Download EKG TUTORIAL

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]
Rapid Interpretation of EKG’S
Dale Dubin, MD
(required reading before the lecture)
PRIORITIES?
6 Step Approach
1
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval
Signs of MI
Signs of Hypertrophy
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
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval
Signs of MI
Signs of Hypertrophy
ST/QT/ T wave abnormalities
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
WolffParkinson- White [WPW] Syndrome
• PR> 0.20 sec [including dropped beats] ? YES
differential for prolonged PR
6 Step Approach
1
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval/ Axis
Signs of MI
Signs of Hypertrophy
ST/QT/ T wave abnormalities
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]
6 Step Approach
1
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval
Signs of MI
Signs of Hypertrophy
ST/QT/ T wave abnormalities
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]
6 Step Approach
1
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval
Signs of MI
Signs of Hypertrophy
ST/QT/ T wave abnormalities
12-lead EKG Interpretation
Six Step Approach
5) signs of hypertrophy[increased voltage of
QRS complexes]
• Right Ventricular Hypertrophy [RVH]
• Left Ventricular Hypertrophy [LVH]
6 Step Approach
1
2
3
4
5
6
Rate and Rhythm
PR interval
QRS interval
Signs of MI
Signs of Hypertrophy
ST/QT/ T wave abnormalities
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 nonspecific*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 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
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 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
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
• Normal
• Abnormal: 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 patients’s
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
patient’s 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
Mechanism of Plaque Disruption in
Atherothrombosis (Acute thrombus)
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.