1. 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—maiese1@comcast.net

2. Rapid Interpretation of EKG’S Dale Dubin, MD (required reading before the lecture)

14. PRIORITIES?

16. 6 Step Approach 1 Rate and Rhythm • PR interval • QRS interval 4 Signs of MI • Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

17. 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

18. 6 Step Approach 1 Rate and Rhythm • PR interval • QRS interval 4 Signs of MI • Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

19. 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 Wolff-Parkinson- White [WPW] Syndrome • PR> 0.20 sec [including dropped beats] ? YES differential for prolonged PR

20. 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

21. 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]

22. 6 Step Approach 1 Rate and Rhythm • PR interval • QRS interval 4 Signs of MI • Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

23. 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]

24. 6 Step Approach 1 Rate and Rhythm • PR interval • QRS interval 4 Signs of MI • Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

25. 12-lead EKG Interpretation Six Step Approach 5) signs of hypertrophy[increased voltage of QRS complexes] • Right Ventricular Hypertrophy [RVH] • Left Ventricular Hypertrophy [LVH]

26. 6 Step Approach 1 Rate and Rhythm • PR interval • QRS interval 4 Signs of MI • Signs of Hypertrophy 6 ST/QT/ T wave abnormalities

27. 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 non-specific*with Hx and + enzymes could be consist with a subendocardial Non-Q wave MIForward

28. 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

29. 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

30. 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

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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

37. Rhythms • Normal • Abnormal: Arrhythmia Dysrhythmia

40. Supraventricular Dysrhythmias