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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:
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Rapid Interpretation of EKG’S
Dale Dubin, MD (required reading before the lecture)
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4/16/2017
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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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PRIORITIES?
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6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities
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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
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6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities
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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
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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
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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]
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6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities
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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]
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6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation Six Step Approach
5) signs of hypertrophy[increased voltage of QRS complexes] Right Ventricular Hypertrophy [RVH] Left Ventricular Hypertrophy [LVH]
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6 Step Approach 1 Rate and Rhythm PR interval QRS interval
4 Signs of MI Signs of Hypertrophy 6 ST/QT/ T wave abnormalities
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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Rhythms Normal Abnormal: Arrhythmia Dysrhythmia
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Supraventricular Dysrhythmias
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Atrioventricular (AV) Block
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Myocardial Infarction
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Ventricular conduction abnormalities
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Ventricular Dysrhythmias
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Pre-Excitation Syndrome (PES)
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Experience is a wonderful thing .
It enables you to recognize a mistake when you make it again.
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Beats Brilliant but lazy.
Average but works hard, Beats Brilliant but lazy.
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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?
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2) What is the cause of the patients’s rapid irregular pulse?
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3) What is the cause of the wide QRS complex?
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4) The patient complains of “extra” beats. What is the arrhythmia? Tx?
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5) What is the arrhythmia?
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6) A patient complains of palpatations. What is the arrhythmia?
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7) The following EKG is obtained during a cardiac arrest
7) The following EKG is obtained during a cardiac arrest. What is the arrhythmia?
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8) What is the cause of the patient’s rapid irregular pulse?
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9) How does the rhythm change abruptly in this patient?
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10) What arrhythmia and conduction disturbance are present on this V1 rhythm strip?
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11) What arrhythmia is present in this patient?
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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
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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?
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14) What conduction disturbance is present?
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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?
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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?
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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?
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16) A patient has recurrent syncope. What is the diagnosis?
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17) The following rhythm strip is obtained post exercise
17) The following rhythm strip is obtained post exercise. What is the diagnosis?
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18) What arrhythmia and conduction disturbance are present?
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19) What conduction abnormality is present?
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20) What arrhythmia is responsible for the tachycardia in this patient with underlying chronic lung disease?
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21) What dysrhythmia is causing the tachycardia
21) What dysrhythmia is causing the tachycardia? What other abnormal finding is present?
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22) A 62 year old women presents with the sudden onset of acute crushing chest pain. What is the diagnosis?
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“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!”
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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.
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Time is Up D:\Clock.htm
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Experience is a wonderful thing .
It enables you to recognize a mistake when you make it again.
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