ekg04-kc13
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EKG TUTORIAL:
APPROACH TO INTERPRETATIONMARIO L MAIESE D O, FACC, FACOI
Clinical Associate Professor UMDNJSOM
South Jersey Heart Group
September 14-15, 2004
For Questions: [email protected]
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Rapid Interpretation of EKGS
Dale Dubin, MD
(required reading before the lecture)
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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 Approach1) 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
Signs of Hypertrophy
6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation
Six Step Approach2) 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
Signs of Hypertrophy
6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation
Six Step Approach3) 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 Approach4) 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
Signs of Hypertrophy
6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation
Six Step Approach5) 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
Signs of Hypertrophy
6 ST/QT/ T wave abnormalities
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12-lead EKG Interpretation
Six Step Approach6) 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 rhythmsregular irregular premature/missed beats
irregular irregular chaotic rhythms
P wavenot 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 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 blockBACK
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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? YESright 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
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Criteria for Infarct Age
Significant ST segment elevation? YESacute infarct [days]
Q waves with inverted T waves ? YESrecent (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 inclusiveP wave with every normal QRS/slow [ supraventricular bradycardiaP wave with every normal QRS/fast [>100] => supraventricular tachycardiano P waves/wide QRS/fast => V TachycardiaBACK
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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 blockBACK
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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 tachBACK
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Rhythms
NormalAbnormal: ArrhythmiaDysrhythmia
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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 patientss 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 patients 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 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?
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14) What conduction disturbance is present?
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Atherothrombotic
Lesion developmentSomeone 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?
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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?
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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! -
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
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Experience is a wonderful thing .
It enables you to recognize a mistake when you make it again.