Introduction to EKG Interpretation
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Transcript of Introduction to EKG Interpretation
EKG Interpretation
Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham
Physician Assistant ProgramPegasus Emergency Group
@PA_Maday #FNPintensive
What we will accomplish today• List the(my) steps to reading EKG
• Analyze normal electrical progression for all 12 leads
• Relate anatomy of the coronary vessels to an EKG
• Recognize common rhythms seen on EKG
• Identify life-threatening conditions on EKG
Steps to Reading EKG• Rate• Rhythm• Axis• Hypertrophy/Enlargement• P-Q-R Waves• Intervals• Ischemia• Miscellaneous
Rate
Rhythm• Need to identify:• Rate• Tachycardia, bradycardia, junctional
• Regular vs Irregular• If irregular, is it regular or irregular?
• Ectopic beats• PVCs, PACs, dropped beats
Arrhythmia
Axis
QRS Deflection Axis DeviationLead I aVF
Positive Positive NormalPositive Negative Left Axis Deviation
Negative Positive Right Axis Deviation
Ventricular HypertrophyLeft Ventricular
Hypertrophy• LAD• S wave in V1 or V2 + R
wave in V5 or V6 > 35mm
Right Ventricular Hypertrophy
• RAD• Large R wave and
inverted T wave in V1• R/S ratio > 1
Atrial EnlargementLeft Atrial
Enlargement• P wave > 0.12s in lead
II• Diphasic or inverted P
wave in V1
• Notched P wave in limb leads
Right Atrial Enlargement
• P wave > 2.5mm in lead II and/or > 1.5mm in V1
P-Q-R Waves• P-Wave• Married to every QRS complex
• Q-Wave• Indicative of old infarct
• R-Wave Progression in precordial leads
Intervals• PR Interval• < 0.2s
• QRS Interval• < 0.08s
• QT Interval • < ½ R-R interval
Ischemia• ST Segments• Measured at J-point• Elevation• Depression
• T-Wave• Normal - always upright in leads I, II, V3-6, and inverted in
aVR• Inverted in ischemia
Miscellaneous• Electrolyte Imbalances• Potassium• Magnesium• Calcium
• Delta wave• W-P-W syndrome
Coronary Anatomy and EKG Lead CorrelationAxis Leads Coronary Vessel
Inferior II, III, and aVF RCA and/or LCxSeptal Anterior V1, V2 V3, V4 LADLateral V5, V6, I, aVL LCx or Diagonal of LAD
Patient #1• 45yo male presents to PCP for pre-operative
screening for arthroscopic ACL repair• Medications• Pantoprazole 40mg daily
• Past Medical History• GERD
• Vital Signs• BP-121/72, HR-78, RR-12, O2-100%, temp-98.9o
Rate - 75Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement - None
P-Q-R Waves – married, no Q, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes
Patient #2• 64yo female with a 2 hour history of chest pain• Medications• Lisinopril10mg daily, Metoprolol 50mg daily, Metformin
500mg BID, Simvastatin 40mg daily• Past Medical History• HTN, DMII, HLD
• Vitals• BP-164/101, HR-62, RR-19, O2-100%, temp-98.7o
Rate - 60Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement - LVH
P-Q-R Waves – married, Q in III, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – STE in II, III, and aVF, STD in aVLMiscellaneous – no changes
Patient #3• 47yo female with a 1 week history of
“palpitations” following a cold 2 weeks ago• Medications• Amlodipine 10mg daily
• Past Medical History• HTN
• Vitals• BP-131/74, HR-82, RR-17, O2-100%, temp-98.8o
Rate - 60Rhythm - IrregularAxis – Normal axisHypertrophy/Enlargement - None
P-Q-R Waves – not all married, no Q, good progression Intervals – elongating PR, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes
Patient #4• 73yo male with 2 week history of shortness of
breath• Medications• HCTZ 25mg daily, Lisinopril 10mg daily, Metoprolol 25mg
daily, Rosuvastatin 20mg daily, ASA 81mg daily• Past Medical History• HTN, CAD, HLD• 1997 – NSTEMI with stents x 3
• Vitals• BP-128/71, HR-86, RR-19, O2-100%, temp-98.2o
Rate - 90Rhythm – Irregularly, irregularAxis – Normal axisHypertrophy/Enlargement - None
P-Q-R Waves – no P waves, no Q, good progression Intervals – no PR, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes
Patient #5• 14yo female coming in for athletic physical.
Occasional palpitations on exertion• Medications• None
• Past Medical History• None
• Vitals• BP-110/61, HR-72, RR-15, O2-100%, temp-98.7o
Rate - 75Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement – LVH, LAE
P-Q-R Waves – married, lateral Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, prolonged QTIschemia – no ST changesMiscellaneous – no changes
Patient #6• 68yo female with a 1 month history of pre-
syncope and dizziness• Medications• Levothyroxine 0.25mcg daily, Metoprolol 25mg daily
• Past Medical History• Hypothyroidism, HTN
• Vitals• BP-137/81, HR-52, RR-16, O2-100%, temp-98.4o
Rate - 47Rhythm – Regular, bradycardiaAxis – Normal axisHypertrophy/Enlargement – none
P-Q-R Waves – married, no Q waves, good progression Intervals – PR>0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes
Patient #7• 59yo male with a 3 day history of palpitations• Medications• Novolin 70/30 before meals, Lantus 40mg qHS,
Olmesartan 40mg daily, Epoetin 50U/kg • Past Medical History• DM, HTN, ESRD
• Vitals• BP-157/95, HR-92, RR-15, O2-100%, temp-98.9o
Rate - 107Rhythm – Regular, tachycardiaAxis – Normal axisHypertrophy/Enlargement – RAE
P-Q-R Waves – married, anterior Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – peaked T waves
Patient #8• 19yo female with a 20min of a “panic attack”• Medications• Alprazolam 1mg TID, Fluoxetine 20mg daily
• Past Medical History• General Anxiety Disorder
• Vitals• BP-164/99, HR-194, RR-25, O2-100%, temp-99.2o
Rate - 220Rhythm – Regular, tachycardiaAxis – LADHypertrophy/Enlargement – none
P-Q-R Waves – no P waves, no Q waves, good progression Intervals – no PRI, QRS<0.1s, QT<1/2 R-RIschemia – widespread ST depressionMiscellaneous – no changes
Patient #9• 41yo female with a 2 history of chest pain and
dyspnea• Medications• Loestrin 21, Propanolol 60mg daily, Propylthiouracil 50mg
TID• Past Medical History• Hyperthyroidism
• Vitals• BP-148/97, HR-78, RR-24, O2-94%, temp-98.4o
Rate - 72Rhythm – RegularAxis – RADHypertrophy/Enlargement – RVH
P-Q-R Waves – married, Q waves in lead III, large, notched R wave in V1-3Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – T wave inversion V1-4 and lead IIIMiscellaneous – no changes
Patient #10• 54yo male with a 2 day history of palpitations• Medications• ASA 81mg daily, Plavix 300mg daily, Simvastatin 80mg
daily, Metoprolol 50mg daily, Amlodipine 10mg daily• Past Medical History• HTN, CAD• 5/2014 – NSTEMI with stents x 3
• Vitals• BP-137/81, HR-70, RR-16, O2-100%, temp-98.8o
Rate - 65Rhythm – RegularAxis – LADHypertrophy/Enlargement – none
P-Q-R Waves – multiple P waves, no Q waves,
good progressionIntervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – noneMiscellaneous – no changes
Patient #11• 62yo male presents for medical clearance for
aortic valve replacement• Medications• Irbesartan 150mg daily, Diltiazem 180mg daily
• Past Medical History• Hypertension• Aortic stenosis
• Vitals• BP-131/76, HR-65, RR-16, O2-100%, temp-98.6o
Rate - 65Rhythm – RegularAxis – LADHypertrophy/Enlargement – ?LVH?
P-Q-R Waves – married, no Q waves, poor progression and broad R wave in lateral leadsIntervals – PR<0.2s, QRS>0.12s, QT<1/2 R-RIschemia – ?STE in anterior leads?Miscellaneous – tiny R and deep S in anterior leads
Patient #12• 23yo female with a 6 month history of intermittent
palpitations• Medications• Depo-Provera
• Past Medical History• None
• Vitals• BP-121/76, HR-60, RR-15, O2-100%, temp-98.7o
Rate - 60Rhythm – RegularAxis – RADHypertrophy/Enlargement – RVH
P-Q-R Waves – married, no Q waves, large R wave in anterior leadsIntervals – short PR, QRS>0.12s, QT<1/2 R-RIschemia – T wave inversion in V1-3
Miscellaneous – delta wave
Patient #13• 61yo male who had a 30min history of chest pain
that has since resolved• Medications• Phenytoin 300mg daily, Celebrex 200mg daily
• Past Medical History• Epilepsy, Osteoarthritis
• Vitals• BP-129/79, HR-70, RR-15, O2-100%, temp-98.8o
Rate - 70Rhythm – RegularAxis – LADHypertrophy/Enlargement – none
P-Q-R Waves – married, no Q waves, good progressionIntervals – PR<0.2s, QRS<0.12s, borderline QTIschemia – Deep T wave inversion in V1-6
Miscellaneous – none
Patient #14• 31yo Asian-American male with an episode of
syncope• Medications• None
• Past Medical History• None
• Vitals• BP-119/72, HR-100, RR-14, O2-100%, temp-98.3o
Rate - 100Rhythm – RegularAxis – normalHypertrophy/Enlargement – ?LVH?
P-Q-R Waves – married, no Q waves, good progressionIntervals – PR<0.2s, QRS<0.12s, QT<1/2 R-RIschemia – STE in V1-2, STD in V4-6,
T wave inversion in V1-3Miscellaneous – none
Brugada SignCoved STE with T wave inversion
Patient #15• 63yo female with 30 minute history of chest pain
while accompanying her husband to the ED with a stroke
• Medications• HCTZ50mg daily, Lisinopril 10mg daily, Amytriptyline
75mg daily• Past Medical History• HTN, Fibromyalgia
• Vitals• BP-168/93, HR-84, RR-16, O2-100%, temp-98.4o
Rate - 82Rhythm – RegularAxis – LADHypertrophy/Enlargement – none
P-Q-R Waves – married, no Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – STE in V1-4
Miscellaneous – Hyperacute T waves
Websites to Bookmark• Life In The Fast Lane • http://lifeinthefastlane.com/
• Amal Mattu – UMD Emergency ECG • http://ekgumem.tumblr.com/
• Dr. Stephen W. Smith ECG Blog • http://hqmeded-ecg.blogspot.com
• Learn The Heart• http://www.learntheheart.com/
• EKG Library• http://www.ecglibrary.com/ecghome.html
• Dr. Frank Yanowitz ECG Learning Center• http://ecg.utah.edu/
Thank You For Your Time
Kristopher R. Maday, MS, PA-C, CNSCAssistant Professor, Academic Coordinator
Physician Assistant ProgramEmail: [email protected]
Twitter: @PA_Maday