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EKGs The Basics for FP Residents

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EKGs The Basics for FP Residents

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    1. EKGs…The Basics for FP Residents Jess Fogler, MD University of California, San Francisco

    2. Part III Misc. Practice

    3. Train your eyes Train your eyes for Rate: Check the computer Train your eyes for Rhythm: Check the rhythm strip Check I, II, avF Train your eyes for Axis: Check I, II Train your eyes for Intervals: PR: check II QT: check the computer QRS: check I, V1

    4. Train your eyes Train your eyes for LVH: Look at…in order avL V3 Check your cheat sheet Read the computer Train your eyes for MI: Look at all T waves Look at all ST segments Check for Q waves Check for R waves in V1-2

    5. Diagnosis of MI In LBBB Diagnosis of MI in LBBB very difficult Treatment decisions best made using non-EKG criteria General thoughts In LBBB ST-T waves are normally directed opposite to main QRS ST-T waves in same direction as QRS raise suspicion of ischemia

    6. Diagnosis of MI In RBBB MI can be diagnosed in RBBB Appearance of pathologic Q’s unaffected MI affects initial portion of QRS RBBB affects terminal portion of QRS Repolarization abnormalities in RBBB normally seen only in leads V1-3

    7. 5: RBBB with LVH and ST depression (ischemia?) Sinus Brady with 1 AVB RBBB LAD by LAFB LVH ST depression T wave inversion V4-6 Think ischemia, dig effect, hypokalemia5: RBBB with LVH and ST depression (ischemia?) Sinus Brady with 1 AVB RBBB LAD by LAFB LVH ST depression T wave inversion V4-6 Think ischemia, dig effect, hypokalemia

    8. 23:RBBB with acute anterior infarct and possible lateral extension Sinus tach RBBB LAD by LAFB ST elevation (rounded) I,L, V1-3 (expect depression in RBBB) ST depression II, III, F Q’sV1-323:RBBB with acute anterior infarct and possible lateral extension Sinus tach RBBB LAD by LAFB ST elevation (rounded) I,L, V1-3 (expect depression in RBBB) ST depression II, III, F Q’sV1-3

    9. 42: Early Repol Ectopic atrial rhythm ST elevation with upward concavity (without reciprocal changes) “Fishhook deformity”: notching of the R wave as it merges with ST segment Tall QRS voltage Prominent symmetric T waves Best seen in V2-5, rarely in V6 42: Early Repol Ectopic atrial rhythm ST elevation with upward concavity (without reciprocal changes) “Fishhook deformity”: notching of the R wave as it merges with ST segment Tall QRS voltage Prominent symmetric T waves Best seen in V2-5, rarely in V6

    10. Early Repolarization T wave starts early (during ST segment) giving impression of ST elevation Most common in younger males ST elevation with upward concavity (without reciprocal changes) “Fishhook deformity”: notching of the R wave as it merges with ST segment Tall QRS voltage Prominent symmetric T waves Best seen in V2-5, rarely in V6

    11. 41: Acute pericarditis (could be ant,inf, apical, lat, epicardial injury…rare)41: Acute pericarditis (could be ant,inf, apical, lat, epicardial injury…rare)

    12. Acute Pericarditis A generalized pathologic process Causes diffuse EKG changes Generalized ST segment elevation due to inflammation on the epicardial surface Concave upward “Knuckle” sign in aVR (PR elevation) PR depression (seen best in lead II) With evolution Diffuse T wave inversions (seen best V3-5) PR elevation is the ST elevation equivalent for the atrium PR depression is a reciprocal changePR elevation is the ST elevation equivalent for the atrium PR depression is a reciprocal change

    13. 58: Hyperkalemia Top: K 5.0 - normal Middle: K 6.6 – peaked T’s Bottom: K 7.0 – M complex58: Hyperkalemia Top: K 5.0 - normal Middle: K 6.6 – peaked T’s Bottom: K 7.0 – M complex

    14. Hyperkalemia EKG changes more reflective of rate of rise rather than absolute value of K+ Early: tall peaked T-waves Symmetric sharp apex Consider also early repolarization Then: deeper, wider QRS Finally: Sine-wave S wave deep and wide, merges with elevated ST Very specific EKG findings in hyerkalemia are more related to the rate of rise of the potassium, rather than the absolute value and the features are best seen V3-4 The earliest findings are tall-peaked T waves, which are symmetric, a little like those in early repolarization. As the potassium increases, the QRS starts to widen, with the R wave becoming shorter and the S wave becoming pulled outward. And finally, this deteriorates into the classic Sine-wave pattern seen here. (And we’re just about out of time, so I think I’d better end here and take some questions.) EKG findings in hyerkalemia are more related to the rate of rise of the potassium, rather than the absolute value and the features are best seen V3-4 The earliest findings are tall-peaked T waves, which are symmetric, a little like those in early repolarization. As the potassium increases, the QRS starts to widen, with the R wave becoming shorter and the S wave becoming pulled outward. And finally, this deteriorates into the classic Sine-wave pattern seen here. (And we’re just about out of time, so I think I’d better end here and take some questions.)

    15. Practice Makes perfect

    16. EKG#2 Normal with T wave inversion V1, IIIEKG#2 Normal with T wave inversion V1, III

    17. EKG #4: RBBB Lead V1: large R’ Lead I: broad terminal S EKG #4: RBBB Lead V1: large R’ Lead I: broad terminal S

    18. EKG #3 Sinus arrythmia LAD LAFB LVH with strainEKG #3 Sinus arrythmia LAD LAFB LVH with strain

    19. EKG #5: Sinus brady AVB RBBB LAD LAFB LVH with biphasic T’sEKG #5: Sinus brady AVB RBBB LAD LAFB LVH with biphasic T’s

    20. EKG #6 LBBB Lead V1: deep wide S wave Lead I: broad, notched R wave (no Q or S) EKG #6 LBBB Lead V1: deep wide S wave Lead I: broad, notched R wave (no Q or S)

    21. EKG #70 Organized afib Inverted T’s inferiorly ?dig effectEKG #70 Organized afib Inverted T’s inferiorly ?dig effect

    22. EKG #14 Sinus tach LAE RAD secondary to LPFB RVHEKG #14 Sinus tach LAE RAD secondary to LPFB RVH

    23. NO TIME This EKG is from the same patient as in the previous EKG only 3 days later. Here you see the ST segments are less elevated and have a rounded look to them. The T waves are biphasic or inverted in many places and the Q waves are more pronounced. You also see a loss of R wave height in all chest leads. Finally, the reciprocal changes seen in the inferior leads are now gone. 20: Same patient as previous EKG 3 days later Rounded ST elevation in V1-5 ST depression in inferior leads basically gone Q’s in V1-4, and more notable now in I,L Loss of R wave height in all precordial leads NO TIME This EKG is from the same patient as in the previous EKG only 3 days later. Here you see the ST segments are less elevated and have a rounded look to them. The T waves are biphasic or inverted in many places and the Q waves are more pronounced. You also see a loss of R wave height in all chest leads. Finally, the reciprocal changes seen in the inferior leads are now gone. 20: Same patient as previous EKG 3 days later Rounded ST elevation in V1-5 ST depression in inferior leads basically gone Q’s in V1-4, and more notable now in I,L Loss of R wave height in all precordial leads

    24. Take a few moments to look at this EKG. See if you can figure out if there is an injury, how extensive it is and how old it is. If we look at the ST segments and T waves and we find flattened and inverted T waves in leads II, III,and F as well as in V5-6 and leads I and L. We also find Q waves in these leads, as well as R waves in V1-3. We can therefore conclude that this is an old inferior infarct with apical, lateral and posterior extension. And this is probably a Lcx lesion in which the LCX was dominant and fed the inferior portion of the LV. 36: Old inferior MI with apical, lateral and posterior extension Probably Lcx lesion NSR LAE LAD secondary to inf MI, LAFB Flat/flipped T’s laterally, inferiorly Q’s in II, III, F, V5-6, I, ?L R’s in V1-3 Take a few moments to look at this EKG. See if you can figure out if there is an injury, how extensive it is and how old it is. If we look at the ST segments and T waves and we find flattened and inverted T waves in leads II, III,and F as well as in V5-6 and leads I and L. We also find Q waves in these leads, as well as R waves in V1-3. We can therefore conclude that this is an old inferior infarct with apical, lateral and posterior extension. And this is probably a Lcx lesion in which the LCX was dominant and fed the inferior portion of the LV. 36: Old inferior MI with apical, lateral and posterior extension Probably Lcx lesion NSR LAE LAD secondary to inf MI, LAFB Flat/flipped T’s laterally, inferiorly Q’s in II, III, F, V5-6, I, ?L R’s in V1-3

    25. EKG #66 Junctional escape rhythm with retrograde PsEKG #66 Junctional escape rhythm with retrograde Ps

    26. EKG #1 Normal EKGEKG #1 Normal EKG

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