Basic EKG and Rhythm      Interpretation William M. Vosik M.D.Milot, Haiti – January 8-12, 2012
Objectives:1. Describe the basic conduction system   within the heart2. Learn basic rhythm strip analysis3. Learn basic EK...
Course Outline• Part 1  – Basic ECG and Arrythmias• Part 2  – “Heart block” and Pacemakers• Part 3  – Ischemia, Injury and...
Conduction System of the Heart• Sinoatrial node (SA node): a small group of cells  that function as the natural pacemaker ...
Conduction System of the Heart• Bundle of His: short bundle of nerve fibers at the  bottom of the AV node, leading to the ...
Conduction System of the Heart1. Impulse originates in SA node and spreads   through both atria simultaneously2. Impulse i...
Conduction System of the HeartRight atrium         Left atrium                               Left ventricleRight ventricle
What am I looking for?• 1. What is the rate? (fast, slow or normal)• 2. What is the rhythm? (regular or  irregular)• 3. Is...
Rhythm Strips• Focus only on the rate and rhythm• Evaluate each strip for:   – Heart rate   – Rhythm: regular/irregular   ...
EKG (electrocardiogram)A picture of the electrical conduction through the heart• P wave (atrial depolarization)• QRS compl...
Intervals• PR Interval: AV conduction  time; the time for impulse to  travel SA node atria AV  node ventricles    – Measur...
Intervals•    ST segment: early    repolarization phase; should be    at baseline; elevation or    depression indicates   ...
Rate• How fast the heart is going  – How many times the heart beats in 1 minute    (bpm)  – A “beat” is a ventricular cont...
Rate• ON RHYTHM STRIP:  – If paper speed is 25 mm/sec (standard), the    vertical lines at top edge of paper represent 3  ...
Rate• ON RHYTHM STRIP: – Count the number of QRS complexes in a 6   second strip and multiply by 10
Rate• ON EKG:  – Measured between two    consecutive QRS waves    (R-R interval)                                 300 150 1...
Rhythm• Regular: equal distance between R waves• Irregular: varying distances between R waves  – Regularly irregular: R wa...
Arrhythmias…       What you need to know:1. Normal or Abnormal?2. Name the Arrhythmia3. Treat the Patient with the Arrhyth...
Basic Rhythms and Arrhythmias•   Normal Sinus Rhythm   • Supraventricular•   Sinus Tachycardia       Tachycardia (SVT)•   ...
Normal Sinus Rhythm•   Rate: 60-100 bpm•   Rhythm: regular•   P -> QRS -> T•   Intervals: All normal
Sinus Tachycardia•   Rate: >100 bpm•   Rhythm: regular•   P -> QRS -> T•   Intervals: All normal
Sinus Tachycardia
Sinus Bradycardia•   Rate: <60 bpm•   Rhythm: Regular•   P -> QRS -> T•   Intervals: All normal
Sinus Bradycardia
Sinus Arrhythmia•   Rate: Any rate, but usually 60-100 bpm•   Rhythm: irregular•   P -> QRS -> T•   Intervals: All normal
Sinus Arrhythmia
Sinus Pause/Arrest• A period of time where there is no heart beat (flat line)   – Somewhat interchangeable, but technicall...
Ectopy• Premature atrial contractions (PACs)  – Irritable focus in atria fires before next sinus    impulse is due  – A co...
Ectopy• Premature ventricular contractions (PVCs)   – Early beat followed by compensatory pause   – Rhythm: Irregular beca...
PVCs
More Advanced Arrhythmias•   Supraventricular Tachycardia (SVT)•   Atrial Fibrillation (AF)•   Atrial Flutter•   Torsades ...
Supraventricular Tachycardia              (SVT)• Narrow QRS tachycardia that originates  above the ventricles; exact mecha...
SVT
Atrial Fibrillation (A-fib, AF)• Rate: Atrial rate so fast it can’t be counted  Rhythm: Irregularly irregular (chaotic)• P...
Atrial Fibrillation (A Fib, AF)
Atrial Fibrillation (A-fib, AF)
Atrial Flutter• Rate: Atrial rate usually 300 bpm (250-350)• 4:1 (V rate: 75 bpm), 3:1 (100 bpm), 2:1 (150 bpm), 1:1  (300...
Atrial Flutter
Atrial Flutter
Multifocal Atrial Tachycardia                  (MAT)• Regularity      No• Rate            Approximately 150’s• P waves    ...
MAT
Ventricular Tachycardia (V Tach, VT)• Ectopic focus in ventricle• Rate: 140 – 250, may start at lower rate• Rhythm: usuall...
Ventricular Tachycardia (V        Tach, VT)
Idioventricular Rhythm  Regularity   Yes  Rate         20-40 bpm  P waves      none  QRS          WIDE
Ventricular TachycardiaRegularity      YesRate            > 100 bpmP waves         Can’t always see themQRS             Wide
Torsades de Pointes Multifocal Ventricular Tachycardia
Ventricular Fibrillation (V Fib, VF)• Chaotic electrical activity in ventricles resulting in  the ventricles quivering; To...
Ventricular Fibrillation (V Fib, VF)
In Summary….1. Is it fast or slow?2. Is it regular or irregular?2.3. Is there a P wave before every QRS complex?
Part 2 – Heart Blocks
Heart Blocks• A blockage at any level of the electrical  conduction system of the heart• 1st degree heart block• 2nd degre...
1st degree heart block• AV node conducts the electrical activity  more slowly than normal• PR interval > 200 ms.• Often se...
2nd Degree Heart Block• Disturbance, delay, or interruption of atrial  impulse conduction to the ventricles  through the a...
2nd Degree Heart Block• Type II (Mobitz II)  – an unexpected nonconducted atrial    impulse, without prior measurable    l...
3rd Degree Heart Block• “Complete” heart block• Complete separation of atria from ventricles• The P waves with a regular P...
Moving on to bundle branch blocks • A reminder of the conduction system…
Bundle Branch Blocks• A condition in which theres a delay or  obstruction along the pathway that  electrical impulses trav...
Bundle Branch Blocks• Wide QRS complex (>= 120 ms)• Left bundle branch block (LBBB): wide,  purely positive QRS deflection...
A bit about devices…• Pacemakers- Used to treat  bradyarrhythmias• Pacemakers have two functions: pace or  sense• If pacin...
Paced Rhythms  Chamber         Chamber        Response to   Paced           Sensed         SensingA = Atrium      A = Atri...
What Type of Pacemaker Is It?
Part 3 – Ischemia, Injury or Infarct
Coronary Athrosclerosis
Ischemia, Injury or Infarct• Ischemia- diminished blood flow to the heart muscle       • ST segment depression and/or T-wa...
Time Passing
Ischemia
12 Lead EKG Practice
ST elevation with AMI• Look for ST elevation >  1mm in two or more  anatomically contiguous  leads
Coronary Circulation:                                 Left                                 Main                           ...
Leads tell location:• Septal  – V1-V2• Anterior  – V3-V4• Inferior  – II, III, AVF• Lateral  – I, AVL, V5-V6
Localization of an MI:
Inferior MI with reciprocal changes in lateral leads
12 Lead EKG Practice
12 Lead EKG Practice
12 Lead EKG Practice
Pericarditis:• Patients present with s/s of MI• Sharp, pleuritic, and POSITIONAL-  relieved by leaning forward• Often acco...
Cases….• A 59 year-old female patient is sitting in  the lobby when she begins to feel her  heart race. You get her back t...
• What is the rhythm?
• A 73 year-old male diabetic patient is in  the lobby waiting to see his internist. He  clutches his chest and slumps ont...
• What is the rhythm?• What do you do next?
• You now see this on the monitor…..• What is the rhythm?• What else to you see?• What do you do next?
• What do you see?• What do you do next?
• A 32 year-old male patient comes into the  clinic complaining of his heart racing. He  has just come up from the Wellnes...
• What is the rhythm?
• A 65 year-old male patient comes into the  clinic to be evaluated for a syncopal  episode. He admits to frequent episode...
• What do you see?• What is the underlying rhythm?
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation
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Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation

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Basic EKG and Rhythm Interpretation Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.

CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.

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  • Is it possible to get a copy of these slides? I'd love to help my young nurses better understand EKG's and this presentation is very good. My email is arynearson@mahaskahealth.org
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  • Write this down- not in your handout
  • Usually doesn’t need treatment;Can be caused by drugs such as CCBs and BBs;Also seen with acute myositis, AMI, and electrolyte disturbances
  • the impulse generated in the SA node in the atrium does not propagate to the ventricles; Because the impulse is blocked, an accessory pacemaker in the lower chambers will typically activate the ventricles.Often significantlybradycardic
  • You will often find P waves buried within QRS or T wave complexes
  • Because it is an prolongation of the ventricular depolarization, the QRS is wide (takes longer for the impulse to go through both ventricles)LEFT: activation of the left ventricle is delayed, which results in the left ventricle contracting later than the right ventricle.
  • Extreme sinus bradycardia, sinus arrest/pauses &gt;2.0 s duration, chronotropic incompetence, heart blocks, tachybrady syndrome (sick sinus syndrome)
  • Atrial fibrillation
  • Ventricular tachycardiaAttach the AED and shock the patient! Get HELP!
  • Sinus rhythmST elevationGet a 12-lead and HELP!
  • Acute MI! Tombstoning!GET HELP! (aka a cardiologist!)
  • How is this different from the atrial fibrillation rhythm we just saw? REGULAR!!!
  • Sinus arrest13 big boxes x .20 seconds = 2.6 second pause!(Much greater than 2.0 seconds and you’re at risk for passing out)
  • Basic EKG and Rhythm Interpretation Symposia - The CRUDEM Foundation

    1. 1. Basic EKG and Rhythm Interpretation William M. Vosik M.D.Milot, Haiti – January 8-12, 2012
    2. 2. Objectives:1. Describe the basic conduction system within the heart2. Learn basic rhythm strip analysis3. Learn basic EKG morphology4. Be able to recognize normal and abnormal rhythms and EKGs
    3. 3. Course Outline• Part 1 – Basic ECG and Arrythmias• Part 2 – “Heart block” and Pacemakers• Part 3 – Ischemia, Injury and Infract
    4. 4. Conduction System of the Heart• Sinoatrial node (SA node): a small group of cells that function as the natural pacemaker of the heart (at 60-100 bpm)• Atrioventricular node (AV node): a small group of cells that: – Slows the conduction impulse from atria to ventricles to allow for ventricular filling – Functions as the backup pacemaker if SA node fails (40-60 bpm) – Screens rapid atrial impulses to protect the ventricles from dangerously fast rates
    5. 5. Conduction System of the Heart• Bundle of His: short bundle of nerve fibers at the bottom of the AV node, leading to the bundle branches• Bundle branches: bundles of nerve fibers located along the septum that carry the impulse into the right and left ventricles – Right bundle branch: travels along the right side of the septum and carries impulse to the RV – Left bundle branch: travels along the left side of the septum and carries impulse to the LV• Purkinje Fibers: hair-like fibers that spread across endocardial surface of both ventricles and rapidly carry impulse to the ventricular muscle cells
    6. 6. Conduction System of the Heart1. Impulse originates in SA node and spreads through both atria simultaneously2. Impulse is delayed in AV node so atria have time to contract and contribute to ventricular filling before ventricles contract3. Impulse travels through Bundle of His, down both bundle branches into the ventricles and through the Purkinje fibers to the ventricular myocardium
    7. 7. Conduction System of the HeartRight atrium Left atrium Left ventricleRight ventricle
    8. 8. What am I looking for?• 1. What is the rate? (fast, slow or normal)• 2. What is the rhythm? (regular or irregular)• 3. Is there a P wave before every QRS complex? (is it sinus rhythm or not)• 4. Is the QRS complex wide or narrow?
    9. 9. Rhythm Strips• Focus only on the rate and rhythm• Evaluate each strip for: – Heart rate – Rhythm: regular/irregular – Location and morphology of P waves – QRS status• *Cannot diagnose acute MI on rhythm strip!
    10. 10. EKG (electrocardiogram)A picture of the electrical conduction through the heart• P wave (atrial depolarization)• QRS complex (ventricular depolarization) – Q wave: first negative deflection from baseline – R wave: positive deflection from baselinie – S wave: negative deflection following an R wave• T wave (ventricular repolarization)
    11. 11. Intervals• PR Interval: AV conduction time; the time for impulse to travel SA node atria AV node ventricles – Measured from beginning of P wave to beginning of QRS. – Normal= 120-200 ms (0.12- 0.20 sec ) – >200 ms: AV block• QRS Duration: time for conduction to travel through LV and RV – Measured from beginning to end of QRS complex (QRS width) – Normal= < 120 ms (0.12 sec)
    12. 12. Intervals• ST segment: early repolarization phase; should be at baseline; elevation or depression indicates injury, ischemia or infarct – From end of S wave to beginning of T wave – More to come on this later…• QT Interval: the time for both ventricular depolarization and repolarization – Dependent upon rate
    13. 13. Rate• How fast the heart is going – How many times the heart beats in 1 minute (bpm) – A “beat” is a ventricular contraction or a QRS complex.• Only reliable if rhythm is regular; if irregular then rate is just an estimation
    14. 14. Rate• ON RHYTHM STRIP: – If paper speed is 25 mm/sec (standard), the vertical lines at top edge of paper represent 3 second intervals – 1 small box = 0.04 sec – There are 5 small boxes within each large box – 1 large box = 0.20 sec
    15. 15. Rate• ON RHYTHM STRIP: – Count the number of QRS complexes in a 6 second strip and multiply by 10
    16. 16. Rate• ON EKG: – Measured between two consecutive QRS waves (R-R interval) 300 150 100 75 60 – Rule of 300’s: • Count the # of large boxes between R waves and divide into 300 • Find an R wave on a dark line. The first big box would be 300, the second 150, 100, 75, 60 bpm.* *This applies only to EKGs printed at 25 mm/sec (standard)
    17. 17. Rhythm• Regular: equal distance between R waves• Irregular: varying distances between R waves – Regularly irregular: R waves occur in a pattern – Irregularly irregular: totally irregular without any pattern• Mark out R-R intervals on a separate piece of paper and hold over EKG to see if all R-R’s map out
    18. 18. Arrhythmias… What you need to know:1. Normal or Abnormal?2. Name the Arrhythmia3. Treat the Patient with the Arrhythmia
    19. 19. Basic Rhythms and Arrhythmias• Normal Sinus Rhythm • Supraventricular• Sinus Tachycardia Tachycardia (SVT)• Sinus Bradycardia • Atrial Fibrillation (AF)• Sinus Arrhythmia • Atrial Flutter• Sinus Arrest • Ventricular Tachycardia• Ectopy (PACs, PVCs) (VT) • Torsades de Pointes • Ventricular Fibrillation (VF)
    20. 20. Normal Sinus Rhythm• Rate: 60-100 bpm• Rhythm: regular• P -> QRS -> T• Intervals: All normal
    21. 21. Sinus Tachycardia• Rate: >100 bpm• Rhythm: regular• P -> QRS -> T• Intervals: All normal
    22. 22. Sinus Tachycardia
    23. 23. Sinus Bradycardia• Rate: <60 bpm• Rhythm: Regular• P -> QRS -> T• Intervals: All normal
    24. 24. Sinus Bradycardia
    25. 25. Sinus Arrhythmia• Rate: Any rate, but usually 60-100 bpm• Rhythm: irregular• P -> QRS -> T• Intervals: All normal
    26. 26. Sinus Arrhythmia
    27. 27. Sinus Pause/Arrest• A period of time where there is no heart beat (flat line) – Somewhat interchangeable, but technically… • Just one impulse fails to form: sinus pause • More than one impulse in a row fails to form: sinus arrest• Rate: can be normal or bradycardia• Rhythm: irregular due to absence of sinus node discharge (evaluate baseline rhythm independently)
    28. 28. Ectopy• Premature atrial contractions (PACs) – Irritable focus in atria fires before next sinus impulse is due – A compensatory pause will follow an ectopic beat – Rate: Normal – Rhythm: Irregular because of the PAC, otherwise baseline rhythm is regular
    29. 29. Ectopy• Premature ventricular contractions (PVCs) – Early beat followed by compensatory pause – Rhythm: Irregular because of the PVC, otherwise baseline rhythm is regular – QRS: Wide
    30. 30. PVCs
    31. 31. More Advanced Arrhythmias• Supraventricular Tachycardia (SVT)• Atrial Fibrillation (AF)• Atrial Flutter• Torsades de Pointes• Ventricular Tachycardia (VT)• Ventricular Fibrillation (VF)
    32. 32. Supraventricular Tachycardia (SVT)• Narrow QRS tachycardia that originates above the ventricles; exact mechanism unknown• Rate: 150-250+• Rhythm: Regular• P waves: Not visible• QRS: Normal (narrow)
    33. 33. SVT
    34. 34. Atrial Fibrillation (A-fib, AF)• Rate: Atrial rate so fast it can’t be counted Rhythm: Irregularly irregular (chaotic)• P-waves: Not present; with no formed atrial impulses visible• PR: not measurable• QRS: usually normal
    35. 35. Atrial Fibrillation (A Fib, AF)
    36. 36. Atrial Fibrillation (A-fib, AF)
    37. 37. Atrial Flutter• Rate: Atrial rate usually 300 bpm (250-350)• 4:1 (V rate: 75 bpm), 3:1 (100 bpm), 2:1 (150 bpm), 1:1 (300 bpm)• Rhythm: Usually regular, can be irregular, depending on AV conduction• P-wave: sawtooth pattern• PR: not measurable• QRS: normal
    38. 38. Atrial Flutter
    39. 39. Atrial Flutter
    40. 40. Multifocal Atrial Tachycardia (MAT)• Regularity No• Rate Approximately 150’s• P waves Different appearing (3 different)• PRI Variable• QRS < . 12 seconds• Causes of MAT: pulmonary disease (especially during acute exacerbations), Dig toxicity, hypoxia, electrolyte imbalances, CHF, nicotine, alcohol, caffeine• Treatment involves treating the underlying cause (sepsis, pulmonary disease) but Calcium Channel
    41. 41. MAT
    42. 42. Ventricular Tachycardia (V Tach, VT)• Ectopic focus in ventricle• Rate: 140 – 250, may start at lower rate• Rhythm: usually regular, may be slightly irregular• P-wave: Not usually present, however, can occasionally see P waves.• PR: not measurable• QRS: wide > 0.12 sec• ACLS protocol to manage (CPR/SHOCK!)
    43. 43. Ventricular Tachycardia (V Tach, VT)
    44. 44. Idioventricular Rhythm Regularity Yes Rate 20-40 bpm P waves none QRS WIDE
    45. 45. Ventricular TachycardiaRegularity YesRate > 100 bpmP waves Can’t always see themQRS Wide
    46. 46. Torsades de Pointes Multifocal Ventricular Tachycardia
    47. 47. Ventricular Fibrillation (V Fib, VF)• Chaotic electrical activity in ventricles resulting in the ventricles quivering; Total loss of cardiac output• Rate: Zero• Rhythm: Chaotic• P-waves: None• QRS: None – Treat per ACLS protocol (CPR/SHOCK!)
    48. 48. Ventricular Fibrillation (V Fib, VF)
    49. 49. In Summary….1. Is it fast or slow?2. Is it regular or irregular?2.3. Is there a P wave before every QRS complex?
    50. 50. Part 2 – Heart Blocks
    51. 51. Heart Blocks• A blockage at any level of the electrical conduction system of the heart• 1st degree heart block• 2nd degree heart block – Type I (Wenkebach) – Type II• 3rd degree (complete) heart block
    52. 52. 1st degree heart block• AV node conducts the electrical activity more slowly than normal• PR interval > 200 ms.• Often seen with bradycardia; usually an incidental finding on a routine EKG
    53. 53. 2nd Degree Heart Block• Disturbance, delay, or interruption of atrial impulse conduction to the ventricles through the atrioventricular node (AVN).• Type I (Wenckebach, Mobitz I) – progressive prolongation of the PR interval until ultimately, the atrial impulse fails to conduct, a QRS complex is not generated, and there is no ventricular contraction
    54. 54. 2nd Degree Heart Block• Type II (Mobitz II) – an unexpected nonconducted atrial impulse, without prior measurable lengthening of the conduction time. Thus, the PR and R-R intervals between conducted beats are constant.
    55. 55. 3rd Degree Heart Block• “Complete” heart block• Complete separation of atria from ventricles• The P waves with a regular P to P interval represents the first rhythm.• The QRS complexes with a regular R to R interval represent the second rhythm. The PR interval will be variable, as the hallmark of complete heart block is no apparent relationship between P waves and QRS complexes.
    56. 56. Moving on to bundle branch blocks • A reminder of the conduction system…
    57. 57. Bundle Branch Blocks• A condition in which theres a delay or obstruction along the pathway that electrical impulses travel to the ventricles• The blockage may occur on the pathway that sends electrical impulses to the left or the right side of your heart.
    58. 58. Bundle Branch Blocks• Wide QRS complex (>= 120 ms)• Left bundle branch block (LBBB): wide, purely positive QRS deflection in V5, V6
    59. 59. A bit about devices…• Pacemakers- Used to treat bradyarrhythmias• Pacemakers have two functions: pace or sense• If pacing in the ventricle will make a wide QRS complex
    60. 60. Paced Rhythms Chamber Chamber Response to Paced Sensed SensingA = Atrium A = Atrium T = TriggeredV = Ventricle V = Ventricle I = InhibitedD = Dual D = Dual D = Dual (D+I) (A+V)O = None (A+V) O = None O = None
    61. 61. What Type of Pacemaker Is It?
    62. 62. Part 3 – Ischemia, Injury or Infarct
    63. 63. Coronary Athrosclerosis
    64. 64. Ischemia, Injury or Infarct• Ischemia- diminished blood flow to the heart muscle • ST segment depression and/or T-wave inversion.• Injury- due to prolonged ischemia and lack of blood flow to the myocardium • ST segment elevation and/or tall, peaky T-waves over area of injury. • Can be reversed with prompt intervention and reperfusion• Infarction- myocardial cells in the infarcted zone are dead and cannot be reperfused – Acute: ST elevation, Q waves may be present – Old: Significant Q waves present – Greater than ¼ amplitude of the R-wave OR – Greater than 0.04 seconds wide (one small box)
    65. 65. Time Passing
    66. 66. Ischemia
    67. 67. 12 Lead EKG Practice
    68. 68. ST elevation with AMI• Look for ST elevation > 1mm in two or more anatomically contiguous leads
    69. 69. Coronary Circulation: Left Main Circumfl ex Left Right Anterior Coronar Descendi y ng ArteryRight Coronary Artery (RCA) Left Main Coronary Artery- Left Ventricle - Inferior Wall - Posterior Wall Left Anterior DescendingCircumflex- Right Ventricle - Left Ventricle - Left Ventricle- SA Node (55%) - Anterior Wall - Lateral wall- AV Node (90%) - Interventricular Septum
    70. 70. Leads tell location:• Septal – V1-V2• Anterior – V3-V4• Inferior – II, III, AVF• Lateral – I, AVL, V5-V6
    71. 71. Localization of an MI:
    72. 72. Inferior MI with reciprocal changes in lateral leads
    73. 73. 12 Lead EKG Practice
    74. 74. 12 Lead EKG Practice
    75. 75. 12 Lead EKG Practice
    76. 76. Pericarditis:• Patients present with s/s of MI• Sharp, pleuritic, and POSITIONAL- relieved by leaning forward• Often accompanied by fever and palpitations• Treated with ASA or NSAID• EKG shows DIFFUSE ST elevation in all leads except aVR
    77. 77. Cases….• A 59 year-old female patient is sitting in the lobby when she begins to feel her heart race. You get her back to a patient room and hook her up to the heart monitor.• This is what you see….
    78. 78. • What is the rhythm?
    79. 79. • A 73 year-old male diabetic patient is in the lobby waiting to see his internist. He clutches his chest and slumps onto the floor. As a member of the Code Blue Team you respond and after swift completion of your ABC’s (airway, breathing, circulation- ACLS protocol!) you hook him up to the monitor.• This is what you see……
    80. 80. • What is the rhythm?• What do you do next?
    81. 81. • You now see this on the monitor…..• What is the rhythm?• What else to you see?• What do you do next?
    82. 82. • What do you see?• What do you do next?
    83. 83. • A 32 year-old male patient comes into the clinic complaining of his heart racing. He has just come up from the Wellness Center downstairs and says he finished his “No Explode” energy drink just prior to beginning his workout. You swiftly take him back to a patient room and hook up the monitor.• This is what you see……
    84. 84. • What is the rhythm?
    85. 85. • A 65 year-old male patient comes into the clinic to be evaluated for a syncopal episode. He admits to frequent episodes of lightheadedness and feeling like he could pass out. You hook him up to the monitor this is what you see…..
    86. 86. • What do you see?• What is the underlying rhythm?

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