Stretching Your ECG Skills...Pinterest: Demystifying the 12 Lead ECG. 18-year-old pre-op ECG for knee surgery. What does this ECG show? Wave-Maven . Clues to limb lead reversal Wilson’s

41st Annual NPO Education ConferenceOctober 12, 2018

Doubletree Lloyd Center, Portland

Stretching Your ECG Skills

Steven A. Wahls, MD, FAAFPAssistant Professor

Residency Focused FacultyOHSU Department of Family Medicine

Conflict of Interest:

• Nothing to disclose

Goals/ learning points

1.60 second review of what we are looking at…2.Read ECGs

1.Remember your flow2.Commit yourself to an interpretation

3.Have fun!

https://commons.wikimedia.org/wiki

From: Katzung B, Trevor, A: Basic & Clinical Pharmacology, 13th Ed. McGraw-Hillwww.accesspharmacy.com

Pinterest: Demystifying the 12 Lead ECG

18-year-old pre-op ECG for knee surgery. What does this ECG show?

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Clues to limb lead reversalWilson’s central terminus•This directionless “zero lead” lead is calculated as the average input from the three limb leads: WCT = 1/3 (RA + LA + LL).

Quick guide to spotting LA/RA reversal•Lead I is completely inverted (P wave, QRS complex and T wave).•Lead aVR often becomes positive.•There may be marked right axis deviation.

Quick guide to spotting LA/LL reversal•Lead III is completely inverted (P wave, QRS complex and T wave)•The P-wave is unexpectedly larger in lead I than lead II (it is usually the other way around).

http://www.frca.co.uk

https://lifeinthefastlane.com

A 65-year-old man complaining of weakness…

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• Mild hyperkalemiaK> 5.5 mEq/L• repolarization abnormalities Peaked T

waves

• Moderate hyperkalemiaK> 6.5 mEq/L• progressive paralysis of the atria: P wave

widens and flattens, increased PR, loss of P.

• Severe hyperkalemiaK> 7.0 mE/L• Increased QRS width, sine wave• conduction abnormalities and bradycardia

LITFL

51

55-year-old woman: why is she dyspneic?

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RAE

LITFL

LAE LITFL

Wagner et al. (2007)

LITFL

75 year old man presented with weakness. BP 220/80.

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ESTES Criteria for LVH

("diagnostic" >5 points; "probable" 4 points)

Sokolov-Lyon criteria for LVH• Voltage: S wave depth in V1 +

tallest R wave height in V5-V6 > 35 mm

• Non-voltage:• Increased RW peak time >50ms

V5 or V6• ST depression/ TW inversion

Left side leads

+ECG Criteria

Points

Voltage Criteria (any of):

· R or S in limb leads ≥ 20 mm

· S in V1 or V2 ≥ 30 mm

· R in V5 or V6 ≥ 30 mm

3 points

ST-T Abnormalities:

· Without digitalis

· With digitalis

3 points

1 point

Left Atrial Enlargement in V1

3 points

Left axis deviation

2 points

QRS duration 0.09 sec

1 point

Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec)

1 point

32 year-old male runner presenting with shortness of breath and chest discomfort over last hour… Wa

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57 year old women complaining of pounding in her chest…

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35 year old Air Transport Pilot for routine screening

ECG Changes seen in Athletes

http://bjsm.bmj.com/content/47/3/125

• Sinus bradycardia (≥30 bpm)• Sinus arrhythmia• Ectopic atrial rhythm• Junctional escape rhythm• First-degree AV block (PR interval>200 ms)• Mobitz type I (Wenckebach) second-degree AV block• Incomplete RBBB• Isolated QRS voltage criteria for LVH• Early repolarization (ST elevation, J-point elevation, J waves, or

terminal QRS slurring)• Convex ST segment elevation & T wave inversion V1–V4

You are reading ECGs and review this. What do you see, and what could cause it?

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Possible causes for LBBB

• Aortic stenosis.• Dilated cardiomyopathy.• Myocardial infarction/ CAD• Primary conduction system disease• Acquired conduction system disease

(e.g. Lyme dis)• HTN• AI

Read this ECG. What is your final impression?

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Elderly woman following a fall, with complaints of fatigue and weakness

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ECG missing its clinical data… Ideas?

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42 year old man with irregular pulse

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59 year old woman with history of palpitations

Sources &Re-sources…

• Nathanson L A, McClennen S, Safran C, Goldberger AL. ECG Wave-Maven: Self-Assessment Program for Students and Clinicians.

• Yanowitz, F G. ECG Learning Center.

• Life in the Fast Lane

• The clinical exercise physiology consortium

• ECGPEDIA

http://ecg.bidmc.harvard.edu/http://ecg.utah.edu/http://lifeinthefastlane.com/ecg-libraryhttp://www.cardiology.org/tools/http://en.ecgpedia.org/wiki/Case_100

Stretching Your ECG SkillsConflict of Interest:Goals/ learning pointsSlide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20ECG Changes seen in AthletesSlide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Sources &�Re-sources…