Methodsfordeterminingrate: Rate=300/# oflargeboxesinRRinterval Countthe#oflargeboxesinRRintervalandmemorize300/150/100/75/60/50/43 CountthenumberofQRSinasixsecondspan(30largeboxes)andmultiplybyten this isespeciallyhelpfulforirregularrhythms Justlookatthetop oftheEKG

Chamberenlargement RAE EKG:Tall peakedPwave>2.5mVinII,tallinitialupstrokeofPinV1,nlPwavewidth Causes:TR,RVH, ASD,PulmHTN LAE

EKG:NotchedPwaveinII,negativedeflection PwaveinV1,Pwiderthan.11sec Causes:MS,MR,LVH

RVH EKG:RAD,R>SinV1,R>7mminV1,R>5mminaVR,Swave<2mminV1, SokolowLyon voltagecriteria:Rin V1+SinV5orV6>1.1 mV Causes:Pulm disease,pulmemboli,congenital heartdisease,PS,sleepapnea LVH EKG:LAD,DeepSwavesinV1& V2,prolongedQRS,STdepression&asymmetricT waveinversioninleftsideprecordial leads,voltagecriteria: o SokolowLyonCriteria:SinV1orV2+RinV5orV6>3.5mVRinV5orV6 >2.6mVRinaVL>1.2mV o Cornell Criteria:Females:RinaVL+SinV3>2mV Males:RinaVL+SinV3 >2.8mV Causes:HTN,AS,HOCM Strainpattern: EKG:DownslopingconvexSTsegmentwithanasymmetrically invertedTwave oppositetotheQRSaxisinleadsV5and/orV6 Extra:Markerofincreasedcardiovascularrisk,especiallyinHTNpatients Lowvoltage EKG:QRS<5mminalllimbleadsor<10inallprecordialleads Causes:pericardial effusion,obesity,diffuseCAD,restrictiveCMY,myxedema,COPD (onlyprecordialleads) Rwaveprogression EKG:Normally QRSbecomepositiveinV3orV4 Causesofearly Rwaveprogression:posteriorMI,RVH

CausesofpoorRwaveprogression:anteriororseptalMI,LVH,LBBB,COPD, cardiomyopathy,normalvariant

Axis: RAD EKG:+90180 inI,+inaVF Causes:pulmHTN,PS,PE,RVH,congenitalheartdisease,lateralMI,LPFB,pacing LAD EKG:3090+inI,inaVF,inII Causes:LVH,aging,inferiorMI,LAFB,pacing

AVBlock: Firstdegreeblock EKG:PR>.2sec,constantPRinterval Causes:Dig,BB,CCB,ClassICantiarrythmics,increasevagaltone,hyperkalemia, inferiorMI,myocarditis,agerelateddegeneration SeconddegreeblockMobitzI(Wenckebach) Characteristics:BlockoccurswithintheAVnode,usuallytransient EKG:PRlengthens& RRgetsshorter untilQRSdropped,PPconstant,irregular rhythm duetodroppedbeats,narrowQRS Causes:Dig,BB,CCB,ClassICantiarrythmics,increasevagaltone,inferiorMI, ischemicheartdisease,myocarditis,normalvariant SeconddegreeblockMobitzII Characteristics:BlockoftenfoundbelowbundleofHiswithinbundlebranchsystem,can progresstoCHBwithoutwarning EKG:PRconstant,PPisregular,irregularrhythmduetodroppedbeats,QRSabitwider thannormal Causes:AnteriorMI,agerelateddegeneration Treatment:Pacemaker,especiallyifsymptomatic Thirddegreeblock(Completeheartblock) Characteristics:Completeabsenceofconductionwith AVdissociation EKG:PP&RRintervalsareconstant,atrial& ventricularratesaredifferent,no relationshipbetweenP&QRS,useQRSwidth&ventricularratetodetermineescape pacerlocation Causes:Dig,BB,CCB,ClassICantiarrythmics,MI,increasevagaltone,myocarditis, endocarditis,agerelateddegeneration,cardiacsurgery,congenital Treatment:Pacemaker

Bundleblocks: RBBB EKG:QRS>.12sec,rSRinV1&V2,widedeepSinleftsideleads,downslopingST &invertedTinV1&V2 Causes:RVH,RVstrain,congenital disease(ASD),primarypulmonarydisease,CAD, myocarditis,degenerativeconductiondisease,WPW,unknowncauses LBBB EKG:QRS>.12sec,widedeepSinV1&V2,rsRinleftsideleads,ST&Toriented oppositetoQRS Causes:STEMI,LVH,cardiomyopathy,HTN,CAD,WPW,idiopathicdegenerative disease LAFB Characteristics:Singlelong& thinbloodsupply,morevulnerable EKG:LAD,small q&tallRinleftleadssmallr&deepSininferiorleads,poor Rwave progression LPFB Characteristics:Doubleshort& thickbloodsupply,suppliesmorearea&moreserious EKG:RAD,smallr&deepSinleftleadssmallq&tallRininferiorleads

Rhythm: Normalsinusrhythm EKG:uprightPwavesinI,II,V1withconstantmorphology,PP&RRintervalsare equal&regular,atrial& ventricularratesidentical60100 Supraventriculardysrhythmias: PrematureAtrialComplexes EKG:IrregularRRinterval,PwaveshapedifferentfromthesinusP Extra: IfAPCoccursearly&AVnodeisnotrepolarized,Pwavewillbeblockedandnot conductcausingapause Atrialtachycardia Characteristics:Rhythmoriginatinginatria,butoutsideSAnode,rate120250 EKG:PP&RRintervalequal,PwavesdifferentfromsinusP AtrialFlutter Fwavesatatrialrate250350,regularorirregulardependingonconduction, QRSnarrow Atrialfibrillation fwavesatatrialrate>350,irregularRR,QRSnarrow Wanderingpacemaker Characteristics:Pacerfrom2ormoresitesinatria

EKG:Pwaveshapevaries,PP&RRintervalsvary,QRSunchanged&narrow, rate60 100 Extra:MATsimilar,exceptwith3ormoreatrialfoci,rate100250,associatedwith COPD

Paroxysmal SVTreentrycircuits AVNRT o Characteristics:Morecommon,downmicroreentry circuitinAVnode, conductedrapidlydownasecondpathway inAVnode o EKG:RetrogradePusuallyburiedorbarelyseen,usuallyventricularrate100200 AVRT o Characteristics:Usesamacroreentrycircuitcalledbundleof Kentbypassingthe AVnode o EKG:RetrogradePcommonlyseenafterQRS,usuallyventricularrate>100 o OrthodromicAVRTmorecommon Characteristics:DownAVnodetoventricles&backupatria narrowQRS o AntidromicAVRT Characteristics:Downbypasstracttoventricles&backupthroughAV nodewideQRS.LookslikeVTbutirregularlyirregularwithsomevery shortRRintervals. NoAVnodalagents(BB,CCB,Dig)!!

WolfParkinsonWhite EKG:PRinterval<.12sec,wideQRS,deltawave TypeA o Characteristics:Bypasstractlinksleftatrium&ventricle o EKG:PositiveQRSinV1 TypeB o Characteristics:Bypasstractlinksrightatrium &ventricle o EKG:NegativeQRSinV1 Junctional escaperhythm EKG:Rate4060,regular,narrowQRS,Pbefore,beforeorburiedinQRS Extra:Acceleratedjunctional rhythmisrate60100,junctionaltachycardiais>100 Ventricularescaperhythm EKG:Rate1540,regular,wideQRS Extra:Acceleratedidioventricularrhythmisrate40100,ventriculartachycardiais>100 Ventriculardysrhythmias: Prematureventricularcomplex Characteristics:prematureectopicimpulseoriginatingbelowbundleofHis EKG:IrregularRR,QRSwide&differentshape,ST&Tareinoppositedirectionofthe ectopicQRS,compensatorypauseassinusnodeisnotreset

VentriculartachycardiawideQRS,threeormorebeatsinarow,complexesroughly similarin appearance,regular Ventricularflutter rate250300 Ventricularfibrillation nocardiacoutput,heartrateorblood pressureearlyuseecoarseVfib, laterisfinerVfib Ventricularasystolenowaveforms TorsadesdePointes Characteristics:AvariantofVTach,associatedwithprolongedQT EKG:VTachwhereQRStwistaroundbaseline Causes:ClassIA drugs,ClassIII drugs,electrolyteabnormalities(hypokalemia, hypomagnesia,hypocalcemia),psychotropicdrugs,liquidproteindiet,congenitalQT prolongation,MI Treatment:discontinueoffendingagent,fixelectrolytes,cardioversion,magnesium, lidocaine,isoproterenol,dilantinoroverdrivepacingbetablockersforcongenitalLong QTSyndrome,butnotacquiredforms CluesforVTach Characteristics:Morelikelyifhistoryofcardiomyopathyorischemicheartdisease EKG:QRS>.14sec, regular,LADat90to180,AVdissociation,precordialleadsall positiveornegative CluesforSVTwith aberrancy EKG:QRS<.14sec,irregular,initialpartofQRSresemblesnormalQRS

Ischemia,infarct: Ischemia Characteristics:Temporaryreversiblebloodflowreduction EKG: InvertedsymmetricTwavesorpseudonormalizationofapreexistingTwave inversion Injury Characteristics:Fromacuteprolongedreductioninbloodsupply,reversiblyifflow establishedbeforedeathoccurs EKG: STdepressionrepresentssubendocardialinjury STelevationrepresents subepicardialinjury Infarction Characteristics:Irreversibledeath EKG: SignificantQwaveswhichare>25%ofRwaveheightand>.04sec Seepage39forAngiographiccorrelation&EKGchangesofvariousMIs

EKGinvariousmedicalconditions: Hypothermia Characteristics:Depressedelectrical&mechanicalactivity EKG: Sinusbrady,PRprolongation,QRSwidening,QTlengthening,ventricular dysrhythmias,Osbornwaves(Jwave)intheterminalportionofQRS Extra:HeightofJwaveproportionaltothedegreeofhypothermia CVA Characteristics:Affectsrepolarization,resolvesovertime EKG: TallpeakedordeeplyinvertedTwaves,wideTwaves,prolongedQT,prominent Uwaves,Qwaves PE Characteristics:Acuterightheartstrain EKG: AcuteRAD,RAE,newRBBB,S1Q3T3(Swaveinlead1,QwaveinleadIII, invertedTinIII)

COPDRAD,RAE,RVE,lowvoltage,poorRwaveprogression HypothyroidLowvoltage,sinusbrady,invertedTwithoutSTdeviationinmostleads HyperthyroidSinustachy,supraventriculardysrhythmias Pericarditis EKG: WidespreadconcaveupST elevationineveryleadexceptaVR,nopathologicQ, PRdepression Extra:Withresolution ofpericarditis,elevatedSTsegmentsresolve,butTwavesmay invertorbecomebiphasicandstaythatwayforweeks Ventricularaneurysm PersistentSTelevation,maystayforyears ASDRBBB,RAD,RAE,RVH MSLAE,RVH,supraventriculardysrhythmias ASLAE,LVH Orthotopictransplant EKG:occasionally2PwavesarepresentfromaretainednativeSAnode,nonspecific STchanges,normalrestingbaselinetachycardia Rejection:lowvoltage,prolongedPR,RAD,RBBB,dysrhythmias Drugeffects: Digoxin Digeffect:STdepressionininferior&lateralleadsandlookscoopedout&coved, elevatedsegmentinV1,flattenedorinvertedT,shortenedQTc,prolongedPR,depressed J,decreasedventricularrate

Digtoxicity:similartodigeffect,significantPRprolongation,supraventricular& ventriculardysrhythmias,highdegreeAVblock

IAdrugsProlongedQTc,widenedQRS,STdepression,Twavechanges,prominentU IBShortenedQTc ICProlongedPR,widenedQRS,prolongedQTc,serious&refractoryventricular dysrhythmias III ProlongedQTc Electrolyteabnormalities: Hypokalemia Characteristics:Prolongsrepolarization EKG: Tflatteningorinversion,UwavesbestinV2V4,TUfusion,STdepression, prominentP,prolongedPR Hyperkalemia Characteristics:Abnormalslowingofconduction EKG: Initially,therearetall peakedTwavesbestinV2V4&wideflatorabsentP waves.Inseverecases,thereswidenedQRS& QRSTfusion thatprogresstosinusoidal waveform.Also,canseeSTdepression,prolongedPRtoAVblock,ventricular dysrhythmias Hypomagnesiasimilartohypokalemia Hypermagnesiasimilartohyperkalemia HypocalcemiaprolongedST,prolongedQTc,dysrhythmias HypercalcemiashortenedST,shortenedQTc, dysrhythmias QTc=QT/RR