EKG Review

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Carol Sadley, Med, PA-C

Ms. Sadley graduated from the UMDNJlRutgers University Physician Assistant Program in 1983, and spent her first years as a "house staff' PA in Drexel Hill, PA. She then spent 8 years developing, directing and facilitating 2 hospital-based Cardiopulmonary Rehabilitation programs in Central New Jersey. In 1993, she accepted a position as a faculty member at the UMDNJ PA Program where she now is an Associate professor. Among other responsibilities, she has taught the PA EKG Course since that time. She also maintains an adjunct faculty position at Rutgers University, where she ahs taught their "EKG Use and Interpretation" class for the past 6 yea$. In addition to teaching full-time, Carol maintains her clinical skills by working part-time at Pleasant Run Family Physicians as a Primary Care PA. Carol is a member of the AAPA, NJSSPA, and currently serves on the Board of the New Jersey PA For:ndation.

EKG REVIEW -L2LF'AD EKGS UMDNJ & CME Resources Seminar - June 15,2004
Steps to look

for in everv 12lead EKG:

Brady = < 60; Tachy = > 100.

1. 2. 3. 4. 5. 6.
7

Rate: 300, 150, 100; 75, 60,50,43;

Rhythm:

reglineg.?; p waves present?; QRS wide?; p:QRS relationship?

Axis: +inI&AVF=normal; +inI&neg. inAVF=LAD; neginl&+inAVF= RAD; neg. in I & AVF= extreme RAD. Axis deviation alone seen with Hemiblocks!
( t u.i' v**.to-) Bundle Branch Block: Wide QRS; RSR' in(V,,t)
Enlargement of atria: A-V Block: fi.rst " (PR>.Z);,second o (Wenckebach & Mobitz ); third o (complete hb).

- $, Notched/RSR'

in(Vyu)

L(noMI)

[, m, AVF: tall p - Right; Lead V, biphasic/neg. = Left.

Hypertrophy of ventricles: R: look for RAD

&

R in

Vl; L: big amplitude

of R &

8.

MI.Iniurv.Ischemia:

Q w11eslST-segment elevation; ST-seg. depression; T waves.

Diagnoses to suspect with abnormal EKG findines:

Acute

PE:

Tachycardia, RVH, RBBB, 51,Qrr ,T,,,pattern.

COPD: Low voltage throughout,

RAD, RAE, RVH.

Digitalis effect: STI(scooped)with flattening or inverted T waves; toxicity: blocks or arrhyts.

Hyperkalemia: Diffuse, peaked/tented T waves;

severe = sine wave Ts. appear.

Hypokalemia: Prolonged Q-T interval; flattened T waves; U waves may Hypercalcemia: Shortened Q-T interval. Hypocalcemia: Prolonged Q-T interval; beware Torsades
de pointes.

Hypothermia:

Bradycardia with all intervals prolonged and appearance of "Osborne wave". or LVH, LAD +/- diffuse Q waves; beware sudden cardiac death
and T wave flattening; (chronic) Diffuse T wave inversion

IHSS/IIOCM: normal

Pericarditis: (acute) Diffuse ST t

Quinidine/sotalol effect or toxicity: Prolonged Q-T: beware Torsades de pointes WPW (Wolff-Parkinson-White Syndrome): PR <.12, QRS > .10 with a delta wave. (Kent)

LGL (Lown-Ganong-Levine Syndrome): PR < .12 , normal QRS, no deltawave; James'fiber

Atrial enlargement: look in II and V1; common in pulmonary

disease, and

with stenotic valves

RAE = amplitude of first portion of p wave > 2.5 mm ([, il, AVF). LAE = amplitude and duration of terminal portion of p wave > I mm and/or block wide (V,).

1 small

Ventricular hypertrophy: common in longstanding hypertension, CHF

ttn

RVH = RAD with R > S in V,, while y5/6 +S in v1/2 r =1h. in

tt;t!"t[n

S > R. in Vu

(with RAD) in evr- 13 mm)o{R I + S Itr > 2s mnr)

Ventricular strain pattern: ST segment depression and T wave inversion in leads with tall waves; RVS in Yl/2; LVS in I, AVL, V5/6.

Infarction:

3 classic

changes:

T wave peaking, followed by T wave inversion ST segment elevation resolving to normal in I-2 days Qwave presence (transmural MI); remains indefi'nitely

[, [, AVF (RCA) Lateral wall MI: I, AVL, V5i6 (L.circ) Vl - V4 (LAD) poor R-wave progression Septal MI: V3-V5 Posterior wall MI: reciprocal changes in Vl (ST segmentJ, and tall R wave) (RCA)
Inferior wall MI: Anterior wall MI:
Non Q-wave

infarction:

T wave inversion and ST segment depression

Angina/Ischemia:

ST segments I and/or T wave inversion (during anginal episodes, usually normal at rest)

Prinzmetal's Angina: ST segments

(Commonly atypical presentation due to coronary

artery spasm) Bundle Branch

Block:

QRS > .10-.12 sec. (Wide QRS)

LBBB: RBBB:

lateral leads( Vr,); tall, broad, notched R wave with T wave inversion and ST segment .lr (Cannot accurately diagnose MI with this finding) RSR/ in V, and/or V, with ST segment l and T wave inversion

Important arrhvthmias to recosnize:

"Saw-tooth" flutter waves; rate frequently 150 with 2:1 block. - atrial flutter: - atrial fibrillation: Irregularly irregular; no p waves; narrow QRS - bigeminy (atrial/ventricular): Every other beat is a premature beat. (PAC/PVC) - pacemaker rhythm: atrial and/or ventricular complexes immediately preceded by pacer spike - pairs/couplets: Two premature atrial or ventricular beats in succession - run of v-tach: > 3 ventricular beats (Wide QRS) in succession - Torsades de Pointes: alternating v-tachy amplitudes - ventricular fibrillation: chaotic, wide, irregular rhythm; ominous! defibrillate immediately if patient has no pulse
(EKGRev.6/04)

UMDNJ & CME Resources Seminar - June t5r2004

Supraventricular Rhythms:
1.

Normal Sinus Rhythm: rate 60-100; identical p waves before every nalrow QRS.
Sinus Tachycardia: rate > 100; all complexes normal as above. Sinus Bradycardia: rate < 60; all complexes normal as above. Sinus Arrhythmia: all complexes normal but rhythmically irregular by >.16 sec. (often assoc. with breathing: expiration - heart slows, especially in children) Sinus Arrest: > 2 seconds in length; SA node ceases to function; usually followed by atrial, nodal, ventricular escape beat. It is termed Sinus Pause when it last 1-2 seconds.

2.

J. 4.

5.

6.

Wandering Atrial Pacemaker: rate < 100; impulses originate from varying foci in atria.

ct,ff

"rkx(

fv''1"t".'rlat cpFF,

7.

Multifocal Atrial Tachycardia: rate > 100; varied p waves

severe COPD)

as above; (often assoc.

with

8.

Paroxysmal Atrial Tachycardia: rate usuallv 150-250; sudden onseti when associated with "l{o\,.\.., \\e..*' urocr., suspect

aigiffiffi.

9.

r-r) c.rrt'O" \,*)nrrct ''supraventricular

Tachycardia: rate L50-250; atrial or junctional; narrow QRS . If nodal in origin, AKA: AV node reentry tachycardia (AVNRT)/circus rhythm.

10. 11.

12,

Atrial Flutter: flutter waves @ 250-350 with narrow QRS. (helpful to invert tracing). f\ls:t t.crrvrrivr rz.r\C = \SQ - Z: \ bivf.l'( Atrial Fibrillation: no discernible p waves; irregularly irregular rhythm; narrow QRS may be slow/<100/controlled, rapid/>10O/uncontrolled, or irregular ventricular response rate. 3so - [;i 7 nr\ C AXi,l \ Premature Atrial Beat/Contraction: early atrial beat with varied p wave; followed by a compensatory pause. (pair/couplet; run, atrial bigeminy, atrial trigeminy).
Junctional Rhythm: rate usually 40-60; narrow, regular QRS with/out p waves which may be inverted, normal, or retrograde.
Premature Junctional Beat/Contraction: early junctional beat; with narrow QRS; followed by a compensatory pause: (junctional bigeminy, trigeminy).

13.

14.

Ventricular Rhythms:

15. 16. T7. 18. 19. 20. 2I. 22. 23.

Idioventricular Rhythm: rate <40; no p waves; wide QRS; occurs as 'back-up' to absent sinus or AV impulse origination.
Accelerated Idioventricular Rhythm (AIVR): rate 40-1001120; short bursts after MI.

Ventricular Tachycardia: rate > 100/120; rapid, wide, bizarre QRS complexes. Ventricular Fibrillation: undeterminable rate; chaotic ventricular depolarization.
Premature Ventricular Contraction/PVC: early, wide bizarre beat; usually no p wave; followed by a compensatory pause. Z-pairlcouplet; 3=run of VT. Torsades de Pointes

: rate 250-3.50; bursts of varying/twisting vr/vF.

Other Arrhythmias:
Wolff-Parkinson-White Syndrome: abnormal AV conduction via Bundle of Kent (accessory fibers) resulting in shortened PR, delta wave, and narrow eRS. Lown-Ganons-Levine Syndrome: bypassed AV conduction via "James bundle/tract" resulting in absent PR interval (no delta wave) and often, fast ventricular response.
Paced rhythm: narrow, vertical spike/s on EKG stimulating atria, ventricles, or both.

AV Blocks:

24. 25.

First degree: consistently lengthened PR intervals >.2 (one large block).

Second degree: Mobitz type I or Wenckebach: a series of cardiac cycles with gradually lengthening PR intervals until one QRS complex is dropped. Alt QRSs are narrow. Mobitz type II: one or more p waves are blocked before conduction to the ventricles

occurs. This produces a2:1,3:r, or higher AV ratio. eRSs may be wide.

26.

Complete/Third degree: total block of conduction to the ventricles. There is no relationship between p waves and the QRS complexes; also, more ps than QRSs.

(EKGRhythmReview04)

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Rate: 120 Rhythm: ST

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Rate: 130 Rhythm: ST with artifact

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Rate:80 Rhythm: Sinus Anhythmia

7.
Rate:75 Rhythm: atrial flutter wl 4:l block

7
Rate:40 Rhythm: atrial flutter w ith variable block

Rate: 135 Rhythm: atrial

fibrillation

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:115 Rhythm: atrial fibrillation

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Rate: 95

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#1 A 58 y/o female presents c/o chest pain x 4 hourr

Axis:

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Prcctice EKG aqswers:

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#1: Rate: 90; Mythm: NSR; Axis: normal;

[:

acute inferior wall

MI (with reciprocal

changes).

#2: Rate: 120; Rhythm: ST; Axis: LAD; !4: LAE, LVH, Old IWMI, borderline lo A-V Block. #3: Rate: 63; Rhythm: NSR; Axis: LAD; Dx: LVH, LBBB