12-Lead EKG Interpretation
10/22/201512-Lead EKG Interpretationjontardiff@aol.comJon Tardiff, BS, PA-COHSU Clinical Assistant ProfessorDisclosures: I work for Virginia GarciaMemorial Health Center,Beaverton, Oregon. And I am a medical editor for Jones & Bartlett Publishing.11 clinics: 39,000 patients from all over the World!Arabic, Somali, Mai Mai, Pashtu, Urdu, ASL, and more!1
10/22/2015Goals for today’s ECG Review: Determine Right vs Left bundle branch blocks Determine Axis Diagnose Acute MI Diagnose old MI Location of the infarct Other Acute Coronary Syndromes Life Threatening Syndromes“Ask questions!” 4Ready?What a 12-Lead EKG can help you do Diagnose ACS / AMI Interpret arrhythmias (computer Dx) Identify life-threatening syndromes (WPW,LGL, Long QT synd., Wellens synd., etc) Infer electrolyte imbalances Infer hypertrophy of any chamber Infer COPD, pericarditis, drug effects, andmore!2
10/22/2015For example:73 y.o. male with nausea, syncope7Acute Inferior MIST elevation8What rhythm?(look at V1 for P waves)3
10/22/2015Atrial flutter (w/septal MI?)The flutter waves are invisible in Lead IIanother example 11WPW with Atrial Fib124
10/22/2015WPW GraphicWolff-Parkinson-White synd. short PR wide QRS delta waveSame pt, converted to SR14Limitations of a 12-Lead ECG Truly useful only 40% of the timeEach ECG is only a 10 sec. snapshotSerial ECGs are necessary, especially for ACSOther labs help corroborate ECG findings(cardiac markers, Cx X-ray) Confounders must be ruled out (dissectinganeurysm, pericarditis, WPW, LBBB, digoxin,RVH)5
10/22/2015Confounder: Left Bundle Branch Block16Limitations of a 12-Lead ECG The ECG is occasionally wrong!Impending AMI with normal ECG!186
10/22/201513 hrs later — Acute Anterior MIElevated ST segments19Confounder: Wolff-Parkinson-White syndromePt is a 4 y.o. child w/ one episode of tachycardiaand shortness of breath.WPW mimicking MI (false Q waves in Lead II, III,AVF, V1, & V3). Also mimicking LBBB.“ECG Pearls” Lead II is the easiest lead to read / most intuitiveBut Lead V1 is our single best lead.Use Lead V3 for QT interval measurement“A Q in III is free.” (isolated Q in Lead III)Half of reading an ECG is knowingwhere the electrode is. The other 80% is: finding the P wave! 7
10/22/2015ECG Lead Placement&Electrophysiology Review22Einthoven’s TriangleLimb LeadsIIIIII (standardleads) -23 Leads I, II, IIIIIIIII248
10/22/2015Normal 12-Lead ECGThe first EKG machineca 1903Rapid Interpretation TipsDr. Willem Einthoven26Dr. Willem Einthoven Invented the electrocardiograph Discovered atrial fibrillation Won Nobel Prize for Medicine 19249
10/22/2015Conduction SystemIIRTPUQSA NodeAV NodeHis BundleBBsSPurkinjeFibers28Lead II upright in L IIP wave axisR upright in L IIR wave axisQ S29QRS Morphology in Lead IIII3010
10/22/2015IntervalsIIPRQRSQTPR Interval: 120 – 200 mSec (3 – 5 boxes)QRS width: 60 – 120 mSec (1½ – 3 boxes)QT/QTc interval: 400 mSec (10 boxes)31Heart Rate CalculationsTriplicate Method: 6-second300, 150, 100,75, 60, 50Quick, easy, sufficient :Count PQRSTin a 6second strip & multiply x 10Easy, & more accurate300 150 100 75 606 secondsHorizontal axis is time (mS); vertical axis is electrical energy 32(mV)Normal Sinus Rhythm6 seconds Whatis the heart rate?3311
10/22/2015EKG LeadsLimb (frontal plane) Leads IIIIIIaVRaVLaVF(standardleads)(augmented leads)34Normal 12-Lead ECG6 Frontal Plane Leads(limb leads)IIIIIILRF3612
10/22/2015AxisLeadsIIIIIIaVR*aVLaVF-37“Knowing where the electrode is”38EKG LeadsLimb (frontalplane) Leads IIIIIIaVRaVLaVF(standardleads)(augmented leads)Chest (precordial)Leads V1V2V3V4V5V6(anteriorleads)(lateralleads)3913
10/22/201540V Lead CutawayV Lead Progression14
10/22/2015Normal 12-Lead ECGLots of ways to read EKGs QRSs wide or narrow? Sinus rhythm or not? Regular or irregular? If not, is it atrial fibrillation? Fast or slow? BBB? P waves? MI?Symptoms: Syncope is bradycardia, heart blocks, or VT Rapid heart beat is AF, SVT, or VTStep-by-step method for reading a 12-Lead4515
10/22/2015Rapid Interpretation TipsRapid Interpretation Tips Identify the rhythm.If supraventricular*,If no LBBB,If present, Rule out other confounders: WPW, pericarditis, LVH,digoxin effect Identify location of infarct, and consider appropriatetreatments: MONA, PCI [or fibrinolytic], nitrateinfusion, heparin infusion, GP IIb, IIIa inhibitor, betablocker, clopidogrel, statin, etc.Supraventricular rhythms Sinus rhythmAtrial fibrillationJunctional rhythmPSVT / AVNRT (AV nodal re-entry tachycardia)Atrial tachycardiaAtrial flutterWandering atrial pacemakerMATNormal 12-Lead ECG16
10/22/2015Rapid Interpretation TipsRapid Interpretation Tips Identify the rhythm.If supraventricular,If no LBBB,If present, Rule out other confounders: WPW, pericarditis, LVH,digoxin effect Identify location of infarct, and consider appropriatetreatments: MONA, PCI [or fibrinolytic], nitrateinfusion, heparin infusion, GP IIb, IIIa inhibitor, betablocker, clopidogrel, statin, etc.The Problem with BundleBranch Blocks Desynchronized contraction of the ventriclesReduced cardiac outputWorsened heart failureLBBB confounds the EKG interpretationand makes it harder to find ACSBundle Branch Blocks(QRS 0.12 sec.)(right-sided lead)V1R’(left-sided lead)notchIrSRight BBB(V1, V2, MCL1:rsR’ pattern)Left BBB(L I, V5, V6:upright QRSwith a notch)5117
10/22/2015Bundle Branch Blocks:Two ur52RBBBV1 & V2LBBBV5 V6(& I, aVL)18
10/22/2015Practice: Bundle Branch Block55Which Bundle Branch is Blocked?1RBBBRight Bundle Branch Block (Lead V1)1RBBB19
10/22/2015Which Bundle Branch is Blocked?2LBBB 12-Lead2LeftBundleBranch BlockLBBB12-Lead(L I, V5, V6)Where is the Pathology?20
10/22/2015Right Bundle Branch BlockWhere is the Pathology?62Left Bundle Branch Block6321
10/22/2015Axis DeterminationWhy We Care About Axis DeviationsThe axis shifts towards hypertrophy& away from infarction65Axis DeviationHorizontal heart (0 ): obesity,3rd trimester pregnancy. AscitesVertical heart (90 ): slender buildLeft Axis Deviation: LBBB,Anterior MI, Inferior MI, Leftanterior hemiblock, LVHNormal axis -20 to 110 Right Axis Deviation: AnteriorMI, Lateral MI, RBBB, COPD,RVH, Left posterior hemiblockExtreme RAD: Ectopic rhythm(VT), massive MI 6622
10/22/2015How to calculate AxisEasiest: the computer does it for you!Easy: find the tallest R wave(if tallest is Lead II normal axis)Even easier: (if Lead II is upright normal axisFunnest: Thumbs up / Thumbs downCalculating Axis: Thumbs Up / Down MethodLead I —Your Left thumbLead aVF —Your Right thumb683Practice: AxisIF6923
10/22/2015Axis PracticeNormal Axis3IF704IF714Left Axis DeviationIF7224
10/22/20155735Right Axis Deviation7467525
10/22/20156Extreme Right Axis Deviation76New 12-Lead ECG FormataVLIIIaVF-aVRIII77New 12-Lead ECG FormatNewaVLIIIaVF-aVRIIIOld26
10/22/2015Rapid Interpretation TipsRapid Interpretation Tips Identify the rhythm.If supraventricular, Rule out left bundle branch block. If no LBBB, Check for: ST elevation, or ST depression with Twave inversion, and/or pathologic Q waves.If present, Rule out other confounders: WPW, pericarditis, LVH,digoxin effect Identify location of infarct, and consider appropriatetreatments: MONA, PCI [or fibrinolytic], nitrateinfusion, heparin infusion, GP IIb, IIIa inhibitor, betablocker, clopidogrel, statin, etc.ST elevation, ST depression, T wave inversion,pathologic Q wavesSTEMINormalIschemiaInjuryInfarction8127
10/22/2015Percutaneous Coronary InterventionRCA before and after stentingBefore stentingAfter stenting8428
10/22/2015STEMI: ECG Changes(normal)(w/onset cx pn)(20 minutes)( 1 hr)(1 hour)(1 week – years)A. Normal ECGB. Hyperacute T wave changes increased T wave amplitude andwidth; may also see ST elevationC. Marked ST elevation withhyperacute T wave changes(transmural injury)D. Pathologic Q waves, less STelevation, terminal T waveinversion (necrosis)E. Pathologic Q waves, T waveinversion (necrosis and fibrosis)F. Pathologic Q waves, loss of Rwaves (fibrosis)MI ECG PatternsWhy Pathologic Q Waves FormNormal qPathologic Q8729
10/22/2015STEMI — Typical Progression88Acute Inferior MIAcute Inferior MI#1Axis is shiftingleftward ST elevationQsQsSame Patient 2 hrs laterAcute Inferior MI #2New ST elevationWorsened ST elevationQsQs30
10/22/2015Same Patient 9 days laterAcute Inferior MI #3Permanent left axisdeviationBut NO anterior infarct (no Qs)Permanent Q waves(inferior wall scar)45% of MIsAcute Anterior MI Page40% of MIsAcute Inferior MI Page31
10/22/20151/3 of Inferior MIsAcute R Ventricle MI Page15% of MIsAcute Lateral MI PageAcute Posterior MI Page32
10/22/2015Practice: Infarct Location97Where is the Pathology?7Acute Anterior MIAcute Anterior MI(ST elevation in V1 - V4)7ST ElevationWhat is the R wave axis?33
10/22/2015Where is the Pathology?8Acute Inferior MIAcute Inferior MIAcuteInferiorMI(STelevation8in II, III, F)Where is the Pathology?9Acute Inferolateral MI34
10/22/20159Acute Inferolateral MIAcute Inferolateral MI(ST elevation in II, III, F, V5, V6)Note the axis has not shifted yet, because it is early in the AMI,and there are no loss of R waves yet.Where is the Pathology?Acute Inferior MI & Right Ventricle MI1010Acute Inferior & Right Ventricle MI35
10/22/2015Where is the MI?Large R wavesST Depression V1, V2, V3 Large R Waves Depressed STs11Normal V1 – V3Acute Posterior MILarge R wavesST Depression V1, V2, V3 Large R Waves Depressed STs11Normal V1 – V3Time for a Break!10836
10/22/2015EKG: Life-Threatening Syndromesjontardiff@aol.comJon Tardiff, BS, PA-C109Clinical Assistant ProfessorGoals of this session:Identify: WPW (Wolff-Parkinson-White) syndrome LGL (Lown-Ganong-Levine) syndrome Brugada syndrome Long QT syndrome Wellens syndrome110What a 12-Lead EKG can help you do Diagnose ACS / AMI Interpret arrhythmias Identify life-threatening syndromes (WPW,LGL, Long QT synd., Wellens’ synd., etc) Infer electrolyte imbalances Infer hypertrophy of any chamber Infer COPD, pericarditis, drug effects, andmore!37
10/22/2015Top 10 Causes of Death In USA 2,000,000 deaths / yearNot shown aredeaths due tomedical errors: 50,000 – 100,000 /year!** if you are 55 y.o., trauma is your most likely risk!Pacemaker Lead Reversal in aDual-Chamber Pacemakeryikes!Wolff-Parkinson-White SyndromeDrs. Wolff,Parkinson,and Whitec. 1930 Short PR Interval Wide QRS “Delta” wave in some leads Causes tachycardias Mimicks MI, BBB Pt is at-risk for sudden death (“R on T”; atrial fibrillation) Incidence may be 1/100038
10/22/2015WPW GraphicWolff-Parkinson-White syndrome(Bundleof Adensoine nNSRWPW patternDrs. Wolff, Parkinson, & WhiteDr. Louis Wolff Chief ofElectrocardiology CAD, unstable angina Vectorcardiology Concert violinistDr. Paul Dudley White The “Father of AmericanCardiology” Helped found the AHA Promoted low cholesteroldiet, normal body weight,normal BP, exercise,cardiac rehab Advocate for World PeaceSir John Parkinson, MD Founded modern British cardiology Pioneer in radiocardiology Beloved Teacher39
10/22/2015AF with WPW—rapidventricular VTrate!WPWmimicking Cardiovert, or AmiodaroneA-Fib with WPW degenerating to V-FibDefibrillate!Pad / Paddle PlacementSynchronized CardioversionFor: pacing defibrillation synchronized cardioversionFor conscious V-Tach, and SVT.Synchronized shock deliversenergy synchronized to the Rwave.However, for V-Fib andunconscious V-Tach, defibrillateinstead with unsynchronizedshock.40
10/22/2015Lown-Ganong-Levine syndrome A “Short PR Syndrome” Normal QRS (NOT wide) No “Delta” wave Must also have episodes of tachycardia in order to be calledLGL syndrome. (Otherwise it’s just a short PR interval.)Dr. LownDr. GanongDr. LevineLown-Ganong-Levinesyndrome Accessory pathway bypassesAV node—inserts into His bundle This shortens the PR interval But the QRS is normal (NOT wide) and there is No “Delta” wave May have reciprocating tachycardiasJames fibersShort PRDrs. Lown, Ganong, & LevineDr. Bernard Lown Developer of thedefibrillator Coronary Care Units Physicians for SocialResponsibility Nobel Peace Prize Single payer healthcare(Mass.) The Lown InstituteDr. William GanongDr. Samuel Levine Electrophysiologist Levine Grading Scale for Neuroendocrinologistheart murmurs (I/VI) Fluid, electrolytes, HTN “Levine Sign” for ACS Author: Review of Medical Coronary thrombosisPhysiology Pernicious anemia Diagnosed FDR with polio Always on call!41
10/22/2015LGL (48 y.o. F)LGL?Short PRBut QRS is narrow,and NO delta waveBrugada Syndrome(a “channelopathy”)Dr. Pedro Brugada Sodium channel defect(the QRS is a sodium event) RBBB on EKG, with STelevation in V1 - V3 SUDS (Sudden UnexplainedDeath Syndrome) 10% of these patients die / year ICD is life-savingBrugada SyndromeRQS The QRS is a sodium event42
10/22/2015AbsoluteRefractoryPeriodRelative RefractoryPeriod(vulnerable period)Polymorphic VTin patients with Brugada SyndromeR on T“R on T” (a PVC on the T wave) causes VT & sudden death“R on T” phenomenon(PVC on T wave: precipitating V-Tach)Torsades de Pointes“R on T” (polymorphic V-Tach)Ventricular Fibrillation43
10/22/2015Long QT SyndromeTorsades de pointes(polymorphic V-Tach) QTc Interval 450 ms( 470 ms ) (normal QTc is 400 ms) Several inherited forms, plus temporary, & iatrogenic causes Incidence may be 1/5000 A possible cause for SIDS Patient is at risk for sudden death from R on T, Torsades de Pointes Beta blockers are therapeutic, along with limiting physical activity Implanted cardioverter / defibrillator (ICD) is life-savingQT IntervalIILong QTRQTRQT should be ½ the R-R intervalQT/QTc interval: 400 mSec (10 boxes)Or: less than ½ the R-R interval131Long QT Syndrome(use Lead V3, or V4, or the longest QT interval on the 12-Lead)44
10/22/2015Dr. Lóng Qú Ti龙曲提医生 Obstetrician Secret Agent Supercop Author: Solving Conflict With DialogJackie Chan成龙先生 Martial artist Actor, Singer Producer, director 100 films Beloved father,husband Great philanthropist!Long QT SyndromeTorsades de pointes(polymorphic V-Tach) Patient is at risk for sudden death from R on T, polymorphic VT Implanted cardioverter / defibrillator (ICD) is life-saving45
10/22/2015ICD Shocking V-TachICD is lifesaving forpatients withLong QTsyndromeIatrogenic Long QTQuestion:What are the Top 3 causes of arrhythmias?The “Top 3” Causes of Arrhythmias:1. Medications2. Medications3. Medications13846
10/22/2015Meds that prolong the QT intervalHere they are!Albuterol ipiprazoleArsenic trioxideArtenimol ilineBortezomib139BosutinibMeds that prolong the QT interval140Meds that prolong the QT interval141EphedrineEpinephrine (Adrenaline)Eribulin olFoscarnetFurosemide quineHydroxyzineIbutilideIloperidoneImipramine conazole47
10/22/2015Meds that prolong the QT interval142KetoconazoleLapatinibLeuprolide (Leuprorelin)Levalbuterol MetaproterenolMethadoneMethamphetamine otinibNorepinephrine anzapineOndansetronOxytocinMeds that prolong the QT oxetinePasireotidePazopanibPentamidinePerflutren lipid aminePimozidePosaconazoleProcainamide (Oral off US uinidineQuinine Meds that prolong the QT ithromycinTerbutalineTetrabenazine (Orphan drug in emide xineVoriconazoleVorinostatZiprasidone159 medications!14448
10/22/2015Treatment for Long QT interval1. Reduce the medications that are causing it.2. Change the medications that are causing it.3. Stop the medications that are causing it!145Wellens’ SyndromeDr. Hein Wellens Small terminal inversion of the T wave in V1, V2, V3Wellens’ SyndromeDr. Hein Wellens Recent Hx of chest pain or anginalequivalents. The patient may be pain-free during theexam and while the ECG is beingacquired. Cardiac markers may be normal.49
10/22/2015Wellens’ Syndrome (a broader definition) Inverted T waves in V1, V2, V3. No loss of R waves, No Qs.Significance of Wellens’ SyndromeImminent catastrophe—Yikes!Significance of Wellens’ Syndrome 75% chance of massive anterior MI Proximal LAD lesion; (50% of LV) The patient should be referred toangiography quickly for PCI (or CABG)to prevent the MI. Stress test is fatal!50
10/22/201595% occlusion of the proximal LADPercutaneous Coronary InterventionArtery before stenting(red is lumen; yellow is obstruction)After stentingNote the much larger lumenThe Spectrum of Acute Coronary SyndromesHealthy CAD Angina Unstable Angina NSTEMI STEMIPatentartery 50% 70%No symptoms 70% or 100%(or vasospasm)Pain onPain at rest;exertion relieved by NTG 90%100%Shock /Death100%Constant pain51
10/22/2015Wrap it Up!Review!WPW: short PR wide QRS Delta waves tachycardias AF sudden deathLGL: short PR normal QRS NO Deltawaves tachycardiasBrugada: elevated STs in V1, V2, V3 RBBB pattern at risk for VT / VFLong QT: QTc 450 (470 ) ms at risk for R on T VT / VFWellens: terminal T wave inversion inV1, V2, V3 impending massive MICase report:44 y.o. male comedianc/o episodes of rapidheart beat. Comes toyour office for exam.52
10/22/201512What is the Syndrome?HIPPA note:this is notRichard Pryor’sactual ECG.12But he didhave WPW.WPWshort PRDelta wavesWide QRSWhat is the syndrome?30 y.o. male with episodes of rapid heart beat1353
10/22/2015LGL (short PR, normal QRS, no Delta wave)13short PRNarrow QRSs35 y.o. male c/o episodes of rapid heart beat.Father died @ 30 y.o., sudden death.Brugada Syndrome1414RBBB, Elevated STs54
10/22/2015What is the Syndrome?15(extra points for the arrhythmia!)15Long QT interval(Wenckebach) 2nd AV Block, Type IDr. Karel WenckebachWhat is the Syndrome?16Chest pains on and off x 2 weeks. But no pain right now.Quiz- Wellens’ syndrome55
10/22/2015Wellens’ Syndrome16Quiz- Wellens’ syndrometerminal T wave inversion in V1, V2, V3Case report:58 y.o. male c/o chest“tightness” and shortnessof breath x 20 minutes,which gradually subsided.Recurrent episodes overseveral months. Pt thoughtit was “acid reflux”, butfinally goes to ED. Pt isnoncompliant with statintherapy, & admits to poordiet. Family Hx cardiacdisease. Hx HTN. Meds:Plavix, ACE inhibitor.EKG follows. What treatment?HIPPA note:this is notBill Clinton’sactual ECG!Angiography reveals 90% occlusion in some coronary arteries.56
10/22/2015But he didhave CABG& becameadherent tohis meds Ischemia / Impending MIno loss of R waves yet but inverted T wavesTreatment: quadruple CABG (coronary artery bypass graft).Excellent outcome:Pt is active, healthy, hasimproved diet, is compliantwith meds.He inspired thousands ofAmericans to go to theirprovider for cardiacevaluations “The Bill Clinton Effect”The benefits of a heart transplant17157
10/22/2015That’s all, Folks!172jontardiff@aol.com58
Rapid Interpretation Tips The first EKG machine ca 1903 Dr. Willem Einthoven Dr. Willem Einthoven Invented the electrocardiograph Discover
PERFORMING AN EKG Last revised: November 2019 Reviewed by: Christina L. Lutz MSN, RN-BC MAC 5500 EKG Cart Procedure Concept: List available EKG orders, load your patient's order to the EKG cart, and transmit the EKG back to the EKG Management System. 1. Press Power 2. Press More (F6) 3. Press Main Menu (F2) 4. Press More (F6) 5. Press Ord Mgr .
(Cerner Powerchart users). CRITICAL STEPS in DOING EKGs in the Non-ED setting: 1. Place EKG Order in Cerner 2. Verify information is correct in EKG machine 3. Obtain EKG 4. Transfer EKG 5. Sign Off EKG Order in Cerner .
ALH891A1 EKG Technician Format: Self-Pace Online / eLearning Program Duration: 6 Months Course Contact Hours: 50 Cost: 1299.00 includes text/s and materials The EKG Technician Profession EKG technicians are in demand! EKG technicians work in physician's offices, hospitals, clinics, and other
all of the PRE-LAB sections, BEFORE coming to the lab. Pre-Lab - Question 1: What is electrocardiogram (EKG)? Plot EKG signal with at least 3 cycles (you can search online to see how EKG signal looks like). Example of possible solution: This is an example of EKG signal. Please find a different figure for your report.
the EKG. This primer will show you how the EKG is produced, what the normal EKG looks like and what some of the more common EKG abnormalities look like. Step 1: How does the heart generate electricity? Within the heart, certain cells are easily excitable.
Give each group 2 copies of the Unit 4 EKG hallenges Packet (merged challenge EKG content for EKGs 13-16), this allows learner groups to all review content and record their group's answers to the interpretation and questions for each EKG Allow 20 minutes for groups to complete the 4 challenges (give updates at 5min increments)
Give each group copies of the Unit 9 EKG hallenges Packet (merged challenge EKG content for EKGs ï ï- ï ò), this allows learner groups to all review content and record their group's answers to the interpretation and questions for each EKG Allow minutes for groups to complete the ð challenges (give updates at min increments)
Dubin, D. (1996). Rapid Interpretation of EKG’s. Tampa Florida: Cover Publishing Co. Evans, T. (1996). ECG Interpretation Cribsheets. 3rd ed. San Francisco, CA: Ring Mountain Press. Recommended Schedule for EKG Practicum: This schedule is given to be used as a guideline to the practicum. The order of the EKGs has been selected to build and .File Size: 971KB
