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Intro To EKGs First Years

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13 views92 pages

Intro To EKGs First Years

Uploaded by

briannaking9
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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The Electrocardiogram

What is it?

Visual representation of cardiac electrical activity over time

Depolarization and repolarization of cardiac myocytes

Does NOT represent cardiac mechanical activity

A normal EKG does not guarantee a normal heart

A normal heart can have an abnormal EKG


Fun Facts

Body tissue conducts electricity – we are salty and wet

If surface electricity can make it to the heart (i.e. defibrillation), cardiac electricity
can make it to the surface

Current flowing towards a lead is represented by a positive (upward) wave

Current flowing away from a lead is represented by a negative (downward) wave


Important Tips

Correct lead placement is critical

Recognition of incorrect lead placement is critical

Variations in lead placement can result in changes that may be interpreted as abnormal
(for example, two EKGs several hours apart)

Automated interpretation is frequently incorrect even if authenticated by a physician

Always remember:
EKGs represent electrical activity only and have nothing to do with mechanical function
Where does the electrical activity come from?
Conduction System

Sinoatrial (SA) node 60 – 100 bpm

Atrioventricular (AV) node 40 – 60 bpm

Bundle of His

Left and right bundle branches 20 – 40 bpm

Purkinje fibers
Rate 60-100

Rate 40-60

Rate 20-40
EKG Paper
Converting Milliseconds to BPM

60,000 divided by milliseconds gives you BPM


60,000 / 1000 ms = 60 BPM

60,000 divided by BPM gives you milliseconds


60,000 / 60 BPM = 1000 ms
Method of Interpretation

Rate? Normal? Too slow? Too fast?


Regular or irregular? R wave to R wave
Are there P waves? Even if hidden
Is there a P wave for every Even if PR interval is different
QRS?
Even if PR interval is different
Is there a QRS for every P
wave? Can be P, QRS, or both

Is anything early or late? PR, QRS, QTc

Are intervals normal?


Normal Intervals

PR: beginning of P to beginning of R 120 – 200 ms

QRS: beginning of Q to end of S 80 – 120 ms

QT: beginning of Q to end of T ~ 460 ms

QTc: QT corrected for heart rate determined by formula


Sinus Rhythm


Rate 60 - 100

Normal PR interval

P wave for every QRS

QRS for every P wave

P – P intervals regular
Sinus Rhythm
Sinus Arrhythmia


Rate 60 - 100

Normal PR interval

P wave for every QRS

QRS for every P wave

P – P intervals slightly irregular
Sinus Arrhythmia
Sinus Bradycardia


Rate < 60

Normal PR interval

P wave for every QRS

QRS for every P wave

P – P intervals regular
Sinus Bradycardia

1480 ms
Sinus Tachycardia


Rate > 100

Gradual onset

Normal P wave morphology

Normal PR interval

P wave for every QRS

QRS for every P wave

QRS is narrow
440 ms
Tachybrady Syndrome
AV Node Blocks
AV Node Blocks

Sinus node is NOT the problem

therefore…

P wave morphology and P – P intervals will be normal


First Degree AV block


P waves are regular

PR interval is regular but > 200 ms

Everything else is normal, narrow QRS
380 ms 380 ms 380 ms 380 ms 380 ms 380 ms
Second Degree Type I (Wenckebach)

P waves are regular

PR progressively increases as conduction through AV node progressively slows

Eventual P wave without a QRS – P waves keep coming at regular rate regardless of
conduction through the AV node

Narrow QRS

Can be confused with complete heart block
180 ms 220 ms 260 ms

800 ms 800 ms 800 ms 800 ms


Second Degree Type II (Mobitz)
 P waves are regular
 PR interval is consistent
 Every QRS has a P wave
 Not every P wave has a QRS
 Everything else is normal
 AV conduction can vary – 2:1, 3:1, etc.
Third Degree AV Block
aka “Complete Heart Block”


P waves regular

QRS regular

No association between P and QRS

QRS is usually wide

Rate is usually very slow (~30)

Can be confused with Wenckebach
600 ms 600 ms 600 ms 600 ms 600 ms 600 ms 600 ms 600 ms 600 ms 600 ms

1440 ms 1440 ms 1440 ms 1440 ms


Abnormal Ventricular Conduction
Left Bundle Branch Block


Always pathologic and evidence of a
cardiomyopathy until proven otherwise

QRS > 120 ms

QRS negative in V1 and V2

Generally nondiagnostic for STEMI
> 120 ms
Right Bundle Branch Block

Can be benign

QRS > 120 ms

Upright R waves in V1 and V2

Will falsely prolong QTc

(need to “correct” the “corrected” QT)
Atrial Arrhythmias
Premature Atrial Complex (PAC)

P-P interval shorter than previous

Ectopic - change in P wave morphology

Narrow QRS
780 ms 480 ms
Atrial Fibrillation

 Always irregular
 No P waves
 Narrow QRS
 Usually fast in acute setting but can be rate
controlled with meds if known diagnosis
Atrial fibrillation is ALWAYS irregular

Irregular is NOT always atrial fibrillation


Atrial Flutter
 P waves regular
 P-P interval around 200 ms (300 bpm)
 QRS narrow
 QRS commonly irregular but can be regular
 AV conduction can vary – 2:1, 3:1, 4:1, etc.
200 ms
Atrial Tachycardia
 Ectopic - change in P wave morphology but consistent
 Usually trigger by a PAC
 Will commonly self terminate
 Can appear very regular
 May be indistinguishable from sinus tachycardia if
onset not witnessed
Multifocal Atrial Tachycardia
 Ectopic – similar to atrial tachycardia but multiple foci
so each P wave is different
 Commonly seen in COPD, lung disease
Ventricular Arrhythmias
Premature Ventricular Complex (PVC)

R-R interval shorter than previous

No P wave

Wide QRS

Can be monomorphic or polymorphic
Ventricular Tachycardia

Wide QRS

No P waves

Almost always fast

Can be monomorphic or polymorphic
Torsades dePointes

“Twisting of pointes”

No P waves

Almost always fast

Usually is self terminating but can persist

Treatment is Magnesium
Ventricular Fibrillation

No P waves

No organized QRS

Complete ventricular chaos

Always lethal

ALWAYS SHOCK WITHOUT HESITATION


Ventricular Escape

No P waves

Wide QRS

Always slow

Agonal – VT, VF, or asystole is imminent
Reentrant Arrhythmias
Reentrant Arrhythmias

SVT – very fast, no P waves, narrow QRS

AVRT

AVNRT

WPW – delta waves
The 12 Lead EKG
Normal 12 Lead
Normal 12 Lead
Normal Axis
Left Axis Deviation


Normal variant

Left ventricular hypertrophy

Ventricular arrhythmias

Mechanical change in heart position due to lung disease,
prior thoracic surgery, etc.
Right Axis Deviation


Normal variant

Right ventricular hypertrophy

Right bundle branch block

S1Q3T3 – suspect acute pulmonary embolus
STEMI

ST elevation myocardial infarction


STEMI

ST segment elevation in at least two contiguous leads

Treatment is the same regardless of region:
revascularization
I See All Leads
Inferior Septal Anterior Lateral
Inferior STEMI
Septal STEMI
Anterior STEMI
Lateral STEMI
Pericarditis

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