 history of vomiting and
confusion. He has PMH of HTN, which is usually controlled by ACEi and has been taking ibuprofen for back pain recently.
Obs:
Pulse 115bpm BP 85/40mmhg RR 22 FiO2 96% oa Urine output 15mls in past 5hrs
ABG
PH 7.21
paCO2 5.0kPa
paO2 12.8kPa HCO3 13.0 BE 11.0
Summary
disorder Resp Acidosis Resp Alkalosis Metabolic Acidosis Metabolic Alkalosis Resp Acidosis with renal compensation Resp Alkalosis with renal compensation Metabolic Acidosis with resp compensation Metabolic Alkalosis with resp compensation pH low high Low High Low* High* Low* High* PaCO2 High low Normal Normal High low low high HCO3 Normal Normal Low High high low low high
Mixed acidosis
Mixed alkalosis
low
high
high
low
low
high
CXR interpretation
Stick to basics!
5.Trachea
6.Mediastinum
CXR interpretation
7.Heart 8.Hilum
Remember left is higher
9.Diaphragm
Look for free air under the diaphragm!
10.Lung fields
Shadowing Air bronchograms Meniscus Reticular Lung markings Pleural plaques Kerly b lines
Lung fields
Look at costophrenic/cardiophrenic angles
Soft tissues
Bones
Clavicles Ribs Vertebrae Shoulders Breast shadows Surgical emphysema
Some questions..
How should a normal xray be taken?
Examples
AXR
Gas
Bones
Stones Soft tissue Fluid
Summary
Systematic approach to ECG, ABG, CXR & AXR!!