EKG TUTORIAL:

APPROACH TO
INTERPRETATION
MARIO L MAIESE D O, FACC, FACOI
Clinical Associate Professor
UMDNJSOM
South Jersey Heart Group
September 14-15, 2004
For Questions: emailmaiese1@comcast.net

Rapid Interpretation of EKGS

Dale Dubin, MD
(required reading before the lecture)

PRIORITIES?

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach
1) rate and rhythm
big box (0.20 sec) rule (for 1,2,3,4,5,& 6 boxes)

300,150,100,75,60,50
--- 60-100 inclusive? YES
nl rate
--- < 60 => bradycardia
--- > 100 => tachycardia
unsure of rhythm? YES
Arrhythmia ID

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach
2) PR interval [nl 0.12-0.20 inclusive]
nl
PR< 0.12 sec? YES
Pre-Excitation Syndrome
[PES]; 11 poss Variants;
delta wave with prolonged QRS
WolffParkinson- White [WPW] Syndrome
PR> 0.20 sec [including dropped beats] ? YES
differential for prolonged PR

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval/ Axis
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach
3) QRS interval [nl < 0.10 sec]
QRS> 0.10 sec YES
differential for wide QRS [bundle branch
block{BBB}pattern]

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach
4) signs of transmural [Q wave infarction]?
Q waves > 0.04 sec in limb leads YES
+ criteria for
MI
Q waves > 1/4 height of the R wave in the same lead
YES
+ criteria for MI
Q waves in more than one limb lead YES
+ criteria
for MI
abnormal R wave progression in precordial [chest] leads
YES
criteria for MI [age & sites]

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach
5) signs of hypertrophy[increased voltage of
QRS complexes]
Right Ventricular Hypertrophy [RVH]
Left Ventricular Hypertrophy [LVH]

6 Step Approach
1 Rate and Rhythm
2 PR interval
3 QRS interval
4 Signs of MI
5 Signs of Hypertrophy
6 ST/QT/ T wave abnormalities

12-lead EKG Interpretation

Six Step Approach

6) ST/QT/T wave abnormalities

ST seg depression [>1mm]? YES
ischemia
ST seg elevation? YES injury
ST scooping? YES digitalis effect
prolonged QT with flat T wave? YES hypo K+
early peaked T waves? YES
hyper K+
inverted T waves without Q waves? YES nonspecific*with Hx and + enzymes could be consist with a
subendocardial Non-Q wave MI Forward

ARRHYTHMIA
IDENTIFICATION
Rhythm: regular regular
regular rhythms
regular irregular
premature/missed beats
irregular irregular
chaotic rhythms
P wave
not present
absent P waves [escape
(late) rhythms]
more P waves than QRSs
AV block

ARRHYTHMIA
IDENTIFICATION
QRS Complex
-all narrow
nl QRS complexes
-mixed narrow and wide
homogeneous
unifocal ventricular ectopy
heterogeneous
multifocal ventricular ectopy
-all wide
wide QRS complexes
BACK

Differential for Prolonged PR Interval

P with every QRS

1st degree heart block

progressive PR prolongation with dropped beats

2nd
degree heart block [Mobitz type 1(Wenckebach)]
constant PR with dropped beats
2nd degree heart
block [Mobitz type 11]
no relationship between p waves and QRS
3rd degree
heart block
BACK

Differential for Wide QRS

No P waves
-all negative in V6 => V tach
-bizzare axis => V tach
PR < 0.12 sec => WPW [QRS> 0.10 & < 0.12]
initial QRS peaked [upright] in V1? YES
right bundle branch block (RBBB) [QRS> 0.12]
QRS wide [downward deflection] overall inV1-V6
[QRS> 0.12]? YES
left bundle branch block (LBBB)

Differential for Wide QRS

LBBB pattern [QRS < 0.12] with axis < 45
degrees? YES
left anterior hemiblock
[LAHB]
LBBB pattern [QRS < 0.12 with axis > 120
degrees? YES
left posterior hemiblock
[LPHB]
BACK

Criteria for Infarct Age

Significant ST segment elevation? YES
acute infarct [days]
Q waves with inverted T waves ? YES
recent (subacute) [days/weeks/months]
significant Q waves only? YES
old
[months/years]
BACK

Regular Rhythms
P wave with every normal QRS => normal sinus
rhythm [NSR]--rate 60-100 inclusive
P wave with every normal QRS/slow [<60] =>
supraventricular bradycardia
P wave with every normal QRS/fast [>100] =>
supraventricular tachycardia
no P waves/wide QRS/fast => V Tachycardia
BACK

Premature/Missed Beats
premature beats [early]
narrow=> PACs/PJCs
wide/same=> unifocal ventricular ectopy
wide/different => multifocal ventricular ectopy
grouped beats with PR => 2nd deg AV block[1]
dropped beats without PR => 2nd deg block [2]
no relationship between P and QRS => 3rd degree AV
block
BACK

Chaotic Rhythms
No P waves [undulating baseline]/irregular
ventricular response => atrial fibrillation [AF]
heterogenious P waves [at least 3 different P
wave configurations usually with varying PR
intervals => multifocal atrial rhythm [if HR >
100 => multifocal atrial tach
BACK

Rhythms
Normal
Abnormal: Arrhythmia
Dysrhythmia

Supraventricular Dysrhythmias

Atrioventricular (AV) Block

Myocardial Infarction

Ventricular conduction abnormalities

Ventricular Dysrhythmias

Pre-Excitation Syndrome (PES)

Experience is a
wonderful thing .
It enables you to
recognize a mistake
when you make it
again.

Average but works hard,

Beats
Brilliant but lazy.

1) A 45 yr old black man is noted to have a

BP of 150/100. He has been hypertensive the
last 10 years. What is the abnormality on the
EKG?

2) What is the cause of the patientss

rapid irregular pulse?

3) What is the cause of the wide

QRS complex?

4) The patient complains of

extra beats. What is the
arrhythmia? Tx?

5) What is the arrhythmia?

6) A patient complains of
palpatations. What is the
arrhythmia?

7) The following EKG is

obtained during a cardiac arrest.
What is the arrhythmia?

8) What is the cause of the

patients rapid irregular pulse?

9) How does the rhythm change

abruptly in this patient?

10) What arrhythmia and

conduction disturbance are
present on this V1 rhythm strip?

11) What arrhythmia is present in

this patient?

12) A 50 yr.-old man presents with chest discomfort. The EKG is most
consistent with which diagnosis?
Acute inferior wall MI
Acute pericarditis
Normal variant early repolarization
Ventricular aneurysm

13) A 63 yr.-old woman had

severe chest pain 6 hours ago.
What does the EKG show?

14) What conduction disturbance

is present?

Atherothrombotic
Lesion development

Mechanism of Plaque Disruption in

Atherothrombosis (Acute thrombus)

15) A 53 yr old man presents with crushing

chest pain. He is hypotensive with jugular
venous distention. What is the EKG
diagnosis?

16) A patient has recurrent

syncope. What is the diagnosis?

17) The following rhythm strip is

obtained post exercise. What is
the diagnosis?

18) What arrhythmia and

conduction disturbance are
present?

19) What conduction abnormality

is present?

20) What arrhythmia is

responsible for the tachycardia in
this patient with underlying
chronic lung disease?

21) What dysrhythmia is causing

the tachycardia? What other
abnormal finding is present?

22) A 62 year old women presents with the

sudden onset of acute crushing chest pain.
What is the diagnosis?

To look is one thing;

To see what you look at is
another,
To understand what you see is a
third;
To learn from what you
understand is still something else,
But to act on what you learn is all
that really matters!

Be Sincere
Be simple in words, manners and gestures.
Amuse as well as instruct.
If you can make a man laugh you can make him
think and believe you.

Time is Up
D:\Clock.htm

Experience is a
wonderful thing .
It enables you to
recognize a mistake
when you make it
again.