EKG04-kc13

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: [email protected]

Rapid Interpretation of EKGS

Dale Dubin, MD

(required reading before the lecture)

Nl: 0 to 90

R axis: 90 to 180

L axis: o to - 90

Indeterminate axis: -90 to -180

PRIORITIES?

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval

4 Signs of MI

Signs of Hypertrophy

6 ST/QT/ T wave abnormalities

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

--- 60-100 inclusive? YES nl rate

--- < 60 => bradycardia

--- > 100 => tachycardia
unsure of rhythm? YES Arrhythmia ID

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval

4 Signs of MI



Six Step Approach

2) PR interval [nl 0.12-0.20 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

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval/ Axis

4 Signs of MI



Six Step Approach

3) QRS interval [nl < 0.10 sec]

QRS> 0.10 sec YES differential for wide QRS [bundle branch block{BBB}pattern]

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval

4 Signs of MI



Six Step Approach

4) signs of transmural [Q wave infarction]?
Q waves > 0.04 sec in limb leads YES + criteria for MIQ waves > 1/4 height of the R wave in the same lead YES + criteria for MIQ waves in more than one limb lead YES + criteria for MIabnormal R wave progression in precordial [chest] leads YES criteria for MI [age & sites]

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval

4 Signs of MI



Six Step Approach

5) signs of hypertrophy[increased voltage of QRS complexes]
Right Ventricular Hypertrophy [RVH]Left Ventricular Hypertrophy [LVH]

6 Step Approach

1 Rate and Rhythm

PR interval

QRS interval

4 Signs of MI



Six Step Approach

6) ST/QT/T wave abnormalities
ST seg depression [>1mm]? YES ischemiaST seg elevation? YES injuryST scooping? YES digitalis effectprolonged 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

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

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

Differential for Prolonged PR Interval
P with every QRS 1st degree heart blockprogressive PR prolongation with dropped beats 2nd degree heart block [Mobitz type 1(Wenckebach)]constant PR with dropped beats 2nd degree heart block [Mobitz type 11]no relationship between p waves and QRS 3rd degree heart block
BACK

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)

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

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

Regular Rhythms
P wave with every normal QRS => normal sinus rhythm [NSR]--rate 60-100 inclusiveP wave with every normal QRS/slow [ supraventricular bradycardiaP wave with every normal QRS/fast [>100] => supraventricular tachycardiano P waves/wide QRS/fast => V Tachycardia
BACK

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

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

Rhythms
NormalAbnormal: Arrhythmia
Dysrhythmia

Supraventricular Dysrhythmias

Atrioventricular (AV) Block

Myocardial Infarction

Ventricular conduction abnormalities

Ventricular Dysrhythmias

Pre-Excitation Syndrome (PES)

Experience is a wonderful thing .

It enables you to recognize a mistake when you make it again.

Average but works hard,

Beats

Brilliant but lazy.

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?

2) What is the cause of the patientss rapid irregular pulse?

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

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

5) What is the arrhythmia?

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

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

8) What is the cause of the patients rapid irregular pulse?

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

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

11) What arrhythmia is present in this patient?

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

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

14) What conduction disturbance is present?

Atherothrombotic
Lesion development

Someone with undetectable disease (either by ETT - [usually identifies > 70% obstruction] or by cath) - 20-30% obstruction->80% of MIs occur in these type vessels.

Revascularization procedures dont decrease the incidence of MIs. But they do decrease mortality. Why?

Mechanism of Plaque Disruption in Atherothrombosis (Acute thrombus)

Someone with undetectable disease (either by ETT - [usually identifies > 70% obstruction] or by cath) - 20-30% obstruction->80% of MIs occur in these type vessels.

Revascularization procedures dont decrease the incidence of MIs. But they do decrease mortality. Why?

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

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

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

18) What arrhythmia and conduction disturbance are present?

19) What conduction abnormality is present?

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

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

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

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!

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.

Time is Up
D:\Clock.htm

Experience is a wonderful thing .

It enables you to recognize a mistake when you make it again.

EKG04-kc13

Documents

flat t wave

pattern6 step approach1

nl rate

inverted t waves

peaked t waves

step approach3 qrs interval

step approach2 pr interval

limb lead