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12 Lead EKG Workshop Contemporary Management of Cardiovascular
Disease in Women
Emily H. Caldwell MSN ACNP Christina L. Craigo MSN ACNP
Los Angeles Cardiology Associates February 9, 2019
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Normal EKG
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Overview
• Heart Rate
• Rhythm
• Intervals
• Axis
• Voltage
• R Wave Progression
• Q Wave
• ST Segments
• T waves
• Device Involvement
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1 large box = 5mm = 0.2 sec
1 small box = 1mm = 0.04sec
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Heart 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
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Rhythm
• P:QRS relationship
– P:QRS =1
– P:QRS < 1
– No P waves (or many)
• Heart Rate
• RR regularity
• P wave morphology
• PR interval
• QRS width
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Intervals
• PR: 0.12-0.20 seconds
• QRS: < 0.10 seconds
– Distinguish between moderate prolongation 0.10-0.12 and marked prolongation 0.12 secs when establishing a differential diagnosis
• Only report QTc- corrects for heart rate
– Bazett’s Formula
• QTc: 0.35-0.43 seconds for heart rates of 60-100 BPM
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QRS Axis
• Represents the major
vector of ventricular
activation- overall
direction of the heart’s
activity
• Axis of –30 to +90
degrees is normal
• Consider the differential-
early clues- once axis is
identified
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QRS Voltage
• Measurement: from baseline to the peak of
the R wave or S wave
– Normal voltage
– Low voltage: Total QRS (R +S) < 5 mm in all
limb leads and < 10 mm in all precordial leads
– Increased voltage
• LVH
• RVH
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R Wave Progression
• Determine the precordial transition zone
(R/S = 1)
• Normal: transition zone = V2-V4
• Poor RWP: transition zone = V5-V6
• Early/Reverse RWP: Decreasing R wave
amplitude across the precordial leads
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Looking for Ischemia, Injury and
Infarct
• Q waves- pathologic or not?
• Changes must be identified in 2 or more
contiguous leads
• The specificity of ST-T wave abnormalities
is provided more by the clinical
circumstances in which the EKG changes
are found than by the particular changes
themselves!
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Normal EKG
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Heart Blocks on EKG
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Classification of AV Blocks
• First Degree
– PR interval fixed, >0.2 sec
• Second Degree
– Type I (Wenckebach/Mobitz I)
• PR gradually lengthened, then drop QRS
– Type II (Mobitz II)
• PR fixed, QRS drops randomly
• High degree AV Block
– Momentary absence of conduction for several seconds
• Third Degree, Complete Heart Block
– PR and QRS dissociated
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QRS duration
• Right Bundle Branch Block
• Left Bundle Branch Block
• If QRS duration is 120msec but waveform
is not typical of RBBB or LBBB, diagnosis
is intraventricular conduction delay
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Bundle Branch Blocks
• An obstruction in the transmission of
impulses through one of the branches, either
the left or the right, of the bundle of His
• A bundle branch block alone is not
significant and requires no treatment
– Understanding causes: MI, many types of heart
disease. Is it new?
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Bundle Branch Blocks-
When is it Significant?
• A bundle branch block complicated by a 1st,
2nd , or 3rd degree AV block or by a
fascicular block, especially when associated
with an acute MI
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Fascicular Blocks (Hemiblocks)
• A fascicle is a bundle of Purkinje fibers – any
main division of the ventricular conduction system
is a fascicle
• There are 3 fascicles in the ventricular conduction
system:
– the Right Bundle Branch
– the Anterior Division of the Left Bundle Branch
– the Posterior Division of the Left Bundle Branch.
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Right Bundle Branch Block
• QRS >/= 120 msec
• Secondary R wave (R’) in V1 and V2 (rsR’ or rSR’)
• Delayed onset of intrinsicoid deflection in V1 and V2
• Secondary ST and T wave changes in V1 and V2
• Wide slurred S wave in I, V5, V6
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LAFB- Left Anterior
Fascicular Block
• Left axis deviation
– With no other responsible factors to explain it
• qR complex (or an R wave) in leads I and
aVL
• rS complex in lead III
• Normal or slightly prolonged QRS duration
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LAFB
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LPFB- Left Posterior
Fascicular Block
• Right axis deviation
– With no other responsible factors to explain it
• Normal or slightly prolonged QRS duration
• rS complex in I and aVL
• Tall R wave II, III and aVF
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LPFB
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Left Bundle Branch Block
• Prolonged QRS duration >/= 120msec
• Delayed onset of intrinsicoid deflection in V5 and V6
• Broad monophasic R waves in I, V5 and V6 that are usually notched or slurred
• Secondary ST and T wave changes opposite in direction to the major QRS deflection
• rS or QS complex in right precordial leads
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LBBB
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Nonspecific intraventricular
conduction delay/disturbance
• QRS >/= 110msec but morphology does not meet
criteria for RBBB/LBBB
• Seen with:
– Antiarrhythmic drug toxicity (esp. IA and IC agents)
– Hyperkalemia
– LVH
– WPW
– Hypothermia
– Severe metabolic disturbances
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Where is the Block?
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75 year old man
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60 yo man with lightheadedness
A > V
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Trifascicular Block
• 1st Degree AV Block
• RBBB
• LAFB or LPFB
• Cardiology referral
– Is the prolonged PRi due to AV node disease or diffuse
distal conduction system disease? only an EP study can
differentiate
– Treatment = Pacemaker, especially if symptomatic
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EKG Pearls
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Typical Flutter
Negative P Waves
Positive P Waves
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Atrial Flutter
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98 yo female who has a hx of AF. Maintained
on digoxin. What is this rhythm?
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• PAT with block
• AF with CHB
• Bi-directional tachycardia
• 2nd or 3rd degree AV block with “dig effect”
• CHB with accelerated junctional or ventricular rhythm
Digoxin Toxicity
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Bi-directional VT
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• Always compare to the patient’s prior EKG
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ST Segment Elevation Patterns
• Hyperacute T wave – may occur as early as
2 mins post myocardial occlusion
• J Point Elevation
• Subtle ST elevation forming broad T wave
• If there is elevation in limb leads, I, II, III,
then worry
• If there is depression in the V leads, then
worry
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Lead Representation of the Heart
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Reciprocal Leads
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Reciprocal ST Depression
ST Elevation
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aVR Elevation
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Posterior MI Criteria
• ST depression in V1-V3
• Prominent R>S in V1-V3
• Upright T waves in V1-V3
• Often coexisting with inferior-lateral MI
• True posterior MI involves the left Cx
artery
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ST elevation P>R, ST
Depression
T wave inversion
Recip
St depression
Lateral MI ST Elevation
R>S, ST Depression, Upright T Waves
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Now compare with a normal
ECG
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Coronary Arteries Supply to the
Conduction System
• SA node: RCA (LCx)
• AV node: RCA (LCx)
• His Bundle: RCA
• Bundle Branches: LAD
• Bradyarrhythmias/conduction disturbances are well recognized complications of acute MI
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72 year old man with nausea and dyspnea
Mobitz Type I: Wenckebach
PR Prolongation
ST Elevation with Reciprocal Changes
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Conduction Disturbances and
Infarct Location • Inferior MI
– Sinus brady most common arrhythmia, but Mobitz I and CHB also seen
– High degree AV block located above the His
– Usually resolves
• Anterior MI – Mobitz II, BBB, CHB
– High degree AV block located below the AVN
– Ppm for pts at high risk for CHB (2 or more: PR prolongation, 2nd degree AVB, left ant or post fascicular block, LBBB, RBBB
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84 yo woman with syncope
ST Elevation
Mobitz II
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65 year old female with acute subarachnoid hemorrhage
T wave inversion in precordial leads
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51 yo female with pericardial effusion
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46 year old man with chest pain
Acute Pericarditis:
Diffuse ST elevation
PR depression
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16 year old female on treatment for palpitations
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NW Axis
Atypical RBBB
66 year old male with a hx CAD, prior MI/PCI, HTN presents with CP, lightheadedness and near syncope