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Ecg in Toxicology

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Slides for a talk by Chris Nickson at CONCEPTOS 2016 in Chile. See also: http://lifeinthefastlane.com/ccc/conceptos/

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THE ECG IN TOXICOLOGY Chris Nickson FACEM FCICM Intensivist, The Alfred ICU
Financial Conflicts of InterestNO! http://litfl.org/CONCEPTOS
ECGINTOXICOLOGY Screening! Identify ECG toxidromes! Risk stratify! Direct therapy! Monitor response
1. Name the poison:! ! A. Quetiapine! B. Digoxin! C. Dothiepin!
Answer: (C)! Dothiepin
QRS = 200 ms! R’ = 3mm! S = 4mm -> R’/S = 0.75!
Right axis deviation of terminal QRS ! Terminal R wave >3 mm R/S ratio >0.7!
QRS widening ! predicts TCA complications! ! >100 ms seizures ! >160 ms dysrhythmias
Worse…!
Better!!
2. Name the poison:! ! A. Quetiapine! B. Digoxin! C. Diltiazem!
Answer: (B)! Digoxin
Cardiac glycoside toxicity! ! increased automaticity! AV node blockade! supraventricular tachycardia !
Regularised atrial fibrillation!
Atrial Flutter with high grade AV block!
Bidirectional ventricular tachycardia!
Digoxin effect!
3. Name the poison:! ! A. Citalopram! B. Sotalol! C. Diltiazem!
Answer: (B)! Sotalol
QT interval = 600 ms! HR = 40/min!
Chan (2007) PMID:17881416 ! DANGER SAFE
The patient is at risk of…!
We need a structured approach!
Structured approach to the electrocardio(toxo)gram! 1  Rate and rhythm 2  PR interval – heart block? ! 3  QRS duration in lead II ! 4 Right axis deviation of QRS ! 5 QT intervals 6  Ectopy and increased automaticity 7  Complications
http://litfl.org/CONCEPTOS

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