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EKG TUTORIAL: APPROACH TO INTERPRETATION

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1 EKG TUTORIAL: APPROACH TO INTERPRETATION
4/16/2017 EKG TUTORIAL: APPROACH TO INTERPRETATION MARIO L MAIESE D O, FACC, FACOI Clinical Associate Professor UMDNJSOM South Jersey Heart Group September 14-15, 2004 For Questions:

2 Rapid Interpretation of EKG’S
Dale Dubin, MD (required reading before the lecture)

3 4/16/2017

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9 4/16/2017 Nl: 0 to 90 R axis: 90 to 180 L axis: o to - 90 Indeterminate axis: -90 to -180

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14 PRIORITIES?

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16 6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

17 12-lead EKG Interpretation Six Step Approach
1) rate and rhythm big box (0.20 sec) rule (for 1,2,3,4,5,& 6 boxes) 300,150,100,75,60,50 inclusive? YES nl rate --- < 60 => bradycardia --- > 100 => tachycardia unsure of rhythm? YES Arrhythmia ID

18 6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

19 12-lead EKG Interpretation Six Step Approach
2) PR interval [nl inclusive] nl PR< 0.12 sec? YES Pre-Excitation Syndrome [PES]; 11 poss Variants; delta wave with prolonged QRS Wolff-Parkinson- White [WPW] Syndrome PR> 0.20 sec [including dropped beats] ? YES differential for prolonged PR

20 6 Step Approach 1 Rate and Rhythm PR interval QRS interval/ Axis
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

21 12-lead EKG Interpretation Six Step Approach
3) QRS interval [nl < 0.10 sec] QRS> 0.10 sec YES differential for wide QRS [bundle branch block{BBB}pattern]

22 6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

23 12-lead EKG Interpretation Six Step Approach
4) signs of transmural [Q wave infarction]? Q waves > 0.04 sec in limb leads YES criteria for MI Q waves > 1/4 height of the R wave in the same lead YES criteria for MI Q waves in more than one limb lead YES criteria for MI abnormal R wave progression in precordial [chest] leads YES criteria for MI [age & sites]

24 6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

25 12-lead EKG Interpretation Six Step Approach
5) signs of hypertrophy[increased voltage of QRS complexes] Right Ventricular Hypertrophy [RVH] Left Ventricular Hypertrophy [LVH]

26 6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

27 12-lead EKG Interpretation Six Step Approach
6) ST/QT/T wave abnormalities ST seg depression [>1mm]? YES ischemia ST seg elevation? YES injury ST scooping? YES digitalis effect prolonged QT with flat T wave? YES hypo K+ early peaked T waves? YES hyper K+ inverted T waves without Q waves? YES non-specific*with Hx and + enzymes could be consist with a subendocardial Non-Q wave MI Forward

28 ARRHYTHMIA IDENTIFICATION
Rhythm: regular regular regular rhythms regular irregular premature/missed beats irregular irregular chaotic rhythms P wave not present absent P waves [escape (late) rhythms] more P waves than QRSs AV block

29 ARRHYTHMIA IDENTIFICATION
QRS Complex -all narrow nl QRS complexes -mixed narrow and wide homogeneous unifocal ventricular ectopy heterogeneous multifocal ventricular ectopy -all wide wide QRS complexes BACK

30 Differential for Prolonged PR Interval
P with every QRS st degree heart block progressive PR prolongation with dropped beats 2nd degree heart block [Mobitz type 1(Wenckebach)] constant PR with dropped beats nd degree heart block [Mobitz type 11] no relationship between p waves and QRS rd degree heart block BACK

31 Differential for Wide QRS
No P waves -all negative in V6 => V tach -bizzare axis => V tach PR < 0.12 sec => WPW [QRS> 0.10 & < 0.12] initial QRS peaked [upright] in V1? YES right bundle branch block (RBBB) [QRS> 0.12] QRS wide [downward deflection] overall inV1-V6 [QRS> 0.12]? YES left bundle branch block (LBBB)

32 Differential for Wide QRS
LBBB pattern [QRS < 0.12] with axis < 45 degrees? YES left anterior hemiblock [LAHB] LBBB pattern [QRS < 0.12 with axis > 120 degrees? YES left posterior hemiblock [LPHB] BACK

33 Criteria for Infarct Age
Significant ST segment elevation? YES acute infarct [days] Q waves with inverted T waves ? YES recent (“subacute”) [days/weeks/months] significant Q waves only? YES old [months/years] BACK

34 Regular Rhythms P wave with every normal QRS => normal sinus rhythm [NSR]--rate inclusive P wave with every normal QRS/slow [<60] => supraventricular bradycardia P wave with every normal QRS/fast [>100] => supraventricular tachycardia no P waves/wide QRS/fast => V Tachycardia BACK

35 Premature/Missed Beats
premature beats [early] narrow=> PACs/PJCs wide/same=> unifocal ventricular ectopy wide/different => multifocal ventricular ectopy grouped beats with PR => 2nd deg AV block[1] dropped beats without PR => 2nd deg block [2] no relationship between P and QRS => 3rd degree AV block BACK

36 Chaotic Rhythms No P waves [undulating baseline]/irregular ventricular response => atrial fibrillation [AF] heterogenious P waves [at least 3 different P wave configurations usually with varying PR intervals => multifocal atrial rhythm [if HR > 100 => multifocal atrial tach BACK

37 Rhythms Normal Abnormal: Arrhythmia Dysrhythmia

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40 Supraventricular Dysrhythmias

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53 Atrioventricular (AV) Block

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63 Myocardial Infarction

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77 Ventricular conduction abnormalities

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87 Ventricular Dysrhythmias

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99 Pre-Excitation Syndrome (PES)

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116 Experience is a wonderful thing .
It enables you to recognize a mistake when you make it again.

117 Beats Brilliant but lazy.
Average but works hard, Beats Brilliant but lazy.

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120 1) A 45 yr old black man is noted to have a BP of 150/100
1) A 45 yr old black man is noted to have a BP of 150/100. He has been hypertensive the last 10 years. What is the abnormality on the EKG?

121 2) What is the cause of the patients’s rapid irregular pulse?

122 3) What is the cause of the wide QRS complex?

123 4) The patient complains of “extra” beats. What is the arrhythmia? Tx?

124 5) What is the arrhythmia?

125 6) A patient complains of palpatations. What is the arrhythmia?

126 7) The following EKG is obtained during a cardiac arrest
7) The following EKG is obtained during a cardiac arrest. What is the arrhythmia?

127 8) What is the cause of the patient’s rapid irregular pulse?

128 9) How does the rhythm change abruptly in this patient?

129 10) What arrhythmia and conduction disturbance are present on this V1 rhythm strip?

130 11) What arrhythmia is present in this patient?

131 12) A 50 yr. -old man presents with chest discomfort
12) A 50 yr.-old man presents with chest discomfort. The EKG is most consistent with which diagnosis? Acute inferior wall MI Acute pericarditis Normal variant “early repolarization” Ventricular aneurysm

132 13) A 63 yr. -old woman had severe chest pain 6 hours ago
13) A 63 yr.-old woman had severe chest pain 6 hours ago. What does the EKG show?

133 14) What conduction disturbance is present?

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135 Atherothrombotic Lesion development
4/16/2017 Someone with undetectable disease (either by ETT - [usually identifies > 70% obstruction] or by cath) % obstruction->80% of MIs occur in these type vessels. Revascularization procedures don’t decrease the incidence of MIs. But they do decrease mortality. Why?

136 Mechanism of Plaque Disruption in Atherothrombosis (Acute thrombus)
4/16/2017 Someone with undetectable disease (either by ETT - [usually identifies > 70% obstruction] or by cath) % obstruction->80% of MIs occur in these type vessels. Revascularization procedures don’t decrease the incidence of MIs. But they do decrease mortality. Why?

137 15) A 53 yr old man presents with crushing chest pain
15) A 53 yr old man presents with crushing chest pain. He is hypotensive with jugular venous distention. What is the EKG diagnosis?

138 16) A patient has recurrent syncope. What is the diagnosis?

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140 17) The following rhythm strip is obtained post exercise
17) The following rhythm strip is obtained post exercise. What is the diagnosis?

141 18) What arrhythmia and conduction disturbance are present?

142 19) What conduction abnormality is present?

143 20) What arrhythmia is responsible for the tachycardia in this patient with underlying chronic lung disease?

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145 21) What dysrhythmia is causing the tachycardia
21) What dysrhythmia is causing the tachycardia? What other abnormal finding is present?

146 22) A 62 year old women presents with the sudden onset of acute crushing chest pain. What is the diagnosis?

147 “To look is one thing; To see what you look at is another, To understand what you see is a third; To learn from what you understand is still something else, But to act on what you learn is all that really matters!”

148 Be Sincere Be simple in words, manners and gestures.
Amuse as well as instruct. If you can make a man laugh you can make him think and believe you.

149 Time is Up D:\Clock.htm

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155 Experience is a wonderful thing .
It enables you to recognize a mistake when you make it again.

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