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INTERPRETATION of ELECTROCARDIOGRAMS

Dive into the world of interpreting electrocardiograms with this detailed outline covering the approach to ECG analysis, unusual cases, and the seven-step approach focusing on rate, rhythm, axis, intervals, hypertrophy, ST/Tw changes, Q waves, and the conduction system. Learn about anatomical localization of ECG findings and normal variants, as well as explore intriguing real-life cases illustrating key principles. This guide by Dr. Brian D. Le, MD, from Presbyterian Hospital, offers a robust resource for understanding and mastering ECG interpretation skills.

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INTERPRETATION of ELECTROCARDIOGRAMS

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  1. INTERPRETATION of ELECTROCARDIOGRAMS BRIAN D. LE, MD Presbyterian Hospital CIVA

  2. Outline • Approach to interpretation of ECGs • Cases illustrating approach principles • Unusual Cases

  3. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  4. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  5. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  6. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  7. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  8. INTERVALS PR < 200 ms QRS < 120 ms QTc: Men < 440 ms, Women < 460 ms

  9. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  10. Left Ventricular Hypertrophy • Cornell +R (aVL)+Sw(V3)>24mm (male) >20mm (female) • Sokolow S(V1) + R(V5)=32mm • Rw (aVL)>11mm • Rw (I)>14mm

  11. Right Ventricular Hypertrophy • 1. RAD>100* • 2. IRBBB • 3. R>S V1 • 4. R<S V6 • 5. R in V1>=7mm • 6. R V1 + S V5 or V6 >=10mm • 7. RAE • 8. strain pattern in rt precordial leads

  12. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  13. ANATOMICAL LOCALIZATION ANTERIOR: V1-V4, SEPTAL V1-V2 LATERAL: V5-V6, I, Avl INFERIOR: II, III, aVF

  14. Seven Step Approach • Rate • Rhythm • Axis • Intervals • Hypertrophy • ST/Tw changes, Q waves • Conduction system

  15. LBBB • QRS > 0.12 sec • wide monophasic R in I, V5 and V6 • (usually notched or slurred) • no Q in I, V5 and V6 • Left Anterior Fascicular Block • LAD > -30', + I, aVR, -II/III/aVF • qR in I and L • rS in II, III and aVF • Left Posterior Fascicular Block • RAD > 100' • small R in I and aVL, Q in II, III, aVF • S1 Q3 pattern • RBBB • QRS>0.12 sec • R' > r in right precordium • wide S in I, V5 and V6

  16. Normal Variants- Juvenile Tw inversions

  17. Nuts and Bolts

  18. Electrode Misplacement

  19. Amplitude Artifact

  20. Parkinson’s Tremor

  21. CASES

  22. Case 1: 21 yo presents for routine physical exam

  23. DEXTROCARDIA

  24. Case 2: 38 yo with one week of URI presents with chest pain

  25. Acute Pericarditis • Stage I--ST elevation, Tw upright, • PR depression • Stage II--ST baseline, flattened Tw • Stage III--inv Tw • Stage IV--Tw baseline, days to wks

  26. Case 3: 48 yo homeless man found unresponsive

  27. Hypothermia

  28. Case 4: 34 yo ESRD missed three days of dialysis

  29. Hyperkalemia

  30. Case 5: 28 yo woman s/p neck surgery

  31. Hypocalcemia

  32. Case 6: 32 yo female on antidepressants had syncope

  33. Acquired Long QT Syndrome

  34. Case 7: 60 yo man with chest pain

  35. Inferior MI with RV infarction and 2:1 and complete heart block

  36. 2:1 Heart block with ventriculophasic effect

  37. Case 8: 80 yo man with syncope

  38. Aflutter with complete heart block Aflutter with complete heart block Aflutter with normal conduction

  39. Aflutter with 1:1 conduction

  40. Aflutter with carotid sinus massage

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