ECG, AXR & Xray simple approach to simple tests

ECGs:
1. Name & DOB, date & time, chest pain? 2. Rate, Rhythm, Axis. Rhythm: p-waves & their relation to QRS complexes. .Axis: use lead I & II. Check this using lead III 3. The most obvious abnormality is 4. P waves shape, PR interval, regular/irregular? 5. Q waves look for territorial distribution. 6. QRS complex duration, narrow or wide? Bundle branch block present? RBBB MaRRoW. LBBB WiLLiaM .Trifascicluar block RBBB, L-axis dev & 1st deg HB 7. ST segment: Elevation infarction (high take off follows a deep S-wave. Diffuse elevation pericarditis). Depression ischaemia. Make sure its in consecutive leads!! 8. Anterior LAD. Lateral Left circumflex. Inferior Right circumflex Hypekalaemia flattened P-w, slurring into wide QRS, Tall tended Twaves. Treatment, ABCDE. 10ml 10% calcium resonium over 2 mins. Salbutamol nebs. 50ml 50% dextrose with 10units actrapid over 30 mins. Calcium resonium (gut binding, works over hours). Monitor venous gas regularly. Heart block: 1st degree long PR; 2nd degree Mobitz I: lengthing PR interval until drop a QRS complex normally transient. Mobitz II: 2-3 Pwaves for each QRS complex (i.e. regular no-conducted action potentials to the ventricles) SERIOUS. 3rd degree complete dissociation, Pwaves beat about 60bpm & QRS about 40bpm.

ABG:
1. Assess oxygenation >10kPa, Is the patient hypoxic? Are they on supplementary O2 (Oxygen should be HIGH) 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 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: FULL normal pH. Partial ABNORMAL pH. Compensation occurs via the lungs (quickly) or the kidneys (over days) to correct the acid/base balance. Causes: Resp acidosis pneumonia, life threatening asthma, COPD, pneumothorax, resp distress, neuromuscular disease, PE only if Massive (type 2 resp failure). Resp alkalosis: hyperventilation (PE, pregnancy, thyrotoxicosis,pain) atypical pneumonia. Metabolic acidosis: DKA, lactate, renal failure, salycilates, hyperkalaemia, re-feeding syndrome, renal tubular acidosis. Consider calculating the anion gap. Metabolic alkalosis: vomiting, diuresis, hypokalaemia, hyperaldosteronism.

CXR:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. type of film/area of body/demographics/date check orientation check adequacy: Rotation/exposure/inflation/position mention the obvious: External material, OBVIOUS ABNORMALITY Trachea Mediastinum Heart cardiothoracic ratio or loss of border or sail sign? Valves/pacemakers. Hilum: Remember left is higher Diaphragm: Look for free air under the diaphragm! Lung fields: a. Shadowing, b. Air bronchograms, c. Meniscus, d. Reticular Lung markings, e. Pleural plaques, f. Kerly b lines, g. Look at costophrenic/cardiophrenic angles, h. Look at lung fields and heart border together. i. Breast shadows. j. Look at pulmonary vessels: Upper lobe diversion. k. Dont miss the edges!- pneumothorax 11. Bones: Clavicles, Ribs, Vertebrae, Shoulders,

AXR
1. Gas normal bowel pattern? Dilated colon/small bowel? Faeces? Double wall sign? (perf) Under the diaphragm??? (perf) Gas in the biliary system (gallstone perf). 2. Bones: fracture, arthritis, dislocation? 3. Stones border of psoas, gall bladder, bladder. (a flebolith is perfectly round with a dark centre. A stone is rougher with a dense centre). Calcification of organs such as adrenals & pancreas. 4. Soft tissue- liver, spleen, kidneys, psoas, 5. Fluid Fluid level may indicate obstruction.