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Reading a EKG

Reading a EKG

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Published by Mayer Rosenberg

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Published by: Mayer Rosenberg on Feb 22, 2008
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12/21/2012

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READING AN EKG
1.
 
Rate
– if regular, then count the number of large squares between R waves; 1 square = 300 bpm, 2 = 150 bpm, 3 = 100 bpm, 4 = 75 bpm, 5 = 60 bpm, 6 = 50 bpm. Each small box = 0.04 s, each large box = 5 small boxes = 0.20 s.
2.
 
Rhythm
– is it regular? (use calipers/ruler to make sure all R-R intervals are the same); are there P waves, and arethey in front of every QRS? (in sinus rhythm, P waves will be upright in lead II); are P waves all identical?3.
 
Intervals
 
PR interval: normally 0.12 to 0.20 seconds (will not exceed a large box)
 
QRS interval: normally 0.04 to 0.10 seconds (no larger than half a large box)
 
QT interval: should be less than half the R-R interval (if HR < 100)4.
 
Axis deviation
– net QRS deflection should be positive in both leads I and aVF
 
Right axis deviation: QRS negative in I, positive in aVF
 
Left axis deviation: QRS positive in I, negative in aVF5.
 
Hypertrophy
 
Left ventricular hypertrophy: sum of deepest S in V
1
or V
2
and tallest R in V
5
or V
6
> 35 mm (patients > 35 yo); R inaVL > 12 mm indicative of “strain”.
 
Left atrial enlargement: P waves are notched (M-shaped) in I, II, or aVL or a deep terminal negative component to P inV
1
 
Right atrial enlargement: tall, peaked P waves (> 2.5 mm) in II, III, aVF
 
Right ventricular hypertrophy: right atrial enlargement, right axis deviation, incomplete RBBB, low voltage tall R wavein V
1
, persistent precordial S waves, right ventricular strain are all suggestive.6.
 
Infarction
 
Q waves
: small, normal Q waves can be seen in lateral leads (I, aVL, V 
4
to V 
6
), while moderate-large sized Q wavesmay be normal in leads III, aVF, aVL, and V 
1
. To localize the infarction, look for groupings of Q waves in the followingleads…
 
InferiorII, III, aVFAnteroseptalV
1
to V
3
AnteriorV
3
and V
4
AnterolateralV
4
and V
6
, I, aVLPosteriorV
1
and V
2
 
R wave progression : transition should occur between V
2
and V
4
.
 
ST segment elevation or depression
: remember that
ischemia is associated with ST depression
, while infarction isassociated with ST elevation. Look for changes in two adjacent leads.
 
T wave inversion
: may be normally inverted in III, aVF, aVL, and V 
1
. T wave inversion indicates areas of ischemia in Q wave infarctions.7.
Heart
 
Block (AV block)
 
1
st
Degree AV block: PR interval > 0.20 sec
 
2
nd
Degree AV block
 
i.
 
Mobitz I: (Wenkeback) PR interval progressively widens until a beat is dropped
 
ii.
 
Mobitz II: PR interval is prolonged, randomly dropped beat
à
Needs Pacemaker 
 
3
rd
Degree AV Block: No connection (dissociation) between atrial and ventricular rates
à
Needs Pacer 
Other pearls
 
Hypokalemia: ST depression, decreased or inverted T waves, U waves
 
Hyperkalemia: peaked T waves, decreased P waves, short QT, widened QRS, sine wave
 
Hypocalcemia: prolonged QT, flat or inverted T waves
 
Hypercalcemia: short or absent ST, decreased QT
c
interval
 
Hypomagnesemia: prolonged QT, flat T waves, prolonged PR, aFib, torsade
 
Hypermagnesemia: short PR, heart block, peaked T waves, widened QRS
0
 
Digitalis toxicity: ST depression (scoop), flat T waves
 
Quinidine: prolonged QT, widened QRS
 
Pericarditis: diffuse ST elevation with PR interval depression
 
Clinical Acid-Base Disturbances
Approach to the Abnormal Blood Gas
Acid-base disorders can be approached with three questions:What is wrong?What caused it?What’s being done about it?The answer to the first question, “What is wrong?” is obtained by simple inspection of the values on the pH, PaCO2, and HCO3-.If all three values are normal, the answer to “What is wrong?” is “Nothing,” and the other two questions can be ignored.If either pH, PaCO2, or HCO3- are abnormal, check the pH. If it’s below 7.4, the answer to “What is wrong?” is “Acidosis.” If above 7.4, “Alkalosis.”If the pH is within the normal range, but the PaCO2 or HCO3- (or both) are abnormal, an acid-base derangement exists, but the body has fully compensated for it. For example, with a pH of 7.35 (normal) and a decreased bicarbonate of 18, an acidosis exists.Check pH, PaCO2, HCO3-.Anything abnormal? If no, quit.pH greater than 7.4 = alkalosispH less than 7.4 = acidosisThe second question is “What caused it?” The answer is “Metabolic” if bicarbonate has caused the observed change in pH from7.4. If carbon dioxide caused it, the answer is “Respiratory.” If both are guilty, the answer is “Mixed metabolic and respiratory.”First look at the bicarbonate. Is it guilty?Increased bicarbonate raises the pH. Low bicarbonate lowers the pH. If you see a pH above 7.4 and the bicarbonate is elevatedabove normal, it means bicarbonate is guilty of raising the pH. So a metabolic alkalosis exists.If the bicarbonate is above 7.4 and the bicarbonate is decreased or normal, bicarbonate is not guilty.

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