ECGs for Acute, Critical and Emergency Care Second Edition, Volume 1 20th Anniversary Edition Amal Mattu, MD Professor and Vice Chair of Academic Affairs Department of Emergency Medicine, University of Maryland School of Medicine Baltimore, Maryland, USA William J. Brady, MD Professor, Vice Chair for Faculty Affairs and The David A. Harrison Distinguished Educator, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, United States and Medical Director, Albemarle County Fire Rescue, Charlottesville, Virginia, USA 0005708612.INDD 1 12-18-2023 16:07:17 This Second edition first published 2024 © 2024 John Wiley & Sons Ltd Edition History BMJ Publishing Group (1e, 2003) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law.
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Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging-in-Publication Data Names: Mattu, Amal, author. | Brady, William, 1960– author. Title: ECGs for acute, critical and emergency care : 20th anniversary / Amal Mattu, William J.
Other titles: ECGs for the emergency physician 2 | Electrocardiography for acute, critical and emergency care Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2024. | Preceded by ECGs for the emergency physician 2 / Amal Mattu, William Brady. | Includes bibliographical references and index.
Identifiers: LCCN 2023037647 (print) | LCCN 2023037648 (ebook) | ISBN 9781119986164 (paperback) | ISBN 9781119986171 (Adobe PDF) | ISBN 9781119986188 (epub) Subjects: MESH: Electrocardiography–methods | Heart Diseases–diagnostic imaging | Emergencies | Emergency Medical Services Classification: LCC RC683.E5 (ebook) | NLM WG 140 | DDC 616.1/207547–dc23/eng/20231128 LC record available at https://lccn.gov/2023037647 LC ebook record available at https://lccn.gov/2023037648 Cover Design: Wiley Cover Image: Courtesy of Amal Mattu Set in 9/13pt Frutiger by Straive, Pondicherry, India ALGrawany Contents Foreword.viii Part 1 Case histories. 3 ECG interpretations and comments. 53 Part 2 Case histories. 83 ECG interpretations and comments.
133 Appendix A: Differential Diagnoses. 159 Appendix B: Commonly used abbreviations.INDD 3 12-14-2023 17:48:37 Foreword There has been a great need for a user-friendly ECG text that fills the void between an introductory text designed for students and an advanced reference source for cardiologists. “ECGs for the Emergency Physician” fills this void. It is an ECG teaching and reference textbook for acute, critical, and emergency care physicians written by two specialists practicing and teaching acute, critical, and emergency care.
Mattu and Brady have created an ECG text that facilitates self-instruction in learning the basics, as well as the complexities, of ECG interpretation. They know that ECG interpretation requires knowledge, insight, and practice. They know “the eye does not see what the mind does not know.” In order to accomplish this goal of teaching ECG interpretation, they have divided their book into two parts. In Part I, as the authors state, are the “bread and butter” ECGs of clinical care.
These are the ECG findings that form the core knowledge necessary for accurate ECG interpretation. In Part II, they teach recognition of more subtle ECG abnormalities, which when mastered, allow the practitioner to approach expert status. The beauty of this text lies in the combination of a collection of ECGs with the authors’ insights and expert observations. This book has great utility as a reference text, a bound ECG teaching file, a board review aide or a resident in emergency medicine’s best friend for learning the art of advanced ECG interpretation.
Its greatest value, however, is for all of us who want to be both challenged and taught by 200 great electrocardiograms and their interpretations. May the forces be with you. Professor of Emergency Medicine and Medicine Chairman Emeritus, Department of Emergency Medicine Vanderbilt Medical Center Nashville, Tennessee Medical Director, Metro Nashville Fire EMS v 0005708614.INDD 5 12-15-2023 10:39:41 Preface We are happy to introduce you to ECGs for Acute, Critical and Emergency Care, Second Edition, Volume 1, 20th Anniversary Edition! Emergency and other acute care physicians must be experts in the use and interpretation of the 12-lead electrocardiogram (ECG). We have prepared this text with this basic, though highly important, thought in mind.
This text represents our effort to further the art and science of electrocardiography as practiced by emergency physicians and other acute/critical care clinicians. A significant number of the patients managed in the emergency department (ED) and other clinical settings present with chest pain, cardiovascular instability, or complaints related to the cardiovascular system. The known benefits of early, accurate diagnosis and rapid, appropriate treatment of cardiovascular emergencies have only reinforced the importance of physician competence in electrocardiographic interpretation. The physician is charged with the responsibility of rapid, accurate diagno- sis followed by appropriate therapy delivered expeditiously.
This evaluation does not infrequently involve the performance of the 12-lead ECG. For example, the patient with chest pain presenting with STEMI must be rapidly and accurately evaluated so that appropriate therapy is offered in a prompt – and correct – fashion. Another example includes the hemodynamically unstable patient with atrioventricular block who must be cared for in a rapid manner. In these instances as well as numerous other scenarios, resuscitative and other therapies are significantly guided by information obtained from the ECG.
The ECG is used frequently in the ED and other acute care settings; numerous presentations may require a 12-lead ECG. For instance, the most frequent indication for ECG performance in the ED is the presence of chest pain; other complaints fre- quently involving ECG analysis include dyspnea and syncope. Physicians obtain an ECG in the ED in the evaluation of sus- pected acute coronary syndrome, pulmonary embolism, and intentional medication overdose, among other situations; the ECG also plays a major role in various diagnostic strategies, such as the “rule-out myocardial infarction” protocol.1 Regardless of the cause, the physician must be an expert in the interpretation of the 12-lead ECG. Interpretation of the ECG is as much an art as it is a science.
Accurate ECG interpretation requires a sound knowledge of the ECG, both the objective criteria necessary for various diagnoses of those patients encountered in the ED as well as a thorough grasp of the various electrocardiographic waveforms and their meaning in the individual patient. And, importantly, the physician must understand the vital concept of interpreting the ECG within the context of the patient’s presentation (i. clinical correlation suggested). We have prepared this text for the physician who manages patients not only in the ED but also in other clinical care settings – whether it be in the office, the hospital ward, critical care unit, the out-of-hospital arena, or other patient-care locale.
We have used actual ECGs from patients treated in our EDs; a brief but accurate history has also been provided in each instance. In certain cases, the history may provide a clue to the diagnosis; yet in other situations, the clinical information will have no relationship to the final diagnosis – as is the case in the ED. We have made an effort to choose the most appropriate ECG for each patient, but as occurs in “real ED,” some of the ECGs are imperfect: the evaluation is hindered by artifact, incomplete electrocardiographic sampling, etc. We have also provided the ECGs in a random fashion, much the way actual patients present to the ED.
We have endeavored to reproduce the reality of the ED when the reader uses this text to expand his or her knowledge of the 12-lead ECG and how it relates to patient care. vi ALGrawany Preface The reader is advised to read the clinical history provided for each ECG and then, much as the clinician would interpret the ECG in the ED, review the 12-lead ECG. After a clinically focused review of the ECG, the reader is then able to review the interpretation. This ECG text has been constructed in two basic sections.
The first half of the text contains ECGs that we feel represent the “bread and butter” of emergency electrocardiography – the core material with which we feel that the acute care physician must be thoroughly familiar. These ECGs were chosen because they represent common electrocardiographic diagnoses that all emergency physicians should know. This section is prepared primarily for the physician-in-training (for example the emergency medicine resident), though practicing physicians and senior medical students will also benefit from reviewing the material. The second half of the text is composed of ECGs that are more challenging.
Electrocardiographic diagnoses are more difficult to establish and will often be based on subtle findings. In some cases, the ECGs in this section were chosen not necessarily because of the related level of difficulty but because of subtle teaching points found, which are likely to be quite challenging for the physician-in-training. It is also crucial to understand that this text is not intended for the “beginner in ECG interpretation.” The text, in essence an electrocardiographic teaching file, is intended for the physician who already possesses a basic understanding of elec- trocardiography, yet desires additional practice and review – a review which is highly clinically pertinent.