ekg tutorial: approach to interpretation mario l maiese d o, facc, facoi clinical associate...
TRANSCRIPT
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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—[email protected]
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Rapid Interpretation of EKG’S
Dale Dubin, MD
(required reading before the lecture)
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PRIORITIES?
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6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 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
--- 60-100 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
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation 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
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6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval/ Axis
4 Signs of MI
5 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
2 PR interval
3 QRS interval
4 Signs of MI
5 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
2 PR interval
3 QRS interval
4 Signs of MI
5 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
2 PR interval
3 QRS interval
4 Signs of MI
5 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 1st degree heart block• progressive 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
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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 60-100 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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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. 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.
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. The EKG is most consistent with which diagnosis?
Acute inferior wall MIAcute pericarditis
Normal variant “early repolarization” Ventricular aneurysm
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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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AtherothromboticLesion development
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Mechanism of Plaque Disruption in Atherothrombosis (Acute thrombus)
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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. 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? 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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