EKG Review

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Carol Sadley, Med, PA-C

Ms. Sadley graduated from the UMDNJlRutgers University PhysicianAssistant Program in 1983, and spent her first years as a "house staff' PA inDrexel Hill, PA. She then spent 8 years developing, directing andfacilitating 2 hospital-based Cardiopulmonary Rehabilitation programs inCentral New Jersey. In 1993, she accepted a position as a faculty member atthe UMDNJ PA Program where she now is an Associate professor. Amongother responsibilities, she has taught the PA EKG Course since that time.She also maintains an adjunct faculty position at Rutgers University, whereshe ahs taught their "EKG Use and Interpretation" class for the past 6 yea$.

In addition to teaching full-time, Carol maintains her clinical skills byworking 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 Boardof the New Jersey PA For:ndation.

EKG REVIEW -L2LF'AD EKGSUMDNJ & CME Resources Seminar - June 15,2004

Steps to look for in everv 12lead EKG:

1. Rate: 300, 150, 100; 75, 60,50,43; Brady = < 60; Tachy = > 100.

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

3. Axis: +inI&AVF=normal; +inI&neg. inAVF=LAD; neginl&+inAVF=RAD; neg. in I & AVF= extreme RAD. Axis deviation alone seen with Hemiblocks!

4. A-V Block: fi.rst " (PR>.Z);,second o (Wenckebach & Mobitz ); third o (complete hb).( t u.i' v**.to-)

5. Bundle Branch Block: Wide QRS; RSR' in(V,,t) - $, Notched/RSR' in(Vyu) - L(noMI)

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

7 . Hypertrophy of ventricles: R: look for RAD & R in Vl; L: big amplitude of R & S

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.

Hypokalemia: Prolonged Q-T interval; flattened T waves; U waves may appear.

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".

IHSS/IIOCM: normal or LVH, LAD +/- diffuse Q waves; beware sudden cardiac death

Pericarditis: (acute) Diffuse ST t and T wave flattening; (chronic) Diffuse T wave inversion

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 1 small

block wide (V,).

Ventricular hypertrophy: common in longstanding hypertension, CHF

RVH = RAD with R > S in V,, while S > R. in Vu (with RAD)ttn =1h. in y5/6 +S in v1/2 r tt;t!"t[n in evr- t 13 mm)o{R I + S Itr > 2s mnr)

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

Infarction: 3 classic changes: T wave peaking, followed by T wave inversionST segment elevation resolving to normal in I-2 days

Qwave presence (transmural MI); remains indefi'nitely

Inferior wall MI: [, [, AVF (RCA) Lateral wall MI: I, AVL, V5i6 (L.circ)Anterior wall MI: Vl - V4 (LAD) poor R-wave progression Septal MI: V3-V5Posterior wall MI: reciprocal changes in Vl (ST segmentJ, and tall R wave) (RCA)Non Q-wave infarction: T wave inversion and ST segment depression

Angina/Ischemia: ST segments I and/or T wave inversion (during anginal episodes, usuallynormal at rest)

Prinzmetal's Angina: ST segments t (Commonly atypical presentation due to coronaryartery spasm)

Bundle Branch Block: QRS > .10-.12 sec. (Wide QRS)

LBBB: lateral leads( Vr,); tall, broad, notched R wave with T wave inversion and

ST segment .lr (Cannot accurately diagnose MI with this finding)RBBB: RSR/ in V, and/or V, with ST segment l and T wave inversion

Important arrhvthmias to recosnize:

- atrial flutter: "Saw-tooth" flutter waves; rate frequently 150 with 2:1 block.- 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:

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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 byatrial, nodal, ventricular escape beat. It is termed Sinus Pause when it last 1-2 seconds.

Wandering Atrial Pacemaker: rate < 100; impulses originate from varying foci in atria.G ct,ff "rkx( fv''1"t".'rlat cpFF,Multifocal Atrial Tachycardia: rate > 100; varied p waves as above; (often assoc. withsevere COPD)

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

r-r) c.rrt'O" \,*)nrrct''supraventricular Tachycardia: rate L50-250; atrial or junctional; narrow QRS . If nodal inorigin, AKA: AV node reentry tachycardia (AVNRT)/circus rhythm.

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 maybe 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 acompensatory pause. (pair/couplet; run, atrial bigeminy, atrial trigeminy).

Junctional Rhythm: rate usually 40-60; narrow, regular QRS with/out p waves which maybe inverted, normal, or retrograde.

Premature Junctional Beat/Contraction: early junctional beat; with narrow QRS; followedby a compensatory pause: (junctional bigeminy, trigeminy).

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Ventricular Rhythms:

15. Idioventricular Rhythm: rate <40; no p waves; wide QRS; occurs as 'back-up' to absentsinus or AV impulse origination.

16. Accelerated Idioventricular Rhythm (AIVR): rate 40-1001120; short bursts after MI.

T7. Ventricular Tachycardia: rate > 100/120; rapid, wide, bizarre QRS complexes.

18. Ventricular Fibrillation: undeterminable rate; chaotic ventricular depolarization.

19. Premature Ventricular Contraction/PVC: early, wide bizarre beat; usually no p wave;followed by a compensatory pause. Z-pairlcouplet; 3=run of VT.

20. Torsades de Pointes : rate 250-3.50; bursts of varying/twisting vr/vF.

Other Arrhythmias:

2I. Wolff-Parkinson-White Syndrome: abnormal AV conduction via Bundle of Kent(accessory fibers) resulting in shortened PR, delta wave, and narrow eRS.

22. Lown-Ganons-Levine Syndrome: bypassed AV conduction via "James bundle/tract"resulting in absent PR interval (no delta wave) and often, fast ventricular response.

23. Paced rhythm: narrow, vertical spike/s on EKG stimulating atria, ventricles, or both.

AV Blocks:

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

25. Second degree: Mobitz type I or Wenckebach: a series of cardiac cycles with graduallylengthening 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 ventriclesoccurs. 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 norelationship between p waves and the QRS complexes; also, more ps than QRSs.

(EKGRhythmReview04)

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))Prcctice EKG aqswers:

#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