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Jason Ryan, MD Intern Report
How to Read an EKG Jason Ryan, MD Intern Report
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How to read an EKG Rate and Rhythm Axis and Intervals Hypertrophy
how fast/slow regular/irregular wide/narrow Axis and Intervals PR, QRS, QT Hypertrophy LAE/RAE LVH/RVH ST Changes and Q waves
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How to read an EKG Rate 300 100 60 40 150 75 50
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How to read an EKG Axis QRS Lead aVF (+) (-) -90o LAD Lead I (-) (+)
RAD Normal Axis 90o
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How to read an EKG Intervals Correct QT 1. QTc=QT/(RR)1/2 (Bazett)
2. QTC=QT (HR-60) (Hodges) QRS QTc <0.46 PR
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How to Read and EKG Atrial Enlargement
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How to Read and EKG Ventricular Enlargement
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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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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 negative I, L Lead II isoelectric (almost no QRS)
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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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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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Left Ventricular Hypertrophy
SV1orV2+ RV5orV6>35mm >40 if 30-40yrs old >60 if 16-30yrs old RaVL>11mm RI + SIII >25mm RaVL + SV3 >28mm(men) or 20mm(wmn)
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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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Sinus Tachycardia All sinus rhythm criteria Rate >100
P before every QRS Upright P in I, II, aVF Inverted P aVR Rate >100
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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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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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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
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Evolution of EKG changes
ST Elevation MI Evolution of EKG changes Normal Acute Hours 1-2 Days 3-7 Days > 7 Days
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Leads go together Anterior
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Leads go together Lateral
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Leads go together Inferior
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