Project: Ghana Emergency Medicine Collaborative
Document Title: EKG and Rhythm Interpretation 101
Author(s): Emily Sagalyn...
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{ Content the ...
Emily Sagalyn, MD
Wilderness/EMS Fellow
University of Utah

3
Patients who should get an EKG
  Reading an EKG
  Identifying ST elevation MI
  Atrial arrythmias
  Nodal Blocks
  Ve...
 

Possible diagoses of:

◦  Acute coronary Syndrome
◦  Myocardial Infarction
◦  Syncope
◦  Stroke
◦  Arrythmia
◦  Hyperk...
 

Multiple ways to read EKGs

 

Do it the same each time

 

Rate, Rhythm, Intervals, Abnormalities
◦  Precordium
◦  ...
http://www.learntheheart.com/Normal.jpgc

7
http://doctorgrasshopper.wordpress.com/tag/ekg/
http://www.brighamandwomens.org/
Departments_and_Services/medicine/service...
 

Rate (< 60 Bradycardia, >100 Tachycardia):
◦  Find a QRS on a big box
◦  Count down: 300, 150, 100, 75, 60, slow…

htt...
 

PR = 0.12 – 0.20 ms, 3-5 small boxes

◦  Corresponds to conduction from SA to AV node

 

QRS < 0.12 ms, 3 small boxe...
http://allaboutim.webs.com/apps/blog/show/next?from_id=5380740

11
http://www.learntheheart.com/Normal.jpg

12
http://www.learntheheart.com/Normal.jpg

13
Inline with baseline
  Elevation:
 

◦  3mm in precordial leads or 1mm in limb leads
◦  Early repolarization vs. pericar...
http://www.learntheheart.com/Normal.jpg
15
http://www.learntheheart.com/Normal.jpg
16
http://www.learntheheart.com/
Further reading:
http://blog.thealo.com/thealo/blog/post/2009/07/31/STEMIPericarditis-Early-...
Monitor, ABCs
ASA, Oxygen if needed, NGT,
morphine if needed
12-Lead EKG if possible and
notify hospital if STEMI
STEMI or...
Atrial
  Ventricular
 

Source undetermined
19
Originate above AV node
  Produce narrow QRS complexes
  Afib: Irregularly irregular
  Aflutter: Regularly irregular, u...
www.ecglibrary.com

21
www.ecglibrary.comc

22
http://www.emedu.org/ecg/crapsanyall.php

23
Originates below AV node
  Wide complex
 

Source undetermined

24
Airway
Oxygen (if hypoxic)
Monitor
Unstable?
Cardioversion
Adenosine: narrow
and wide and regular
- 6mg IV push
- 12mg sec...
 

1st degree: prolonged PR > 220ms (one big
box)

Source undetermined

26
PR interval progressively longer until it
doesn’t conduct
  Stable, no intervention usually needed
 

Source undetermine...
Consistent PR interval
  P that doesn’t conduct
  Sign of conduction problem below the AV
node
  Can progress to 3rd de...
Complete dysfunction of AV node
  Atria and ventricles not communicating
 

Source undetermined

29
IV, O2, Monitor
  Transport
  3rd degree block + unstable
 

◦  May need to pace

Atropine?
  May not work given A-V d...
 

Other causes:

◦  Sinus node dysfunction
◦  Heart attack
◦  Medications
◦  Electrolyte abnormalities
◦  Hypothermia

3...
Assess, typically < 50 BPM
Identify and treat underlying
condition.
•  Maintain airway and assist
breathing if necessary
•...
Persistent Bradycardia causing:
- Hypotension
- Acutely altered mental status
- Signs of shock
- Ischemic chest discomfort...
 

Determine if

◦  Unstable: vital organ function is impaired, or
impending cardiac arrest

  Altered mental status, ac...
Right Bundle Branch Block
  Left Bundle Branch Block
  Premature Ventricular Contractions (PVCs)
  Ventricular Tachycar...
 
 
 

QRS > 120 ms (3 small boxes)
rsR’ – “bunny ears” in precordial leads
Slurred s waves in I, V5, V6

Source undete...
WRS > 120ms (3 small boxes)
  No Q waves in I, V5, V6
  Monomorphic R wave in I, V5, V6
  ST and T waves are in opposit...
Source undetermined

38
 

A new LBBB + symptoms of ischemic heart
disease = Acute MI until proven otherwise
◦  Chest pain
◦  Syncope
◦  Shortnes...
Source undetermined

40
Occur before you would expect another beat
  Wide complex – originate below AV node
  Pause after before the next
  Pat...
Source undetermined
42
Source undetermined

43
VT can have a pulse  tachycardia algorithm
  Pulses VT or VF  Cardiac Arrest algorithm
 

Source undetermined

44
 
 
 
 
 

“Twisting around a point”
Type of ventricular fibrillation
Electrolyte imbalances (Magnesium)
Electrical A...
Pulseless electrical Activity
  Any wave form without a pulse
 

Source undetermined

46
“Flatline”
  No cardiac activity
  No ventricular depolarization
 

Source undetermined

47
5Hs
 
 
 

 
 

Hypovolemia
Hypoxia
Hydrogen ions
(Acidosis)
Hypo-/hyperkalemia
Hypothermia

5Ts
 
 
 
 
 

Tens...
 

CPR: push hard and fast
◦  ≥2 inches, ≥100/min

Minimize interruptions
  Avoid excessive
ventillation
  Change compr...
Biphasic: manufacturer
recommendation (120-200J),
if unknown use maximal dose
Monophasic: 360J

Epi (IV/IO): 1mg (1:10,000...
Once advanced airway is
placed
100 compression/min
No pauses for
ventillation

51
Source undetermined

52
Hyperkalemia	
  
  2-­‐3	
  degree	
  heart	
  block,	
  wide	
  complex	
  tachycardias,	
  
progression	
  to	
  vf	
  ...
Source undetermined

54
Small	
  or	
  absent	
  t	
  waves	
  
  Prominent	
  U	
  waves	
  
  First	
  or	
  second	
  degree	
  AV	
  block	
...
Source undetermined

56
 

Sodium	
  channel	
  blocker:	
  includes	
  Ia	
  arrythmias	
  (quinidine,	
  procainamide)	
  
IC	
  anRarrythmias:...
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GEMC- EKG and Rhythm Interpretation 101-for Residents

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This is a lecture by Emily Sagalyn from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- EKG and Rhythm Interpretation 101-for Residents

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: EKG and Rhythm Interpretation 101 Author(s): Emily Sagalyn (University of Utah), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2  
  3. 3. Emily Sagalyn, MD Wilderness/EMS Fellow University of Utah 3
  4. 4. Patients who should get an EKG   Reading an EKG   Identifying ST elevation MI   Atrial arrythmias   Nodal Blocks   Ventricular arrythmias   ACLS algorithms   4
  5. 5.   Possible diagoses of: ◦  Acute coronary Syndrome ◦  Myocardial Infarction ◦  Syncope ◦  Stroke ◦  Arrythmia ◦  Hyperkalemia (includes renal failure) ◦  Overdose ◦  Other electrolyte abnormalities 5
  6. 6.   Multiple ways to read EKGs   Do it the same each time   Rate, Rhythm, Intervals, Abnormalities ◦  Precordium ◦  Territories 6
  7. 7. http://www.learntheheart.com/Normal.jpgc 7
  8. 8. http://doctorgrasshopper.wordpress.com/tag/ekg/ http://www.brighamandwomens.org/ Departments_and_Services/medicine/services/cvcenter/Patient/ pacemaker.aspx 8
  9. 9.   Rate (< 60 Bradycardia, >100 Tachycardia): ◦  Find a QRS on a big box ◦  Count down: 300, 150, 100, 75, 60, slow… http://www.learntheheart.com/Normal.jpg   Rhythm ◦  Is there a p before every QRS? Yes  NSR 9
  10. 10.   PR = 0.12 – 0.20 ms, 3-5 small boxes ◦  Corresponds to conduction from SA to AV node   QRS < 0.12 ms, 3 small boxes ◦  Conduction through ventricular system http://www.learntheheart.com/Normal.jpg 10
  11. 11. http://allaboutim.webs.com/apps/blog/show/next?from_id=5380740 11
  12. 12. http://www.learntheheart.com/Normal.jpg 12
  13. 13. http://www.learntheheart.com/Normal.jpg 13
  14. 14. Inline with baseline   Elevation:   ◦  3mm in precordial leads or 1mm in limb leads ◦  Early repolarization vs. pericarditis vs. STEMI   Depression ◦  One small box below baseline ◦  Ischemia, reciprocal changes 14
  15. 15. http://www.learntheheart.com/Normal.jpg 15
  16. 16. http://www.learntheheart.com/Normal.jpg 16
  17. 17. http://www.learntheheart.com/ Further reading: http://blog.thealo.com/thealo/blog/post/2009/07/31/STEMIPericarditis-Early-Repolarization.aspx 17
  18. 18. Monitor, ABCs ASA, Oxygen if needed, NGT, morphine if needed 12-Lead EKG if possible and notify hospital if STEMI STEMI or new LBBB  cath lab door to balloon time < 90 min! To hospital for further care but not immediate cath lab 18
  19. 19. Atrial   Ventricular   Source undetermined 19
  20. 20. Originate above AV node   Produce narrow QRS complexes   Afib: Irregularly irregular   Aflutter: Regularly irregular, usually 2:1 condution (rate 150)   Source undetermined ◦  Afib/flutter often seen with respiratory problems ◦  COPD/Asthma, PE   SVT: regular, fast, narrow complex, no visible p waves ◦  Drugs, electrolyte imbalance, bad wiring 20
  21. 21. www.ecglibrary.com 21
  22. 22. www.ecglibrary.comc 22
  23. 23. http://www.emedu.org/ecg/crapsanyall.php 23
  24. 24. Originates below AV node   Wide complex   Source undetermined 24
  25. 25. Airway Oxygen (if hypoxic) Monitor Unstable? Cardioversion Adenosine: narrow and wide and regular - 6mg IV push - 12mg second dose American Heart Association 25
  26. 26.   1st degree: prolonged PR > 220ms (one big box) Source undetermined 26
  27. 27. PR interval progressively longer until it doesn’t conduct   Stable, no intervention usually needed   Source undetermined 27
  28. 28. Consistent PR interval   P that doesn’t conduct   Sign of conduction problem below the AV node   Can progress to 3rd degree block (bad)   http://www.ncbi.nlm.nih.gov/books/NBK2219/ 28
  29. 29. Complete dysfunction of AV node   Atria and ventricles not communicating   Source undetermined 29
  30. 30. IV, O2, Monitor   Transport   3rd degree block + unstable   ◦  May need to pace Atropine?   May not work given A-V dissociation     Definitive treatment: Pacemaker 30
  31. 31.   Other causes: ◦  Sinus node dysfunction ◦  Heart attack ◦  Medications ◦  Electrolyte abnormalities ◦  Hypothermia 31
  32. 32. Assess, typically < 50 BPM Identify and treat underlying condition. •  Maintain airway and assist breathing if necessary •  Oxygen (if hypoxemic) •  Monitor •  IV access • 12-Lead EKG, do not delay treatment if not available Source undetermined 32
  33. 33. Persistent Bradycardia causing: - Hypotension - Acutely altered mental status - Signs of shock - Ischemic chest discomfort - Acute heart failure Atropine If ineffective: - Pacing or Dopamine or Epi Source undetermined Dosing: Atropine: 0.5 mg IV. Can repeat Q3-5 min. Max 3mg Dopamine: 2-10mcg/kg/min drip Epi: 2-10 mcg/min drip 33
  34. 34.   Determine if ◦  Unstable: vital organ function is impaired, or impending cardiac arrest   Altered mental status, acute heart failure, hypotension ◦  Symptomatic: lightheadedness of dizziness If a person is symptomatic but stable, have more time   If unstable have to intervene   Determine cause of instability and treat underlying cause   34
  35. 35. Right Bundle Branch Block   Left Bundle Branch Block   Premature Ventricular Contractions (PVCs)   Ventricular Tachycardia   Ventricular Fibrillation   Torsade de Points   35
  36. 36.       QRS > 120 ms (3 small boxes) rsR’ – “bunny ears” in precordial leads Slurred s waves in I, V5, V6 Source undetermined 36
  37. 37. WRS > 120ms (3 small boxes)   No Q waves in I, V5, V6   Monomorphic R wave in I, V5, V6   ST and T waves are in opposite direction than QRS complex   ◦  Discordance 37
  38. 38. Source undetermined 38
  39. 39.   A new LBBB + symptoms of ischemic heart disease = Acute MI until proven otherwise ◦  Chest pain ◦  Syncope ◦  Shortness of breath ◦  Nausea/vomiting ◦  Diaphoresis   MI in old LBBB ◦  If discordance is broken (QRS and ST-T waves are in the SAME direction) BE CONCERNED! 39
  40. 40. Source undetermined 40
  41. 41. Occur before you would expect another beat   Wide complex – originate below AV node   Pause after before the next   Patients can feel “flip-flop” in chest or a skipped beat   41
  42. 42. Source undetermined 42
  43. 43. Source undetermined 43
  44. 44. VT can have a pulse  tachycardia algorithm   Pulses VT or VF  Cardiac Arrest algorithm   Source undetermined 44
  45. 45.           “Twisting around a point” Type of ventricular fibrillation Electrolyte imbalances (Magnesium) Electrical Abnormalities (Prolonged QT) Give Mag 45
  46. 46. Pulseless electrical Activity   Any wave form without a pulse   Source undetermined 46
  47. 47. “Flatline”   No cardiac activity   No ventricular depolarization   Source undetermined 47
  48. 48. 5Hs           Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hypo-/hyperkalemia Hypothermia 5Ts           Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis (pulmonary) Thrombosis (coronary) 48
  49. 49.   CPR: push hard and fast ◦  ≥2 inches, ≥100/min Minimize interruptions   Avoid excessive ventillation   Change compressors every 2 min   30:2 ratio if no advanced airway   49
  50. 50. Biphasic: manufacturer recommendation (120-200J), if unknown use maximal dose Monophasic: 360J Epi (IV/IO): 1mg (1:10,000) Q3-5min Advanced airway: King tube or ETT Amio (IV/IO): First dose 300mg Second dose 150mg If at any point rhythm become unshockable go to asystole 50 pathway
  51. 51. Once advanced airway is placed 100 compression/min No pauses for ventillation 51
  52. 52. Source undetermined 52
  53. 53. Hyperkalemia     2-­‐3  degree  heart  block,  wide  complex  tachycardias,   progression  to  vf  and  asystole     6.5-­‐7.5  peaked  t  waves     7.5-­‐8.0  widening  of  the  qrs     10-­‐12  sine  wave,  vf,  asystole     53
  54. 54. Source undetermined 54
  55. 55. Small  or  absent  t  waves     Prominent  U  waves     First  or  second  degree  AV  block     Slight  ST  depression     55
  56. 56. Source undetermined 56
  57. 57.   Sodium  channel  blocker:  includes  Ia  arrythmias  (quinidine,  procainamide)   IC  anRarrythmias:  flecainide,  encainide   Local  anestheRcs:  bupivacaine   AnRmalarias:  chloroquine,  hydroxychloroquin     Dextropropoxyphene   Propranolol   Carbamazepine   Quinine     Seizures,  and  ventricular  arrythmias       Ekg:  intraventricular  conducRon  delay  QRS  >100ms  in  lead  II   Right  axis  deviaRon,  terminal  r  wave  in  aVR     QRS  greater  than  100ms  predicRve  of  seizures,  >  160  predicRve  of  VT     Clinical  management:  IV,  monitor  O2   IV  sodium  bicarb  100meq,  repeart  every  few  mintues  unRl  QRS  narrows   Intubate:  hypervenRllate  ph  7.5     Seizures:  IV  benzos   Hypotension:  crystalloid,  vasopressors  (norepi)   Arrythmias:  bicarb,  lidocaine  if  necessary                           57

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