EKG TUTORIAL: APPROACH TO INTERPRETATION

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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 emailmaiese1_at_comcast.net

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Rapid Interpretation of EKGS

• Dale Dubin, MD
• (required reading before the lecture)

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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)
• 300,150,100,75,60,5
  0
• --- 60-100 inclusive? YES nl
  rate
• --- lt 60 gt bradycardia
• --- gt 100 gt 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 0.12-0.20 inclusive nl
• PRlt 0.12 sec? YES Pre-Excitation
  Syndrome PES 11 poss Variants
  
• delta wave with prolonged QRS
  Wolff-Parkinson- White WPW Syndrome
• PRgt 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 lt 0.10 sec
• QRSgt 0.10 sec YES differential for wide QRS
  bundle branch blockBBBpattern

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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 gt 0.04 sec in limb leads YES
  criteria for MI
• Q waves gt 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 hypertrophyincreased 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 gt1mm? 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-specificwith 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 gt V tach
• -bizzare axis gt V tach
• PR lt 0.12 sec gt WPW QRSgt 0.10 lt 0.12
• initial QRS peaked upright in V1? YES
• right bundle branch block (RBBB) QRSgt
  0.12
• QRS wide downward deflection overall inV1-V6
  QRSgt 0.12? YES left bundle branch block
  (LBBB)

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Differential for Wide QRS

• LBBB pattern QRS lt 0.12 with axis lt 45 degrees?
  YES left anterior hemiblock LAHB
• LBBB pattern QRS lt 0.12 with axis gt 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 gt normal sinus
  rhythm NSR--rate 60-100 inclusive
• P wave with every normal QRS/slow lt60 gt
  supraventricular bradycardia
• P wave with every normal QRS/fast gt100 gt
  supraventricular tachycardia
• no P waves/wide QRS/fast gt V Tachycardia
• 
  BACK

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Premature/Missed Beats

• premature beats early
• narrowgt PACs/PJCs
• wide/samegt unifocal ventricular ectopy
• wide/different gt multifocal ventricular
  ectopy
• grouped beats with PR gt 2nd deg AV block1
• dropped beats without PR gt 2nd deg block 2
• no relationship between P and QRS gt 3rd degree
  AV block
• 
  BACK

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Chaotic Rhythms

• No P waves undulating baseline/irregular
  ventricular response gt atrial fibrillation AF
• heterogenious P waves at least 3 different P
  wave configurations usually with varying PR
  intervals gt multifocal atrial rhythm if HR gt
  100 gt 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 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 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
thirdTo 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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