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How to Read an EKG Jason Ryan, MD Intern Report. How to read an EKG 1.Rate and Rhythm  how fast/slow  regular/irregular  wide/narrow 2.Axis and Intervals.

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Presentation on theme: "How to Read an EKG Jason Ryan, MD Intern Report. How to read an EKG 1.Rate and Rhythm  how fast/slow  regular/irregular  wide/narrow 2.Axis and Intervals."— Presentation transcript:

1 How to Read an EKG Jason Ryan, MD Intern Report

2 How to read an EKG 1.Rate and Rhythm  how fast/slow  regular/irregular  wide/narrow 2.Axis and Intervals  PR, QRS, QT 3.Hypertrophy  LAE/RAE  LVH/RVH 4.ST Changes and Q waves

3 How to read an EKG Rate 300 150 100 75 60 50 40

4 How to read an EKG Axis QRS 0o0o 90 o -90 o -180 o RAD LAD Normal Axis Lead I (-) (+) Lead aVF (+) (-)

5 How to read an EKG Intervals PR 0.14-0.21 QRS 0.7-011 QTc <0.46 Correct QT 1. QTc=QT/(RR) 1/2 (Bazett) 2. QTC=QT + 0.00175(HR- 60) (Hodges)

6 How to Read and EKG Atrial Enlargement

7 How to Read and EKG Ventricular Enlargement

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9 Sinus Rhythm Rate between 60 to 100 P wave before every QRS –Smooth contour –Either all positive or all negative except V1 –<0.12s and <0.2mv Upright P waves in I, II, aVF Negative P wave in aVR

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11 Limb Lead Reversal Right and Left arm reversed –P wave positive aVR –P wave negative aVL and I –Limb leads look normal Right arm and Right leg reversed –P wave positive aVR –P wave negative I, L –Lead II isoelectric (almost no QRS)

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14 Left Bundle Branch Block Criteria: –QRS > 120ms (3 small boxes) –Broad, notched, or slurred R waves in I, aVL, and V5- V6 –Secondary ST-T changes in I, aVL, and V5-V6 –Absence of Q waves in I, V5-V6 –R-wave peak time >60ms (1.5 small boxes) V5-V6 Separate criteria for STE AMI

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16 Right Bundle Branch Block Criteria: –QRS >120ms (3 small boxes) –R’ in the right precordial leads with R’>R –Secondary ST-T changes in R precordial leads Supporting findings: –Slurred S wave in I, aVL, left precordial leads Usual criteria for STE AMI apply

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18 Left Ventricular Hypertrophy S V1orV2 + R V5orV6 >35mm –>40 if 30-40yrs old –>60 if 16-30yrs old R aVL >11mm R I + S III >25mm R aVL + S V3 >28mm(men) or 20mm(wmn)

19 Left Ventricular Hypertrophy Associated ST-T wave abnormalities –STD and TWI in V5-V6 Leads where QRS is mainly positive –Slight STE with upright T in V1-V2 Leas where QRS is mainly negative

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21 Sinus Tachycardia All sinus rhythm criteria –P before every QRS –Upright P in I, II, aVF –Inverted P aVR Rate >100

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23 T Wave Inversions Indicative of subendocardial or evolving ischemia Can be a normal variant in several leads or in the presence of BBB Can be caused by several other conditions –Hypertrophic obstructive cardiomyopathy –Intracranial processes (hemorrhage) –Medications or electrolyte abnormalities –Myocarditis/pericarditis or pulmonary embolism

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25 ST depressions Horizontal ST depressions are strongly suggestive of ischemia in the appropriate clinical setting Don’t necessarily localize –Stress testing –Reciprocal changes Several other conditions can provoke ST depressions: –LVH –Medications or electrolytes –Bundle Branch Block –Pulmonary embolism

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27 ST Elevations Localizes best of all ischemic EKG changes Usually indication of acute myocardial injury (occluded artery) Several conditions can also cause ST elevations: –Pericarditis –Early repolarization –LBBB –LVH

28 ST Elevation MI Evolution of EKG changes NormalAcuteHours1-2 Days3-7 Days> 7 Days

29 Leads go together Anterior

30 Leads go together Lateral

31 Leads go together Inferior

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