Jennifer Carlquist PA-C, ER CAQ SVMH, Central Coast Cardiology, CHOMP ER, Watsonville ER - GAPA

Jennifer Carlquist PA-C, ER CAQ
  SVMH, Central Coast Cardiology,
CHOMP ER, Watsonville ER

Disclosures

Objectives

 Review normal cardiac conduction
 Rhythm review
 How to assess heart rate
 10 step program to assess an EKG
 Normal EKG review
 Where’s the STEMI?
 Trouble Shooting

Pop Quiz

Name that tune…

Back to Basics

What makes this a normal EKG?

Normal conduction

You have to know what normal is to know what
abnormal is.
 Introducing…. NSR.
 When the president is in charge.

Who runs the heart?

 President
 VP
 Secretary
 Speaker of House

 The heart is like a committee – every member has
  a vote and voice

You need 1
 “man” in
             60-100
  charge
             40-60

         20-40
                 0-20

When everyone tries to overthrow the government

When the president goes on vacation…

Patient dizzy. PMD put her on Metoprolol 100
                mg for HTN.

CHADS2VASC: 3. Treatment?

Sinus Tachycardia

    Rate: >100 – 160 BPM

    Regularity: Regular

    P wave: Present, PR interval constant

__________________ and _________ can cause sinus tachycardia.

SVT

These patients will most likely have a ___________ blood
                        pressure.

36 y/o military wife with four kids

Atrial Fibrillation
Rate: Variable, ventricular response can be fast or slow.
Regularity: Irregularly irregular
P wave: None; chaotic atrial activity

                          Patients lose their ___________ in atrial fibrillation.

10 Step Program
1.What is my general impression?
2.Is there anything that sticks out?
3.What is the rate?
4.What are the intervals?
5.What is the rhythm?
6.What is the axis?
7.Is there any hypertrophy?
8.Is there any ischemia or infarction?
9.What is the differential diagnosis of the abnormality?
10. How can I put it all together with the patient?

These numbers……MATTER

 PR Interval - .12 - .20 (120 ms – 200 ms)
 QRS Complex - below .12 (120 ms)
 QT Interval – below 460 ms

 A normal QRS should be no longer than ____ boxes

Is this EKG normal?

Rate: 60 – 100 BPM
PR: 120-200 MS
QRS: under 120 MS
QTc: 460 MS
Axis: 0 - 90

It is as easy as this…
P – P wave? PR interval?
Q – QRS – wide? QT interval? Q Wave?
R – Rate? Rhythm? RR interval?
S – ST elevation?
T – T waves (shape, size, position)

Nitty Gritty Basics

Six second method

Example EKG

 Lets look at the intervals

Problem P waves

T Wave
 Corresponds to the rapid ventricular repolarization
 Normally rounded and positive
 R on T phenomenon

T Wave Mugshots

What is happening here?

LAD occlusion

Q Waves
Non Pathologic Q waves
Q waves of less than 1/3 R

Pathologic Q waves
1/3 height of R wave

Pathologic Q waves

What part of the heart can we not see here?

Which ones are “contiguous”?

             AVR       VI
 Lead I                              v4

II           AVL       V2            v5

III          AVF       V3            V6

“Reciprocal changes”

Where’s the STEMI
       MI

Is this a STEMI?

How I approach an EKG

• Fast/ Slow    • Arrhythmia   • MI

Intervene       Intervene      Intervene

Second Tier Triage

      Subtle MI

       Stemi
       Mimic

      C/C based

Palpitations
                                    tree
Getting to the
root of the
cause
                 AFIB/Flutter
                                                  PVC’s
                       SVT WPW        Sick sinus VT

Priority Chief Complaints

 Palpitations – WPW, SVT, AF. VT
 Chest pain – MI, S1, q3, T3
 Dyspnea – MI, s1, q3, t3, R axis, LVH
 Dizzy light headed – Arrhythmia, QT,
  WPW
 Weakness – EVERYTHING
 Dialysis – peaked T, slow rate

17 year old with Palpitations

 WAVE
 PR interval (

Lets try our six second method…

Weakness in a 70 year old

Really, computer?

Is the hr correct?

Somatic Tremors

“Toothbrush Tachycardia”

Baseline Sway

Figure 4-4: Baseline Sway

60-Cycle Interference

Figure 4-5: 60-Cycle Interference

Take Home Points

 The president should always run the heart
 Don’t trust the EKG interpretation
 PQRST
 The EKG family should always be holding hands
 Memorize your intervals
 Know the big bad wolves

Jcarlquist.com

References
   12-Lead ECG: The Art Of Interpretation – Tomas Garcia

   Friberg L, Rosenqvist M, Lip GY. Evaluation of risk stratification schemes for ischaemic stroke
    and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort
    study. Eur Heart J 2012; 33:1500.

   Electrophysiology: Ventricular tachycardia: diagnosis of broad QRS complex tachycardia.
    AU Wellens HJ
   SO Heart. 2001;86(5):579

   Miller JM, Hsia HH, Rothman SA, et al. Ventricular tachycardia versus supraventricular
    tachycardia with aberration: electrocardiographic distinctions. In: Cardiac
    Electrophysiology From Cell to Bedside, Zipes DP, Jalife Jose (Eds), W.B. Saunders,
    Philadelphia 2000. p.696.

   Akhtar M, Shenasa M, Jazayeri M, et al. Wide QRS complex tachycardia. Reappraisal of a
    common clinical problem. Ann Intern Med 1988; 109:905.