EASY EKG INTERPRETATION
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Transcript of EASY EKG INTERPRETATION
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EKG Interpretation
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Objectives
The Basics
Interpretation
Clinical Pearls
Practice Recognition
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The Normal Conduction System
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Lead Placement
aVF
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All Limb Leads
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Precordial Leads
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EKG Distributions
Anteroseptal: V1, V2, V3, V4
Anterior: V1V4
Anterolateral: V4V6, I, aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF, and V5
and V6
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Waveforms
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Interpretation
Develop a systematic approach to reading EKGs and use itevery time
The system we will practice is:
Rate
Rhythm (including intervals and blocks) Axis
Hypertrophy
Ischemia
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Rate
Rule of 300- Divide 300 by the number of boxes between each
QRS = rate
Number ofbig boxes
Rate
1 300
2 150
3 100
4 75
5 60
6 50
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Rate
HR of 60-100 per minute is normal
HR > 100 = tachycardia
HR < 60 = bradycardia
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Differential Diagnosis of Tachycardia
Tachycardia Narrow Complex Wide Complex
Regular ST
SVT
Atrial flutter
ST w/ aberrancy
SVT w/ aberrancy
VT
Irregular A-fib
A-flutter w/variable conduction
MAT
A-fib w/ aberrancy
A-fib w/ WPWVT
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What is the heart rate?
(300 / 6) = 50 bpm
www.uptodate.com
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Rhythm
Sinus
Originating from SA
node P wave before every
QRS
P wave in same
direction as QRS
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What is this rhythm?
Normal sinus rhythm
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Normal Intervals
PR
0.20 sec (less than one largebox)
QRS 0.08 0.10 sec (1-2 small
boxes)
QT
450 ms in men, 460 ms in
women
Based on sex / heart rate
Half the R-R interval withnormal HR
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Prolonged QT
Normal
Men 450ms
Women 460ms
Corrected QT (QTc) QTm/(R-R)
Causes
Drugs (Na channel blockers)
Hypocalcemia, hypomagnesemia, hypokalemia
Hypothermia
AMI
Congenital
Increased ICP
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Blocks
AV blocks
First degree block
PR interval fixed and > 0.2 sec
Second degree block, Mobitz type 1
PR gradually lengthened, then drop QRS
Second degree block, Mobitz type 2
PR fixed, but drop QRS randomly
Type 3 block
PR and QRS dissociated
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What is this rhythm?
First degree AV block PR is fixed and longer than
0.2 sec
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What is this rhythm?
Type 1 second degree block (Wenckebach)
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What is this rhythm?
Type 2 second degree AV block Dropped QRS
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What is this rhythm?
3rd degree heart block (complete)
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The QRS Axis
Represents the overall direction of the hearts activity
Axis of30 to +90 degrees is normal
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The Quadrant Approach
QRS up in I and up in aVF = Normal
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What is the axis?
Normal- QRS up in I and aVF
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Hypertrophy
Add the larger S wave of V1 or V2 in mm, to the larger R wave
of V5 or V6.
Sum is > 35mm = LVH
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Ischemia
Usually indicated by ST changes
Elevation = Acute infarction
Depression = Ischemia
Can manifest as T wave changes
Remote ischemia shown by q waves
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What is the diagnosis?
Acute inferior MI with ST elevation in leads II, III, aVF
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What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia
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Lets Practice
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Normal Sinus Rhythm
Mattu, 2003
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First Degree Heart Block
PR interval >200ms
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Accelerated Idioventricular
Ventricular escape rhythm, 40-110 bpm
Seen in AMI, a marker of reperfusion
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Junctional Rhythm
Rate 40-60, no p waves, narrow complex QRS
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Hyperkalemia
Tall, narrow and symmetric T waves
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Wellens Sign
ST elevation and biphasic T wave in V2 and V3
Sign of large proximal LAD lesion
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Brugada Syndrome
RBBB or incomplete RBBB in V1-V3 with convex ST elevation
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Brugada Syndrome
Autosomal dominant genetic mutation of sodium channels
Causes syncope, v-fib, self terminating VT, and sudden cardiacdeath
Can be intermittent on EKG
Most common in middle-aged males Can be induced in EP lab
Need ICD
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Premature Atrial Contractions
Trigeminy pattern
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Atrial Flutter with Variable Block
Sawtooth waves
Typically at HR of 150
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Torsades de Pointes
Notice twisting pattern
Treatment: Magnesium 2 grams IV
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Digitalis
Dubin, 4th ed. 1989
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Lateral MI
Reciprocal changes
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Inferolateral MI
ST elevation II, III, aVF
ST depression in aVL, V1-V3 are reciprocal changes
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Anterolateral / Inferior Ischemia
LVH, AV junctional rhythm, bradycardia
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Left Bundle Branch Block
Monophasic R wave in I and V6, QRS > 0.12 secLoss of R wave in precordial leadsQRS T wave discordance I, V1, V6
Consider cardiac ischemia if a new finding
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Right Bundle Branch Block
V1: RSR prime pattern with inverted T wave
V6: Wide deep slurred S wave
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First Degree Heart Block, Mobitz Type I (Wenckebach)
PR progressively lengthens until QRS drops
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Supraventricular Tachycardia
Narrow complex, regular; retrograde P waves, rate
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Right Ventricular Myocardial Infarction
Found in 1/3 of patients with inferior MI
Increased morbidity and mortality
ST elevation in V4-V6 of Right-sided EKG
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Ventricular Tachycardia
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Prolonged QT
QT > 450 ms
Inferior and anterolateral ischemia
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Second Degree Heart Block, Mobitz Type II
PR interval fixed, QRS dropped intermittently
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Acute Pulmonary Embolism
SIQIIITIII in 10-15%
T-wave inversions, especially occurring ininferior and anteroseptal simultaneously
RAD
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Wolff-Parkinson-White Syndrome
Short PR interval 0.10 secDelta wave
Can simulate ventricular hypertrophy, BBB and previous MI
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Hypokalemia
U wavesCan also see PVCs, ST depression, small T waves
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Thank You
Any Questions?