EKG Interpretation

Kristopher R. Maday, MS, PA-C, CNSCUniversity of Alabama at Birmingham

Physician Assistant ProgramPegasus Emergency Group

@PA_Maday #FNPintensive

What we will accomplish today• List the(my) steps to reading EKG

• Analyze normal electrical progression for all 12 leads

• Relate anatomy of the coronary vessels to an EKG

• Recognize common rhythms seen on EKG

• Identify life-threatening conditions on EKG

Steps to Reading EKG• Rate• Rhythm• Axis• Hypertrophy/Enlargement• P-Q-R Waves• Intervals• Ischemia• Miscellaneous

Rate

Rhythm• Need to identify:• Rate• Tachycardia, bradycardia, junctional

• Regular vs Irregular• If irregular, is it regular or irregular?

• Ectopic beats• PVCs, PACs, dropped beats

Arrhythmia

Axis

QRS Deflection Axis DeviationLead I aVF

Positive Positive NormalPositive Negative Left Axis Deviation

Negative Positive Right Axis Deviation

Ventricular HypertrophyLeft Ventricular

Hypertrophy• LAD• S wave in V1 or V2 + R

wave in V5 or V6 > 35mm

Right Ventricular Hypertrophy

• RAD• Large R wave and

inverted T wave in V1• R/S ratio > 1

Atrial EnlargementLeft Atrial

Enlargement• P wave > 0.12s in lead

II• Diphasic or inverted P

wave in V1

• Notched P wave in limb leads

Right Atrial Enlargement

• P wave > 2.5mm in lead II and/or > 1.5mm in V1

P-Q-R Waves• P-Wave• Married to every QRS complex

• Q-Wave• Indicative of old infarct

• R-Wave Progression in precordial leads

Intervals• PR Interval• < 0.2s

• QRS Interval• < 0.08s

• QT Interval • < ½ R-R interval

Ischemia• ST Segments• Measured at J-point• Elevation• Depression

• T-Wave• Normal - always upright in leads I, II, V3-6, and inverted in

aVR• Inverted in ischemia

Miscellaneous• Electrolyte Imbalances• Potassium• Magnesium• Calcium

• Delta wave• W-P-W syndrome

Coronary Anatomy and EKG Lead CorrelationAxis Leads Coronary Vessel

Inferior II, III, and aVF RCA and/or LCxSeptal Anterior V1, V2 V3, V4 LADLateral V5, V6, I, aVL LCx or Diagonal of LAD

Patient #1• 45yo male presents to PCP for pre-operative

screening for arthroscopic ACL repair• Medications• Pantoprazole 40mg daily

• Past Medical History• GERD

• Vital Signs• BP-121/72, HR-78, RR-12, O2-100%, temp-98.9o

Rate - 75Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement - None

P-Q-R Waves – married, no Q, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes

Patient #2• 64yo female with a 2 hour history of chest pain• Medications• Lisinopril10mg daily, Metoprolol 50mg daily, Metformin

500mg BID, Simvastatin 40mg daily• Past Medical History• HTN, DMII, HLD

• Vitals• BP-164/101, HR-62, RR-19, O2-100%, temp-98.7o

Rate - 60Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement - LVH

P-Q-R Waves – married, Q in III, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – STE in II, III, and aVF, STD in aVLMiscellaneous – no changes

Patient #3• 47yo female with a 1 week history of

“palpitations” following a cold 2 weeks ago• Medications• Amlodipine 10mg daily

• Past Medical History• HTN

• Vitals• BP-131/74, HR-82, RR-17, O2-100%, temp-98.8o

Rate - 60Rhythm - IrregularAxis – Normal axisHypertrophy/Enlargement - None

P-Q-R Waves – not all married, no Q, good progression Intervals – elongating PR, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes

Patient #4• 73yo male with 2 week history of shortness of

breath• Medications• HCTZ 25mg daily, Lisinopril 10mg daily, Metoprolol 25mg

daily, Rosuvastatin 20mg daily, ASA 81mg daily• Past Medical History• HTN, CAD, HLD• 1997 – NSTEMI with stents x 3

• Vitals• BP-128/71, HR-86, RR-19, O2-100%, temp-98.2o

Rate - 90Rhythm – Irregularly, irregularAxis – Normal axisHypertrophy/Enlargement - None

P-Q-R Waves – no P waves, no Q, good progression Intervals – no PR, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes

Patient #5• 14yo female coming in for athletic physical.

Occasional palpitations on exertion• Medications• None

• Past Medical History• None

• Vitals• BP-110/61, HR-72, RR-15, O2-100%, temp-98.7o

Rate - 75Rhythm - RegularAxis – Normal axisHypertrophy/Enlargement – LVH, LAE

P-Q-R Waves – married, lateral Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, prolonged QTIschemia – no ST changesMiscellaneous – no changes

Patient #6• 68yo female with a 1 month history of pre-

syncope and dizziness• Medications• Levothyroxine 0.25mcg daily, Metoprolol 25mg daily

• Past Medical History• Hypothyroidism, HTN

• Vitals• BP-137/81, HR-52, RR-16, O2-100%, temp-98.4o

Rate - 47Rhythm – Regular, bradycardiaAxis – Normal axisHypertrophy/Enlargement – none

P-Q-R Waves – married, no Q waves, good progression Intervals – PR>0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – no changes

Patient #7• 59yo male with a 3 day history of palpitations• Medications• Novolin 70/30 before meals, Lantus 40mg qHS,

Olmesartan 40mg daily, Epoetin 50U/kg • Past Medical History• DM, HTN, ESRD

• Vitals• BP-157/95, HR-92, RR-15, O2-100%, temp-98.9o

Rate - 107Rhythm – Regular, tachycardiaAxis – Normal axisHypertrophy/Enlargement – RAE

P-Q-R Waves – married, anterior Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – no ST changesMiscellaneous – peaked T waves

Patient #8• 19yo female with a 20min of a “panic attack”• Medications• Alprazolam 1mg TID, Fluoxetine 20mg daily

• Past Medical History• General Anxiety Disorder

• Vitals• BP-164/99, HR-194, RR-25, O2-100%, temp-99.2o

Rate - 220Rhythm – Regular, tachycardiaAxis – LADHypertrophy/Enlargement – none

P-Q-R Waves – no P waves, no Q waves, good progression Intervals – no PRI, QRS<0.1s, QT<1/2 R-RIschemia – widespread ST depressionMiscellaneous – no changes

Patient #9• 41yo female with a 2 history of chest pain and

dyspnea• Medications• Loestrin 21, Propanolol 60mg daily, Propylthiouracil 50mg

TID• Past Medical History• Hyperthyroidism

• Vitals• BP-148/97, HR-78, RR-24, O2-94%, temp-98.4o

Rate - 72Rhythm – RegularAxis – RADHypertrophy/Enlargement – RVH

P-Q-R Waves – married, Q waves in lead III, large, notched R wave in V1-3Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – T wave inversion V1-4 and lead IIIMiscellaneous – no changes

Patient #10• 54yo male with a 2 day history of palpitations• Medications• ASA 81mg daily, Plavix 300mg daily, Simvastatin 80mg

daily, Metoprolol 50mg daily, Amlodipine 10mg daily• Past Medical History• HTN, CAD• 5/2014 – NSTEMI with stents x 3

• Vitals• BP-137/81, HR-70, RR-16, O2-100%, temp-98.8o

Rate - 65Rhythm – RegularAxis – LADHypertrophy/Enlargement – none

P-Q-R Waves – multiple P waves, no Q waves,

good progressionIntervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – noneMiscellaneous – no changes

Patient #11• 62yo male presents for medical clearance for

aortic valve replacement• Medications• Irbesartan 150mg daily, Diltiazem 180mg daily

• Past Medical History• Hypertension• Aortic stenosis

• Vitals• BP-131/76, HR-65, RR-16, O2-100%, temp-98.6o

Rate - 65Rhythm – RegularAxis – LADHypertrophy/Enlargement – ?LVH?

P-Q-R Waves – married, no Q waves, poor progression and broad R wave in lateral leadsIntervals – PR<0.2s, QRS>0.12s, QT<1/2 R-RIschemia – ?STE in anterior leads?Miscellaneous – tiny R and deep S in anterior leads

Patient #12• 23yo female with a 6 month history of intermittent

palpitations• Medications• Depo-Provera

• Past Medical History• None

• Vitals• BP-121/76, HR-60, RR-15, O2-100%, temp-98.7o

Rate - 60Rhythm – RegularAxis – RADHypertrophy/Enlargement – RVH

P-Q-R Waves – married, no Q waves, large R wave in anterior leadsIntervals – short PR, QRS>0.12s, QT<1/2 R-RIschemia – T wave inversion in V1-3

Miscellaneous – delta wave

Patient #13• 61yo male who had a 30min history of chest pain

that has since resolved• Medications• Phenytoin 300mg daily, Celebrex 200mg daily

• Past Medical History• Epilepsy, Osteoarthritis

• Vitals• BP-129/79, HR-70, RR-15, O2-100%, temp-98.8o

Rate - 70Rhythm – RegularAxis – LADHypertrophy/Enlargement – none

P-Q-R Waves – married, no Q waves, good progressionIntervals – PR<0.2s, QRS<0.12s, borderline QTIschemia – Deep T wave inversion in V1-6

Miscellaneous – none

Patient #14• 31yo Asian-American male with an episode of

syncope• Medications• None

• Past Medical History• None

• Vitals• BP-119/72, HR-100, RR-14, O2-100%, temp-98.3o

Rate - 100Rhythm – RegularAxis – normalHypertrophy/Enlargement – ?LVH?

P-Q-R Waves – married, no Q waves, good progressionIntervals – PR<0.2s, QRS<0.12s, QT<1/2 R-RIschemia – STE in V1-2, STD in V4-6,

T wave inversion in V1-3Miscellaneous – none

Brugada SignCoved STE with T wave inversion

Patient #15• 63yo female with 30 minute history of chest pain

while accompanying her husband to the ED with a stroke

• Medications• HCTZ50mg daily, Lisinopril 10mg daily, Amytriptyline

75mg daily• Past Medical History• HTN, Fibromyalgia

• Vitals• BP-168/93, HR-84, RR-16, O2-100%, temp-98.4o

Rate - 82Rhythm – RegularAxis – LADHypertrophy/Enlargement – none

P-Q-R Waves – married, no Q waves, good progression Intervals – PR<0.2s, QRS<0.1s, QT<1/2 R-RIschemia – STE in V1-4

Miscellaneous – Hyperacute T waves

Websites to Bookmark• Life In The Fast Lane • http://lifeinthefastlane.com/

• Amal Mattu – UMD Emergency ECG • http://ekgumem.tumblr.com/

• Dr. Stephen W. Smith ECG Blog • http://hqmeded-ecg.blogspot.com

• Learn The Heart• http://www.learntheheart.com/

• EKG Library• http://www.ecglibrary.com/ecghome.html

• Dr. Frank Yanowitz ECG Learning Center• http://ecg.utah.edu/

Thank You For Your Time

Kristopher R. Maday, MS, PA-C, CNSCAssistant Professor, Academic Coordinator

Physician Assistant ProgramEmail: maday@uab.edu

Twitter: @PA_Maday