ECG
Pierre-Alexis Balaz
Created on September 12, 2024
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Transcript
JOUER
BANQUE A ECGDUSMUR BMPM
Clinique non fournie
ECG normal
BBG + ST+
BBG simple
1
Présence des critères de Sgarbossa, signant un ST+ malgré le BBG
ECG normal
BBG + ST+
BBG simple
1
SCA ST+ avec BBG
- Destination = coro
- Coro = IVA
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- Homme de 39ans. ATCD : Tabac actif 2 paquets/jour
- HDLM : douleur tho type brulure isolée, spontanément résolutive 2j auparavant. Récidive la veille, EVA 3/10. Consult au cab.
- TNT : disparition de la douleur. Pas de douleur à l’arrivée du SMUR
Pericardite
ECG normal
Syndrome de Wellens
2
- Homme de 39ans. ATCD : Tabac actif 2 paquets/jour
- HDLM : douleur tho type brulure isolée, spontanément résolutive 2j auparavant. Récidive la veille, EVA 3/10. Consult au cab.
- TNT : disparition de la douleur. Pas de douleur à l’arrivée du SMUR
Pericardite
ECG normal
Syndrome de Wellens
2
Wellens type 2
- Ancien « syndrome de menace de l’IVA »
- Destination = SIC ou coro selon les auteurs et les équipes
- Coro = IVA complète
- A noter, l’ECG présente des signes d’IDM récent (récidive)
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Clinique : douleur thoracique typique
STEMI (OMI)
Repolarisation précoce
ECG normal
3
STEMI (OMI)
Repolarisation précoce
ECG normal
3
Clinique : douleur thoracique typique
Quelques minutes plus tard....
3
Toujours prépositionner les patchs de défibrillation dans les St+...
STEMI inférieur (OMI)
- Onde de Pardee en inférieur
- Aspect d'ondes T hyperamples ischémiques V3-V4-V5
- "Hyperacute T waves"
- On remarque aussi un BAV 1
- Evolution vers TV/FV
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Femme, 82ans, cancer du sein. HAD avec IDE. Somnolente, TA 7/4, SaO2 90%AA
STEMI (OMI)
Hyperkaliémie
ECG normal
4
Femme, 82ans, cancer du sein. HAD avec IDE. Somnolente, TA 7/4, SaO2 90%AA
STEMI (OMI)
Hyperkaliémie
ECG normal
4
Hyperkaliémie
- Dissociation A-V,
- BBD avec QSR en lames de sabre,
- QTc très allongé
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Après 1 ampoule de gluconate de calcium
4
Changement de polarité des QRS en inférieur
Après une 2ième ampoule de gluconate de calcium
4
Réapparition de complexes normaux, raccourcissement QT
Après aérosols de Salbutamol
4
FC 68 avec QT normal, complexes réguliers
H 69a ATCD : Coronaropathie stentée 2009 + resténose 2012 // AAA ttt par endoprothese 2016 // AOMI // tabac // dyslipidémie Douleur de repos depuis 3 j cervicale et omoplate. Consulte MT ce jour : pouls et sat imprenable, appel SMUR G15, SaO2 imprenable puis 97% en AA par la suite HD = TA 98/60 et 81/45, 155, signes hypoperfusion periph, pouls radiaux et fémoraux non perçus Bdc reguliers, pas de souffle cardiaque franc ni abdo
TV
TSV
ECG normal
5
H 69a ATCD : Coronaropathie stentée 2009 + resténose 2012 // AAA ttt par endoprothese 2016 // AOMI // tabac // dyslipidémie Douleur de repos depuis 3 j cervicale et omoplate. Consulte MT ce jour : pouls et sat imprenable, appel SMUR G15, SaO2 imprenable puis 97% en AA par la suite HD = TA 98/60 et 81/45, 155, signes hypoperfusion periph, pouls radiaux et fémoraux non perçus Bdc reguliers, pas de souffle cardiaque franc ni abdo
TV
TSV
ECG normal
5
TV
- cf ci-contre
- VT score
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H 75a, troubles de la conscience, contexte de douleur tho depuis une semaineTA 8/6 // FC 132 // SaO2 95%
ECG normal
Hypokaliémie
Tamponnade
6
H 75a, troubles de la conscience, contexte de douleur tho depuis une semaineTA 8/6 // FC 132 // SaO2 95%
ECG normal
Hyperkaliémie
Tamponnade
6
Tamponnade
- Micro-voltage
- Alternance respiratoire de l’amplitude des QRS (D2 long)
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H 35 ans, ECG de routine dans le cadre de son suivi
Equivalent ST+
ECG normal
WPW
7
H 35 ans, ECG de routine dans le cadre de son suivi
Equivalent ST+
ECG normal
WPW
7
ECG normal !Il parait que cela arrive...
H 35 ans, ECG de routine dans le cadre de son suivi
ECG normal
Repolarisation précoce
SCA ST +
8
Douleur thoracique typique
H 35 ans, ECG de routine dans le cadre de son suivi
ECG normal
Repolarisation précoce
SCA ST +
8
Douleur thoracique typique
Quelques minutes après...
8
SCA ST+
- SCA St+ (inféro-latero-basal)
- Destination = coro
- Importance d’anticiper la pose de patchs de défibrillation !
Homme de 41 ans, douleur thoracique typique
Onde J d'Osborn
ECG normal
SCA ST+
9
Homme de 41 ans, douleur thoracique typique
Onde J d'Osborn
ECG normal
SCA ST+
9
SCA ST+
- SCA St+ (inféro-latero-basal)
- Destination = coro
- Femme d'environ 40ans
- Retrouvée G6 au domicile
- Apyretique
SCA ST+
HSA
ECG normal
10
- Femme d'environ 40ans
- Retrouvée G6 au domicile
- Apyretique
SCA ST+
HSA
ECG normal
10
Tamponnade
- Tako-tsubo-like, ou cardiopathie neurogénique de stress
- Dans un contexte d’HSA (Fisher 4)
- Destination = rea
- Mauvais pronostic...
- Peut mimer des troubles du rythme, des troubles de la repolarisation...
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Homme de 43 ans, douleur thoracique atypique depuis 1h
Hyperkaliémie
ECG normal
Tble du rythme + ST+
11
Homme de 43 ans, douleur thoracique atypique depuis 1h
Hyperkaliémie
ECG normal
Tble du rythme + ST+
11
STEMI avec BAV 2
- BAV 2, Möbitz 4:1, ischémique, sur St+ inférieur
- Destination = coro
- Coro = occlusion CD3
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Homme de 73ans, malaise et douleur thoracique a 48h d'une échec de cryoablation de FA chez un patient porteur d'un DAI monochambre en prévention secondaire d'une coronaropâthie stentée et pontée.Le DAI est réglé en VVI à 60bpm
Syndrome du Pacemaker
ECG normal
STEMI
12
Homme de 73ans, malaise et douleur thoracique a 48h d'une échec de cryoablation de FA chez un patient porteur d'un DAI monochambre en prévention secondaire d'une coronaropathie stentée et pontée.Le DAI est réglé en VVI à 60bpm
Syndrome du Pacemaker
ECG normal
STEMI
12
Syndrome du pacemaker
- Dyspnée, palpitation, fatigabilité...
- Mecanisme :
- Activation rétrograde des oreillettes, juste après le ventricule
- La contraction atriale "tombe" sur valves fermées, explicant les symptômes
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Douleur thoracique typique
BBG
ECG normal
Equivalent STEMI
13
Douleur thoracique typique
BBG
ECG normal
Equivalent STEMI
13
Equivalent ST+
- Plusieurs éléments sont visibles sur cet ECG :
- l'onde de De Winter (équivalent ST+)
- Le sus décalage en AVR
E-cardiogram.com : les équivalents ST+
E-cardiogram.com : l'onde de De Winter
Homme de 43ans, sans ATCD, qui présente une douleur tho avec irradiation dans le bras gauche + nausées au cours d'un effort physique modéré (chez son kiné)
HVG
ECG normal
Equivalent STEMI
14
Homme de 43ans, sans ATCD, qui présente une douleur tho avec irradiation dans le bras gauche + nausées au cours d'un effort physique modéré (chez son kiné)
HVG
ECG normal
Equivalent STEMI
14
Equivalent ST+
- Hyperacute T wave
- Ondes T hyper-amples, ischémiques
- > 75% du QRS
- Phase sur-aigue de l'occlusion coronaire
E-cardiogram.com : les équivalents ST+
82 ans, IRA dialysée, Rao et RM. Malaise, asthénie et sensation de douleur tho type brulure thoracique.
Hyperkaliémie
ECG normal
Equivalent STEMI
15
82 ans, IRA dialysée, Rao et RM. Malaise, asthénie et sensation de douleur tho type brulure thoracique.
Hyperkaliémie
ECG normal
Equivalent STEMI
15
D2 long
15
Hyperkaliémie
- Dissociation A-V,
- BBD avec QSR en lames de sabre
- QTc très allongé
- Destination : réa pour EER
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Homme de 60ans
- Pas d’ATCD
- Angor d’effort depuis 1 semaine
- Tropo en ville = normale
- Reconsulte son MG pour aggravation de la douleur
- Douleur présente à l’arrivée (ECG 1), puis disparait (ECG 2, 3 et 4)
ECG normal
Syndrome de Wellens
HVG
16
Homme de 60ans
- Pas d’ATCD
- Angor d’effort depuis 1 semaine
- Tropo en ville = normale
- Reconsulte son MG pour aggravation de la douleur
- Douleur présente à l’arrivée (ECG 1), puis disparait (ECG 2, 3 et 4)
ECG normal
Syndrome de Wellens
HVG
16
Quelques minutes plus tard...
16
Wellens type 2
- Ancien « syndrome de menace de l’IVA »
- Destination = SIC ou coro selon les auteurs et les équipes
- Coro = IVA complète
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Femme 77ans
- ATCD : dialyse (dialysée la veille)
- Dyspnée, sueurs, jambes indurées
ECG normal
SCA ST+
Hyperkaliémie
17
Femme 77ans
- ATCD : dialyse (dialysée la veille)
- Dyspnée, sueurs, jambes indurées
ECG normal
SCA ST+
Hyperkaliémie
17
Hyperkaliémie
- Dissociation A-V,
- BBD avec QSR en lames de sabre
- QTc très allongé
- Destination : réa pour EER
- Bio : K+ = 10mmol/L...
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Homme 70ans
- ATCD : Diabete, HTA
- Gène thoracique depuis 4h
- Epreuve d’effort negative
- Pas d’effet de la TNT
SCA ST+
ECG normal
HVG
18
Homme 70ans
- ATCD : Diabete, HTA
- Gène thoracique depuis 4h
- Epreuve d’effort negative
- Pas d’effet de la TNT
SCA ST+
ECG normal
HVG
18
SCA ST+ avec BBD
- SCA ST+ sur BBD (visible notamment en latéral)
- Onde T inversée = semi-récent
- Destination = Coro
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Femme 30ans, feu d’appartement. G5, couverte de suie. SaO2 70% - SpCO 65%
Hyperkaliémie
ECG normal
Intoxication CO
19
Femme 30ans, feu d’appartement. G5, couverte de suie. SaO2 70% - SpCO 65%
Hyperkaliémie
ECG normal
Intoxication CO
19
Intoxication au CO
- Troubles de la repolarisation sur intoxication au CO
- NON SPECIFIQUE
- Destination = caisson hyperbare (même si St+ franc !)
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Homme, 25 ans, palpitations sur le lieu de travail. Conscient mais inconfortable- FC 265, TA 11/6
TSV
TV
ECG normal
20
Homme, 25 ans, palpitations sur le lieu de travail. Conscient mais inconfortable- FC 265, TA 11/6
TSV
TV
ECG normal
20
TV infundibulaire
- Aspect de retard gauche non crochet
- Axe vertical ou droit (QRS positifs en D2-D3)
- BENIN !
- TRaitement : adénosine (ou BB- ou diltiazem)
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Après 25mg de DILTIAZEM (TILDIEM)
20
26ans, surpoids, tabac, ATCD familial d'IDM (père). Douleur thoracique (constrictive) de repos, précordiale gauche irradiant dans le bras + 1 vomissement Episode similaire la veille, cédant spontanément après 20min. Cliniquement RAS.
STEMI
Myocardite
ECG normal
21
26ans, surpoids, tabac, ATCD familial d'IDM (père). Douleur thoracique (constrictive) de repos, précordiale gauche irradiant dans le bras + 1 vomissement Episode similaire la veille, cédant spontanément après 20min. Cliniquement RAS.
STEMI
Myocardite
ECG normal
21
Myo(péri)cardite
- En faveur d’une myocardite, on cherchera des signes de péricardite :
- Tachycardie,
- Sous-décalage de PQ en inférolatéral (ex DII et V4-V5),
- QRS non ou peu modifiés par l’ischémie
- Sus-décalage de ST plutôt non convexe et maximum en DII-V5 ou V4 > V3 > V2, sans miroir ou un miroir inapproprié
- Ratio ST/T en V6 > 25% de l’amplitude de R
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Merci à tous !
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Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight
- Visit the Analytics settings;
- Activate user tracking;
- Let the communication flow!
Use this space to add awesome interactivity. Include text, images, videos, tables, PDFs... even interactive questions!Premium tip: Get information on how your audience interacts with your creation:
Got an idea?
Here you can include a relevant fact to highlight
Here you can include a relevant fact to highlight