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1
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2
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3
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- ALWAYS, ALWAYS, ALWAYS:
- 1. Rate
- 2. Rhythm (includes analysis of
intervals)
- 3. Axis
- 4. Hypertrophy
- 5. Ischemia, Injury, or Infarct
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4
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5
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6
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- Count the # of large boxes between 2
- successive R-waves:
- 1 box = 300 bpm
- 2 boxes = 150 bpm
- 3 boxes = 100 bpm
- 4 boxes = 75 bpm
- 5 boxes = 60 bpm
- 6 boxes = 50 bpm
- 7 boxes = 43 bpm
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7
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- Standard Way: Count the number of
QRS-complexes in a 3 second span (15 large boxes) and multiply by 20!
- Aryana’s Way: Count the number of
QRS-complexes in a 10 second span (the entire EKG) and multiply by 6!
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8
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9
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- Every QRS is preceded by a P-wave
- 2. Normal P-waves, must have:
- A. Normal Morphology:
- 1. P-wave duration < 0.12 sec (< 3
boxes)
- 2. P-wave height < 2.5 mm
- B. Normal Axis – upright P-wave in leads
II, III & aVF, and negative in aVR
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10
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- Sinus Tachycardia: Normal
P-waves, HR usually <150 bpm
- Proxysmal Atrial Tachycardia (PAT): P-waves are different from sinus (may
be inverted) or absent
- Atrial Flutter: Large
“saw-toothed” flutter-waves, +/– variable AV-block
- AV-Nodal Re-entrant Tachycardia (AVNRT):
Most common form of PSVT, +/– P-waves
- AV Re-entrant Tachycardia (AVRT):
A common form of PSVT, +/– P-waves, + accessory pathway
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11
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12
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- Atrial Fibrillation: No recognizable
P-waves
- Multifocal Atrial Tachycardia (MAT):
Three (3) consecutive P-waves with different morphologies,
usually associated with COPD
- 3. Any “regular” SVT with variable AV-block: Examples: PAT or a. flutter with variable
AV-block
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13
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14
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- 1. Ventricular Tachycardia (VT)
- a. Definition: ≥ 3 consecutive PVC’s
- b. If it last > 30 seconds = sustained
VT
- c. If stable, Rx: Amiodarone
- d. If unstable, always DC-cardiovert!
- 2. Torsades des Pointes (Polymorphic VT)
- a. Often preceded by a prolonged
QT interval
- b. Other etiology: Quinidine, Procainamide, or TCA
- c. Rx of choice: Magnesium Sulfate (MgSO4)
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15
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- Rhythm Rate (bpm)
- • Normal Sinus Rhythm 60 – 100
- • Idioventricular “Escape”
Rhythm 20 – 40
- • Junctional “Escape”
Rhythm 40 – 60
- • Accelerated Idioventricular
(AIVR) 40 – 120
- • Sinus Tachycardia (ST) 100 – 150
- • *SVT &
Ventricular Tach. (VT) 150 –
250
- • Atrial Flutter & Torsades
des Pointes 250 – 350
- • Atrial Fib. & Ventricular
Fib. 350 – 450
- * Excludes ST, atrial fibrillation & atrial
flutter
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16
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- P-wave < 0.110 sec (approximately 3 small boxes)
- PR interval = beginning of the P-wave to the
- beginning of QRS. Normal = 0.120
to 0.200 sec
- QRS interval = from the first deflection to return to the baseline. Normal < 0.120 sec
- 4. QT interval = beginning of the
QRS to the END of the T-wave. Normal
< 0.450 sec
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17
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18
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- First Degree AV-Block
- a) PR interval is prolonged (>
0.200 sec), but
- constant, beat to beat
- b) Generally considered a benign
conduction
- defect
- c) Rx: None
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19
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- a) Mobitz Type-I (Wenkebach)
- 1. Progressive PR interval prolongation with
- intermittently dropped QRS complexes
- 2. Rx: None
- b) Mobitz Type-II
- 1. PR intervals are constant
- 2. P-waves fail to conduct with
a fixed block
- (“dropped beats”)
- 3. Rx: Pacemaker!
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20
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- P-waves are unrelated to QRS complexes (complete AV-dissociation)
- b) Presence of TWO independent rhythms:
- an atrial (P-waves) & a ventricular (QRS)
- P-waves are regular & marching through!
- QRS complexes are regular
- e) On exam: S1 of variable intensity & large
cannon a-waves in the jugular venous pulse
- f) Rx: Pacemaker!
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21
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22
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- 1. RBBB:
- a) QRS duration > 0.120
seconds
- b) MARROW: “M” in V1 (+/– “W” in V6)
- 2. LBBB:
- a) QRS > .120 seconds
- b) WILLIAM: “M” in V6 (+/– “W” in V1)
- 3. Hemi-blocks:
- a) Left Anterior: LAD; nothing else to explain it
- b) Left Posterior: RAD; nothing else to explain it
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23
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24
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- Always look at leads I and aVF:
- If both I & aVF are positive
= Normal axis
- If I is positive but aVF is negative
= LAD
- If I is negative but aVF is positive
= RAD
- If both I & aVF are negative
= Northwest
- Axis or “No Man’s Land”
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25
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26
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27
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28
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29
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- * ST segment = from the end of
the QRS to the beginning of the T-wave
- ST depression & T-wave inversion are consistent with myocardial ischemia
- ST elevation is consistent with myocardial injury
- Q-waves are consistent with myocardial infarct
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30
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31
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32
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- Hyperkalemia – Tall peaked T-waves
- Acute Pericarditis:
- CP relieved by sitting up or leaning forward
- On exam, could hear a pericardial friction rub
- Usually, you see diffuse ST segment elevations along with PR segment
depressions
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33
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Notes