ECGs, ABGs and Xrays

Interpretation of simple investigations By Dr Tejal Parekh and Dr Eleanor Marshall

Aims and Objectives

Aim: ***PASS THE OSCE***

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?

2. Rate, Rhythm, Axis

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)

Right axis Normal tall thin

RVH Posterior fascicular block Right heart strain massive PE

Systematic approach 2.
P waves shape, PR interval, regular/irregular?

Q waves look for territorial distribution

QRS complex duration, narrow or wide? Bundle
branch block present? RBBB MaRRoW LBBB WiLLiaM Trifascicluar RBBB, L-axis dev & 1st deg HB

 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

 T- waves: tented (must be taller than voltage meter),

inverted what are the causes??

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

Once you spot an abnormality, describe it & look for

signs of compromise/related features

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

3.Determine the respiratory component

PaCO3
>6.0 kPa Respiratory Acidosis <4.7 Kpa Respiratory Alkalosis

ABGs
4.Determine the metabolic component
HC03
<22 mmol-1 Metabolic Acidosis >26mmol-1 Metabolic Alkalosis

5.Combine points 2-4 and determine which is the

primary disturbance

6. Determine whether compensation is partial or full

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

doctor this patient is unwell...he is hypotensive

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

What is this? What are you going to do about it?

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!

1. type of film/area of body/demographics/date

2.check orientation 3.check adequacy Rotation/exposure/inflation/position 4.mention the obvious External material OBVIOUS ABNORMALITY

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

Look at lung fields and heart border together

Heart border affected? Middle lobe consolidation

Look at pulmonary vessels

Upper lobe diversion

Dont miss the edges!- pneumothorax

 Soft tissues
Bones
Clavicles Ribs Vertebrae Shoulders Breast shadows Surgical emphysema

Present findings coherently- important negatives aswell Diagnosis

Some questions..
How should a normal xray be taken?

What are the problems with a supine film?

What can cause deviation of trachea? What causes widening of the mediastinum? Causes of hilar lymphadenopathy? Causes of raised hemi-diaphragm? Causes of alveolar shadowing? Causes of reticular shadowing?

Examples

AXR
Gas

Bones
Stones Soft tissue Fluid

Common OSCE questions x2

Summary
Systematic approach to ECG, ABG, CXR & AXR!!

Good luck, youll be great!