ekg boot camp - heart rhythm center · rate • rule of 300- divide 300 by the number of boxes...
TRANSCRIPT
![Page 1: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/1.jpg)
AvinashKhanna,MD,FACC,FSCAI
February 10, 2018
EKG Boot Camp
![Page 2: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/2.jpg)
Objectives
• TheBasics• Interpreta/on• ClinicalPearls• Prac/ceRecogni/on
![Page 3: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/3.jpg)
The Normal Conduction System
![Page 4: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/4.jpg)
11 Step Method for Reading EKG’s
“DataGathering”–steps1-4
• 1.Standardiza/on–makesurepaperandpaperspeedisstandardized• 2.HeartRate• 3.Intervals–PR,QT,QRSwidth• 4.Axis–normalvs.devia/on
![Page 5: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/5.jpg)
11 Step Method for Reading EKG’s
“Diagnoses”
– 5.Rhythm– 6.Atrioventricular(AV)BlockDisturbances– 7.BundleBranchBlockorHemiblock
– 8.Preexcita/onConduc/on– 9.EnlargementandHypertrophy– 10.CoronaryArteryDisease– 11.UWerConfusion
![Page 6: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/6.jpg)
Lead Placement
![Page 7: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/7.jpg)
Rate
• Ruleof300-Divide300bythenumberofboxesbetweeneachQRS=rate
Number of big boxes
Rate
1 300
2 150
3 100
4 75
5 60
6 50
![Page 8: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/8.jpg)
What is the heart rate?
(300 / 6) = 50 bpm
www.uptodate.com
![Page 9: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/9.jpg)
Normal Intervals
• PR-0.20sec(lessthanonelargebox)
• QRS-0.08–0.10sec(1-2smallboxes)
• QT-450msinmen,460msinwomen-Basedonsex/heartrate-HalftheR-RintervalwithnormalHR
![Page 10: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/10.jpg)
Prolonged QT
• Normal-Men450ms-Women460ms
• CorrectedQT(QTc)-QTm/√(R-R)
• Causes-Drugs(Nachannelblockers)-Hypocalcemia,hypomagnesemia,hypokalemia-Hypothermia-AMI-Congenital-IncreasedICP
![Page 11: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/11.jpg)
The QRS Axis
• Represents the overall direction of the heart’s activity
• Axis of –30 to +90 degrees is normal
![Page 12: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/12.jpg)
The Quadrant Approach
• QRSupinIandupinaVF=Normal
![Page 13: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/13.jpg)
What is the axis? • Normal-QRSupinIandaVF
![Page 14: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/14.jpg)
Rhythm
• Sinus- Origina/ngfromSAnode
- PwavebeforeeveryQRS
- Pwaveinsamedirec/onasQRS
![Page 15: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/15.jpg)
What is this rhythm? Normalsinusrhythm:
![Page 16: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/16.jpg)
Supraventricular Arrhythmias
• PSVT-regular;Pwavesretrogradeifvisible;rate150-250bpm;caro/dmassage:slowsorterminates
• FluWer–regular;saw-toothedpaWern;2:1,3:1,4:1,etc.block;atrialrate250-350bpm;ventricularrate½,⅓,¼,etc.ofatrialrate;caro/dmassage:increasesblock
• Fibrilla/on–irregular;undula/ngbaseline;atrialrate350to500bpm;variableventricularrate;caro/dmassage:mayslowventricularrate
• Mul/focalatrialtachycardia(MAT)–irregular;atleast3differentPwavemorphologies;rate–usually100to200bpm;some/mes
• <100bpm;caro/dmassage:noeffect
• PAT–regular;100to200bpm;characteris/cwarm-upperiodintheautoma/cform;caro/dmassage:noeffect,ormildslowing
![Page 17: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/17.jpg)
Supraventricular Arrhythmias
![Page 18: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/18.jpg)
Ventricular Arrhythmias
Torsades de Pointes
![Page 19: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/19.jpg)
Blocks AVblocks
– Firstdegreeblock- PRintervalfixedand>0.2sec
– Seconddegreeblock,Mobitztype1- PRgraduallylengthened,thendropQRS
– Seconddegreeblock,Mobitztype2- PRfixed,butdropQRSrandomly
– Type3block- PRandQRSdissociated
![Page 20: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/20.jpg)
What is this rhythm? FirstdegreeAVblock
PRisfixedandlongerthan0.2sec
![Page 21: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/21.jpg)
What is this rhythm?
Type1seconddegreeblock(Wenckebach)
![Page 22: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/22.jpg)
What is this rhythm? AV block
Dropped QRS
Type 2 second degree
![Page 23: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/23.jpg)
What is this rhythm?
3rddegreeheartblock(complete)
![Page 24: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/24.jpg)
Bundle Branch Blocks
RBBBcriteria:1.QRScomplex>0.12seconds2.RSR’inleadsV1andV2(rabbitears)withSTsegmentdepressionandTwaveinversion3.ReciprocalchangesinleadsV5,V6,I,andaVL
![Page 25: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/25.jpg)
LBBBcriteria:1.QRScomplex>0.12seconds
2.BroadornotchedRwavewithprolongedupstrokeinleadsV5,V6,I,andaVLwithSTsegmentdepressionandTwaveinversion.
3.ReciprocalchangesinleadsV1andV2.
4.Lemaxisdevia/onmaybepresent.
![Page 26: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/26.jpg)
Hemiblocks Diagnosedbylookingatrightorlemaxisdevia/on:
• Le#AnteriorHemiblock• 1.NormalQRSdura/onandnoSTsegmentorTwavechanges
• 2.Lemaxisdevia/ongreaterthan-30°• 3.Noothercauseoflemaxisdevia/onispresent
• Le#PosteriorHemiblock• 1.NormalQRSdura/onandnoSTsegmentorTwavechanges• 2.Rightaxisdevia/on
• 3.Noothercauseofrightaxisdevia/onispresent
![Page 27: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/27.jpg)
Bifascicular Block
• RBBBwithLAH- RBBB–QRS>0.12secandRSR’inV1andV2withLAH–lemaxisdevia/on
• RBBBwithLPH- RBBB–RS>0.12secandRSR’inV1andV2withLPH–rightaxisdevia/on
![Page 28: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/28.jpg)
Preexcitation
• Wolff-Parkinson-White(WPW)Syndrome- 1.PRinterval<0.12sec
- 2.WideQRScomplexes- 3.Deltawavesseeninsomeleads
• Lown-Ganong-Levine(LGL)Syndrome- 1.PRinterval<0.12sec- 2.NormalQRSwidth
- 3.Nodeltawave
![Page 29: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/29.jpg)
Preexcitation
WPW LGL
![Page 30: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/30.jpg)
Atrial Enlargement LookatPwavesinleadsIIandV1
• Rightatrialenlargement(Ppulmonale)• 1.Increasedamplitudein
firstpor/onofPwave• 2.Nochangeindura/onofPwave
• Lematrialenlargement(pmitrale)
• 1.Occasionally,increasedamplitudeofterminalpartofPwave
• 2.Moreconsistently,increasedPwavedura/on
![Page 31: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/31.jpg)
Ventricular Hypertrophy
LookattheQRScomplexesinallleads
• Rightventricularhypertrophy(RVH)- 1.RAD>100°- 2.Ra/oofRwaveamplitudetoSwaveamplitude>1inV1and<1inV6
• Lemventricularhypertrophy(LVH)PrecordialCriteria LimbLeadCriteriaRwaveinV5orV6+SwaveinV1orV2>35mm
RwaveinaVL>13mm
RwaveinV5>26mm RwaveinaVF>21mm
RwaveinV6>18mm RwaveinI>14mm
RwaveinV6>RwaveinV5 RwaveinI+SwaveinIII>25mm
![Page 32: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/32.jpg)
Myocardial Infarction
• Dx–Hx,PE,serialcardiacenzymes,serialEKG’s
• 3EKGstagesofacuteMI• 1.Twavepeaksandtheninverts• 2.STsegmentelevates• 3.Qwavesappear
![Page 33: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/33.jpg)
Q Waves
• CriteriaforsignificantQwaves- Qwave>0.04secondsindura/on- Qwavedepth>⅓heightofRwaveinsameQRScomplex
- QwavesarenormalinleadIIIandaVRduetheirrightwardorienta/on.
![Page 34: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/34.jpg)
Localizing MI on EKG • InferiorinfarcKon–leadsII,III,aVF
-Omencausedbyocclusionofrightcoronaryarteryoritsdescendingbranch-Reciprocalchangesinanteriorandlemlateralleads
• LateralinfarcKon–leadsI,aVL,V5,V6-Omencausedbyocclusionoflemcircumflexartery-Reciprocalchangesininferiorleads
• AnteriorinfarcKon–anyoftheprecordialleads(V1-V6)-Omencausedbyocclusionoflemanteriordescendingartery-Reciprocalchangesininferiorleads
• PosteriorinfarcKon–reciprocalchangesinleadV1(STsegmentdepression,tallRwave)-Omencausedbyocclusionofrightcoronaryartery
![Page 35: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/35.jpg)
Localizing MI on EKG
![Page 36: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/36.jpg)
![Page 37: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/37.jpg)
ST segment
• ElevaKon- Seenwithevolvinginfarc/on,Prinzmetal’sangina- Othercauses–Jpointeleva/on,apicalballooningsyndrome,acutepericardi/s,acutemyocardi/s,hyperkalemia,pulmonaryembolism,Brugadasyndrome,hypothermia
• Depression- Seenwithtypicalexer/onalangina,non-QwaveMI- Indicatorof+stresstest
![Page 38: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/38.jpg)
Electrolyte Abnormalities on EKG
• Hyperkalemia–peakedTwaves,prolongedPR,flaWenedPwaves,widenedQRS,mergingQRSwithTwavesintosinewave,AVblock,VF
• Hypokalemia–STdepression,flaWenedTwaves,Uwaves
• Hypocalcemia–prolongedQTinterval
• Hypercalcemia–shortenedQTinterval
![Page 39: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/39.jpg)
Drugs
• Digitalis- Therapeu/clevels–STsegmentandTwavechangesinleadswithtallRwaves
- Toxiclevels–tachyarrhythmiasandconduc/onblocks;PATwithblockismostcharacteris/c.
• Mul/pledrugsassociatedwithprolongedQTinterval,Uwaves- Sotalol,quinidine,procainamide,disopyramide,amiodarone,dofe/lide,dronedarone,TCA’s,erythromycin,quinolones,phenothiazines,variousan/fungals,somean/histamines,citalopram(onlyprolongedQTinterval–dose-dependent)
![Page 40: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/40.jpg)
Digitalis
Dubin, 4th ed. 1989
![Page 41: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/41.jpg)
EKG ∆’s in other Cardiac Conditions
• PericardiKs:DiffuseSTsegmenteleva/onsandTwaveinversions;largeeffusionmaycauselowvoltageandelectricalalternans(alteringQRSamplitudeoraxisandwanderingbaseline)
• MyocardiKs:conduc/onblocks
• HypertrophicCardiomyopathy:ventricularhypertrophy,lemaxisdevia/on,septalQwaves
![Page 42: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/42.jpg)
EKG ∆’s in Pulmonary Disorders
• COPD:lowvoltage,rightaxisdevia/on,andpoorRwaveprogression.
• Chroniccorpulmonale:Ppulmonalewithrightventricularhypertrophyandrepolariza/onabnormali/es
• Acutepulmonaryembolism:rightventricularhypertrophywithstrain,RBBB,andS1Q3T3(withTwaveinversion).Sinustachycardiaandatrialfibrilla/onarecommon.
![Page 43: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/43.jpg)
EKG ∆’s in Other Conditions
• Hypothermia:Osbornwaves,prolongedintervals,sinusbradycardia,slowatrialfibrilla/on,bewareofmuscletremorar/fact
• CNSDisease:diffuseTwaveinversionwithTwaveswideanddeep,Uwaves
![Page 44: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/44.jpg)
Utter Confusion
• Verifyleadplacement
• RepeatEKG• RepeatstandardizedprocessofEKGanalysis-star/ngover
fromthebeginningwithbasics–rate,intervals,axis,rhythm,etc.andproceedthroughen/restepwiseanalysis
![Page 45: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/45.jpg)
Case
• 45yomalepresentswithacuteSOBs/plongvaca/oninParis
• PMHx-asthma,Crohn’sdisease,anxiety,GERD,tobaccoabuse
• VS37,148/92,130,26• Pa/entappearsuncomfortablebutotherwise
unremarkableexam
![Page 46: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/46.jpg)
Case
AcutePEwithsinustachycardia,aPVC,andS1Q3T3paWern
![Page 47: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/47.jpg)
Case
• 27yofemalepresentstotheEDwithc/ochestdiscomfortandpalpita/onsamerstudyingallnightforgraduateschoolexams
• Appearsnervousand“uneasy”withrapidpulse• PMHx–unremarkable;nomeds,admitstooccasionalalcohol,non-smoker,deniesillicitdruguse,usedcoffeetostayawaketostudy
![Page 48: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/48.jpg)
Case
SVT:regular,narrow-QRStachycardia,rateof160bpm
![Page 49: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/49.jpg)
Case
• 46yomalepresentstoEDwithc/osevereHApersis/ngover5hoursdespiteacetaminophenandNSAIDaWemptsasabor/vetherapy
• PMHx:occasionallemshoulderpain,non-smoker
• Construc/onworker• VSS;unremarkableexam
![Page 50: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/50.jpg)
Normal ECG
![Page 51: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/51.jpg)
Case
• 28yomalepresentsforcommercialdriver’slicense(CDL)evalua/on
• Nocomplaints
• VSS;asymptoma/c;examwithoutsignificantfindings
![Page 52: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/52.jpg)
Case
• Diagnosis?EKGfindings?
![Page 53: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/53.jpg)
Case
• Typicalpreexcita/on(WPW)paWern
• ShortPRintervalanddeltawavesinmanyleads• Txiscloseobserva/onunlesspa/enthashadSVToratrialfibrilla/onwhichindicatestxwithabla/onofaccessorypathway
![Page 54: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/54.jpg)
Case
• 32yomalepresentstoEDwithc/ofeelingsickforthelast6days
• Symptomsincludefevers,cough,anddifficultycatchinghisbreath
• PMHx:hyperlipidemia,obesity,metabolicsyndrome
• VS38.1,105,128/84,22
![Page 55: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/55.jpg)
AcutepericardiKs:diffuseSTeleva/onwithPRsegmentdepressionisdiagnos/cDiagnosis?EKGfindings?
![Page 56: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/56.jpg)
Case
• 67yomalepresentstohiscardiologistforout-pa/ent6weekpost-hospitalvisit
• Previoushospitaliza/onfornon-cardiacchestpain
• Post-hospitalcardiacmeds:ACEinhibitor,betablocker,aspirin,nitrate
• Nocurrentcomplaints
![Page 57: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/57.jpg)
Case
• Atrialfibrilla/on:irregularlyirregularwithoutPwaves
• RBBB:wideQRSwithrsR’paWerninV1,broadSwavesinleadsIandaVL
• Inferiorinfarct:non-acute(>1week)pathologicQwavesininferiorleads(II,III,andaVF)
![Page 58: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/58.jpg)
Case
• 79yomalebroughttoEDviaEMSwithchestpain,SOB,andnear-syncope
• PMHx:unobtainablesecondarytopa/entdistress
• VS:36.9,140’s,82/40,28
![Page 59: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/59.jpg)
Case
Monomorphicsustainedventriculartachycardia(VT)–couldrapidlydeteriorateintoVF,torsadesdepointes,asystole,orsuddendeath.
![Page 60: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/60.jpg)
What is the diagnosis?
AcuteinferiorMIwithSTeleva/oninleadsII,III,aVF
![Page 61: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/61.jpg)
Junctional Rhythm
Rate 40-60, no p waves, narrow complex QRS
![Page 62: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/62.jpg)
Hyperkalemia
Tall, narrow and symmetric T waves
![Page 63: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/63.jpg)
Wellen’s Sign
ST elevation and biphasic T wave in V2 and V3 Sign of large proximal LAD lesion
![Page 64: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/64.jpg)
Brugada Syndrome
RBBB or incomplete RBBB in V1-V3 with convex ST elevation
Male39Years
![Page 65: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/65.jpg)
Brugada Syndrome
• Autosomaldominantgene/cmuta/onofsodiumchannels
• Causessyncope,v-fib,selftermina/ngVT,andsuddencardiacdeath
• CanbeintermiWentonEKG• Mostcommoninmiddle-agedmales• CanbeinducedinEPlab• NeedICD
![Page 66: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/66.jpg)
Second Degree Heart Block, Mobitz Type II
PR interval fixed, QRS dropped intermittently
![Page 67: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/67.jpg)
Hypokalemia
U waves: Can also see PVCs, ST depression, small T waves
![Page 68: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/68.jpg)
![Page 69: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/69.jpg)
![Page 70: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/70.jpg)
![Page 71: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/71.jpg)
Bonus Case
• 18yomaleundergoingmilitaryphysicalexamandevalua/onpriortobootcamp
• Nocomplaints
• PMHx–denies• VSS;examunremarkable
![Page 72: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/72.jpg)
Bonus Case
• Diagnosis?EKGfindings?
![Page 73: EKG Boot Camp - Heart Rhythm Center · Rate • Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50](https://reader030.vdocuments.us/reader030/viewer/2022041122/5f37a48fcba80777eb2b2b13/html5/thumbnails/73.jpg)
Bonus Case
• Reversedarmleads–invertedPwavesinleadIwithnormalRwaveprogressioninprecordialleads