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The Art of EKG Rhythm Interpretation

St. George's University, Emergency Medicine Club
by

Joe Rauscher

on 18 September 2016

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Transcript of The Art of EKG Rhythm Interpretation

The Art of EKG
Rhythm Interpretation

Anatomy Review
Mechanical
Electrical
Electrophysiology
Ion Movement
Excitable Myocytes
Cardiac Action Potential
Intrinsic Rates
Concentration Gradients
Transmembrane Potential
Impermeability
Transmembrane Proteins
Ion Channels
Voltage Gated
Ligand Gated
Pacemaker Cells
SA, AV
Specialized Rapidly Conducting Tissues
Atrial and Ventricular Myocytes
EKG - Graph
Time vs. Voltage
Heart Rate
Calculations
Axis Standards
X-axis = Time
25 mm/sec
vs. 50 mm/sec
Y-axis = Voltage
0.1 mV/mm
(1 mV/cm)
Rate
Small Boxes = 1500/17 = 88
Large Boxes = 300/3 = 100 ... (alternatively 300/3.5 = 86)
Quick HR = # of QRS in 6 seconds x10 = 9 x 10 = 90
EKG
Rhythm Analysis

Lead II
Where to start? Where to Look?
At the beginning :)
Intervals
P = 0.08 - 0.10 s
PRI = 0.12 - 0.20 s
QRS =
0.06 - 0.10 (0.12)
What do we want to know?
Rate
R-R Interval (Regular vs. Irregular)
P Waves (Interval, Presence and Morphology)
PR Interval
QRS (Interval, Presence and Morphology)
T Wave (Morphology)
Morphology and Labeling of the QRS
Q Wave = First Negative Deflection
R Wave = First Positive Deflection
S Wave = The Negative Deflection below the isoelectric line following a Q or R
J Point = Where the QRS ends and the ST segment begins
Approach to the EKG
EKG
Physiology
Patient
QRS Axis
Atrial Rhythms
Rate: 88 (1500/17) or 75<100 (300/4>3)
Regularity: Regular
P waves: Regular, Present for each QRS, Upright and Round
PRI: 0.18
QRS: 0.06 (narrow), Regular, Present for each P wave,Uniform
T waves: Upright
Answer: Sinus Rhythm
Rate: 34 (1500/44) 37 (300/8)
Regularity: Regular
P waves: Regular, Present, Upright and Round
PRI: 0.16
QRS: 0.08 (narrow), Regular, Present for each P, Uniform
T wave: Upright
Answer: Sinus Bradycardia
Rate: 115 (1500/13) or 120 (300/2.5) (100<150)
Regularity: Regular
P waves: Regular, Present for each QRS, Upright, Round
PRI: 0.16
QRS: 0.06 (narrow), Regular, Present for each P, Uniform
T waves: Upright
Answer: Sinus Tachycardia
Rate: 88 (mostly) (1500/17) (100 - 107) *80* (6 second strip)
Regularity: Irregular (has some regular R-R intervals)
P waves: Present for each QRS, Each P is different in shape and direction
PRI: variable (all <0.20)
QRS: 0.06 (narrow), Present for each P wave, Uniform
T waves: Upright
Answer: Wandering Atrial Pacemaker

(If Rate > 100: Multifocal Atrial Tachycardia)
Rate: 57 (1500/26) or 60 (300/5)
Regularity: Regular
P waves: Regular, Present, Round, Upright
PRI: 0.10
QRS: 0.14 (wide), Regular, Present for each P, Uniform
Note: seemingly narrow complex with wide base
Note: slurring of R wave is known as a delta wave
T waves: Upright
Answer: Sinus Rhythm with WPW pre-excitation pattern
Note: Anticipated Clinical Course
Junctional Rhythms
Rate: 188 (1500/8) or ~150 (300/2)
Regularity: Regular
P waves: Unknown
PRI: Unknown
QRS: 0.04 (narrow), Regular, Uniform
T waves: Upright
Answer: SVT (Supraventricular Tachycardia)
SVT
Indeterminate Rhythm
Sinus Rhythm
Ventricular
Rhythms

Rate: 48 (1500/31) 50 (300/6)
Regularity: Regular
P Waves: Present for each QRS, Uniform, Inverted
PRI: 0.12
QRS: 0.06 (narrow), Present for each P,
T waves: Present
Answer: Junctional Rhythm
Rate: 115 (1500/13) 120 (300/2.5) 100 (300/3)
Regularity: Regular
P waves: Regular, Present for each QRS, Inverted
PRI: 0.10
QRS: 0.04 (narrow), Regular, Present for each P, Uniform
T waves: Upright
Answer: Accelerated Junctional
Rate: 79 (1500/19) 75 (300/4)
Regularity: Regular with noted Gaps
P waves: Regular,
Not Present for each QRS
, Upright, Round
PRI
: 0.16 (
Consistent when QRS is present
)
QRS: 0.10 (narrow),
Not Present for each P
, Uniform
T waves: Inverted
Answer: Second Degree AV Block Type II
Mobitz II
Rate: 88 - 100 (1500/17 - 1500/15)
Regularity: Regular - Slightly irregular, Noted gap
P waves: Regular*,
Not Present for each QRS
, Upright, Pointed
PRI
: 0.18 (
Consistent when QRS is present
)
QRS: 0.06 (narrow),
Not Present for each P
, Uniform
Note: Aberrant Complex
0.08 (narrow), different axis than the other QRS, no P wave
(Junctional Escape Beat)
T waves: Inverted
Answer: Second Degree AV Block Type II
Mobitz II
Rate: 63 (1500/24) 60 (300/5)
Regularity: Regular
P waves: Regular, Present for each QRS, Upright, Round
PRI: 0.34
QRS: 0.08 (narrow), Regular, Present for each P, Uniform
T waves: Upright
Answer: First Degree AV Block
Rate: 52 (1500/29) 55 (300/5.5) 50 (300/6)
Regularity: Regular with noted gap
P waves: Regular,
Not Present for each QRS
, Upright, Round
PRI:
Increasing with each complex
, (No PRI for 5th P wave)
QRS: 0.06 (narrow), Regular (with gap),
Not Present for each P
, Uniform
T waves: Present
Answer: Second Degree AV Block Type I
Mobitz I
Wenckebach
Rate:
QRS: 33 (1500/45) 33 (300/9)
P: 75 (1500/20) 75 (300/4)
Regularity: Regular
P waves:
No Pattern associated with QRS
, Uniform, Round, Upright
PRI:
Inconsistent, no pattern
QRS: 0.24 (
Wide
),
No Pattern associated with P
, Uniform
T waves: Present
Unable to discern - check other leads (axis)
Answer: Third Degreee AV Block
Complete Heart Block
Rate: 71 (1500/21) 75 (300/4)
Regularity: Regular*
P waves: Regular, Present for each QRS, Upright and Round
*Aberrant P - Sinusoidal, Associated with QRS
PRI: 0.14
QRS: 0.06 (narrow), Regular, Present for each P wave, Uniform
*Aberrant QRS - 0.06 (narrow), Associated with P
T waves: Upright
Answer: Sinus Rhythm with PAC (Premature Atrial Contraction)
Rate: 71 (1500/21) 75 (300/4)
Regularity: Regular* (with aberrant complex)
P waves: Regular, Present for each QRS, Upright and Round
PRI: 0.14
QRS: 0.06 (narrow), Regular, Present for each P wave, Uniform
*Aberrant QRS - 0.06 (narrow), No Associated P wave
T waves: Upright
Answer: Sinus Rhythm with PJC (Premature Junctional Contraction)
Rate: 71 (1500/21) 75 (300/4)
Regularity: Regular*
P waves: Regular, Present for each QRS, Upright and Round
PRI: 0.18
QRS: 0.08 (narrow), Regular, Present for each P wave, Uniform
*Aberrant QRS-1: 0.28 (Wide), No Associated P wave
*Aberrant QRS-2: 0.36 (Wide), No Associated P wave
T waves: Upright
Answer: Sinus Rhythm with Multifocal PVC's (Premature Ventricular Contractions)
(If they were the same shape with same axis they are termed Unifocal)
Rate:
QRS: 36 (1500/41) 38 (300/8)
P: 83 (1500/18) 75 (300/4)
Regularity: Regular
P waves:
No Pattern associated with QRS
, Uniform, Round, Upright
PRI:
Inconsistent, no pattern
QRS: 0.20 (
Wide
),
No Pattern associated with P
, Uniform
T waves: Present
Unable to discern - check other leads (axis)
Answer: Third Degreee AV Block
Complete Heart Block
Rate: 42 (1500/35) 42 (300/7)
Regularity: Regular
P waves: Absent
PRI: N/A
QRS: 0.14 (Wide)
T waves: Inverted
Note: May be inverted normally
Answer: Idioventricular Rhythm (IVR)
Rate: 250 (1500/6) 300 (300/1)
Regularity: Regular
P waves: Absent
PRI: N/A
QRS: 0.14 (Wide)
T waves: Upright
Note: May be upright or inverted
Answer: Ventricular Tachycardia
(VTach, VT)
Answer: VTach
VTach Criteria
***only
one
of these needs to be met for it to be considered VTach***
1: Extreme Right Axis Deviation + Positive V1
2: QRS Morphology in V1 or V6
V1: Positive, Taller Left 'peak', or Slurring to R wave
V1: Negative, 'fat' R wave, notching/slurring on Q or S wave
V6: Any negative complex, Qr complex with a 'fat' Q
3: Right Axis Deviation + Negative V1
4: Concordance V1 to V6 (Up or Down)
5: RS Interval (any V lead) is >100 msec
6: QRS >140 msec
Answer: VTach
Rate: 375 (1500/4) 300 (300/1)
Regularity: Regular
P waves: N/A
PRI: N/A
QRS: 0.12 (wide)
Note: Alternating amplitude of QRS "a twisting ribbon of points"
T waves: Unable to discern
Answer: Torsades de Pointes
Rate: 300 (1500/5) 300 (300/1)
Regularity: Regular
P waves: N/A
PRI: N/A
QRS: 0.14 (wide)
Note: Alternating amplitude of QRS "a twisting ribbon of points"
T waves: Unable to discern
Answer: Torsades de Pointes
Rate: Unknown (fast)
Regularity: Irregular
P waves: N/A
PRI: N/A
QRS: N/A
Note: Although there isn't a complex here, there is still uncoordinated electrical activity
T waves: N/A
Answer: Ventricular Fibrillation
Rate: "0" [39 (1500/38)]
Regularity: "Regular"
P Waves: Present, round, upright
PRI: N/A
QRS: N/A
T Waves: N/A
Answer: Asystole
P Wave Asystole
Rate: 0
Regularity: N/A
P waves: N/A
PRI: N/A
QRS: N/A
T waves: N/A
Answer: Asystole
St. George's University

Emergency Medicine Club
EKG Rhythms
http://www.sguemc.com
http://www.facebook.com/groups/sguemc/
secretary@sguemc.com
Joe Rauscher, AAS, BS, NRP, FPC
MD Candidate, St. George's University

jrausch1@sgu.edu
Sinoatrial Node
Atrioventricular Node
Purkinje Fibers
0.04 Seconds
(40 msec)
0.20 seconds
(200 msec)
What's the Heart Rate?
P
Rate: 75 (300/4)
Regularity: Regular
P waves: N/A
Note: Saw-toothed appearance of atrial waves
Note: 4x 'teeth' for each QRS
PRI: N/A
QRS: (?) Narrow
T waves: Unable to discern
Answer: Atrial Flutter (4:1)
Rate: ~ 110 (6 second strip method)
(5.5 complexes/3 seconds)
Regularity: Irregular
P waves: Unable to discern
Note: unorganized atrial electrical activity
PRI: N/A
QRS: 0.08 (narrow), uniform
T waves:
Answer: Atrial Fibrillation
Rate: 200 (6 second strip method)
Regularity: Irregular
P waves: None seen
PRI: N/A
QRS: 0.08 (narrow), uniform (generally)
T waves: Upright
Answer: Atrial Fibrillation with a Rapid Ventricular Response
(AFib with RVR)
(SVT)
St. George's University
Emergency Medicine Club

"J" Point
Fast, Slow or Normal?
Is it a nice pretty pattern or does it look weird?
Are the intervals the same or different?
12-Lead EKG:
Morphological Variance
& Pathology

Myocardial Pathology due to Hypoxia
Bundle Branch Blocks
& Hemiblocks

Hypertrophy
LVH vs. RVH

Notable EKG's
EKG Changes & Toxicology
St. George's University
Emergency Medicine Club

Hypoxia
Ischemia
Injury
Infarction
Acute vs. Old
Ischemia
Injury/Infarct
Septal
Inferior
Anterior
Lateral
Inferoposterior
Anterolateral
LAFB
Rapid Axis
RBBB
LBBB
LPFB
LVH Criteria
RVH Criteria
RVH Criteria
Right axis deviation of +110° or more
Dominant R wave in V1 (> 7mm tall or R/S ratio > 1)
Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1)
QRS duration < 120ms (i.e. changes not due to RBBB)
Supporting Criteria
Right atrial enlargement (P pulmonale)
Right ventricular strain pattern
ST depression / T wave inversion in the right precordial (V1-4) and inferior (II, III, aVF) leads
S1 S2 S3 pattern
Far right axis deviation with dominant S waves in leads I, II and III
Deep S waves in the lateral leads (I, aVL, V5-V6)
RBBB (complete or incomplete may be caused by RVH)
Causes
Pulmonary hypertension
Mitral stenosis
Pulmonary embolism
Chronic lung disease (cor pulmonale)
Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
Dysrhythmogenic right ventricular cardiomyopathy
Pathophysiology and the EKG

The left ventricle hypertrophies in response to pressure overload secondary to conditions such as aortic stenosis and hypertension.

This results in increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3).

The thickened LV wall leads to prolonged depolarisation (increased R wave peak time) and delayed repolarisation (ST and T-wave abnormalities) in the lateral leads.

***Voltage criteria must be accompanied by non-voltage criteria
to be considered diagnostic of LVH***
Voltage Criteria
Limb Leads
Precordial Leads
R wave in lead I + S wave in lead III > 25 mm
R wave in aVL > 11 mm
R wave in aVF > 20 mm
S wave in aVR > 14 mm
R wave in V4, V5 or V6 > 26 mm
R wave in V5 or V6 plus S wave in V1 > 35 mm
Largest R wave plus largest S wave in precordial leads > 45 mm
Non-voltage Crtieria
Increased R wave peak time > 50 ms in leads V5 or V6
ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern
Left atrial enlargement
Left axis deviation
ST elevation in the right precordial leads V1-3 (“discordant” to the deep S waves)
Prominent U waves (proportional to increased QRS amplitude)
Other findings with LVH
Causes
Hypertension
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Coarctation of the aorta
Hypertrophic cardiomyopathy
Pericarditis
Pulmonary Embolus
Hyperkalemia
Inhibitors of fast Na+ channels
Cardiovascular drugs:
Type Ia antidysrhythmics
Quinidine, Disopyramide, Procainamide
Type Ic antiarrhythmics
Flecainide, Encainide, Propafenone, Moricizine
Beta Blockers
Propranolol & Others*
Calcium Channel Blockers
Verapamil, Diltiazem
Psychiatric drugs:
Carbamazepine
Cyclic antidepressants
Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Maprotiline)
Neuroleptics
Thioridazine, Mesoridazine
Other antidepressants
Citalopram
Antipsychotics
Loxapine
Other drugs:
Amantadine, Chloroquine, Hydroxychloroquine, Orphenadrine
Antihistamines
Diphenhydramine
Narcotic
Propoxyphene
Illicit drugs:
Cocaine
Toxins:
Quinine, Saxitoxin, Tetrodotoxin
EKG Changes
QRS widening
Right bundle branch pattern
R wave elevation in aVR lead
Rightward deviation of QRS axis
Ventricular tachycardia (VT) and ventricular fibrillation (VF)
Bradycardia with wide QRS complex
Asystole
ST/T changes consistent with ischemia (cocaine toxicity)
Inhibitors of outward K+ channels
1. Cardiovascular drugs:
Class IA antidysrhythmics**
Disopyramide, Quinidine, Procainamide
Class IC antidysrhythmics
Encainide, Flecainide, Moricizine, Propafenone
Class III antidysrhythmics**
Amiodarone, Dronedarone, Dofetilide, Ibutilide, Sotalol, Vernakalant
Anti-anginal/vasodilators*,**
Bepridil, Prenylamine, Terodiline
Antihypertensives
Ketanserin*
2. Psychiatric drugs:
Antipsychotics
Chlorpromazine, Droperidol, Haloperidol, Mesoridazine, Pimozide, Quetiapine, Risperidone, Thioridazine, Ziprasidone
Cyclic antidepressants
Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Maprotiline
Other antidepressants
Citalopram, Venlafaxine
Phenothiazines
3. Other drugs:
Antihistamines
Astemizole, Diphenhydramine, Loratidine, Terfenadine*, Hydroxyzine
Serotonin 5-HT4 receptor agonist
Cisaprid*,**
Antimicrobials and antimalarics
Ciprofloxacin, Gatifloxacin,Levofloxacin, Moxifloxacin, Sparfloxacin, Clarithromycin**, Erythromycin**, Pentamidine**, Chloroquine**, Halofantrine, Hydroxychloroquine, etc.
Arsenic trioxide
Probucol*
4. Synthetic opioids:
Levomethadyl
5. Opium alkaloids:
Papaverine**
6. Toxins:
Quinine, Organophosphates
EKG Changes
QT interval prolongation
T- or U-wave abnormalities
Premature ventricular beats
Sinus tachycardia
Inhibitors of Slow Calcium Channels
1. Dihydropyridines:
1st generation: Nicardipine, Nifedipine
2nd generation: Felodipine, Isradipine, Nimodipine
3rd generation: Amlodipine, Nitrendipine
4th generation: Lercanidipine, Lacidipine
2. Phenylalkylamine:
Verapamil
Gallopamil
3. Benzothiazepine:
Diltiazem
4. Non-selective:
Bepridil
Mibefradil
Fluspirilene
EKG Changes
Sinus bradycardia
Reflex tachycardia
ex. Nifedipine
Varying degrees of AV block
Sinus arrest with AV junctional rhythm
Asystole
Wide QRS complex
ST/T changes
Other Toxicological EKG Changes
Na+/K+ ATPase blockers
Digoxin
Beta-adrenergic blockers
Sympathetic Inhibiting Agents
Sympathomimetics
Anticholinergics
Cholinomimetics
Chemical Asphyxiants
Poisonous Animals/Plants
Illicit Drugs
Organophosphate Poisoning
The "Ladle Sign"
Patterned ST Depression - 2 or more contiguous leads
ST Elevation in 2 or more contiguous leads
Medical Conditions
that we can diagnose
and/or support with
EKG Changes

Accelerated idioventricular rhythm
Accelerated junctional rhythm
Arrhythmogenic right ventricular dysplasia
Atrial flutter
Atrial fibrillation
Atrial tachycardia
Automatic junctional tachycardia
AV block: 1st degree
AV block: 2nd degree, Mobitz I (Wenckebach)
AV block: 2nd degree, Mobitz II
AV block: 2nd degree, “fixed ratio blocks”
AV block: 2nd degree, “high grade AV block”
AV block: 3rd degree
AVNRT (AV-nodal re-entry tachycardia)
AVRT (atrioventricular re-entry tachycardia)
Benign early repolarization
Beta-blocker toxicity
Bidirectional VT
Bifascicular block
Biventricular enlargement
Biatrial enlargement
Brugada syndrome
Calcium-channel blocker toxicity
Carbamazepine cardiotoxicity
Cardiomyopathy, dilated
Cardiomyopathy, hypertrophic
Cardiomyopathy, restrictive
Chronic obstructive pulmonary disease (COPD)
De Winter’s T waves
Dextrocardia
Digoxin effect/toxicity
Ectopic atrial tachycardia
Ectopic beats, atrial, junctional, ventricular
Electrical alternans
Escape rhythms, junctional, ventricular
Fascicular VT
Fusion beats
Hypercalcemia
Hyperkalemia
Hyperthyroidism
Hypocalcemia
Hypokalemia
Hypomagnesemia
Hypothermia
Hypothyroidism
Interventricular Conduction Delay (QRS widening)
Intracranial haemorrhage
Intrinsicoid deflection
Junctional tachycardia
Lead reversals: Limb Lead Reversals
Lead reversal: Left arm/right arm
Left atrial enlargement
Left anterior fascicular block
Left axis deviation
Left bundle branch block
Left BBB with MI (Sgarbossa criteria)
Left main coronary artery occlusion
Left posterior fascicular block
Left ventricular aneurysm
Left ventricular hypertrophy
Lown-Ganong-Levine syndrome
Low QRS Voltage
Movement artifact
Multifocal atrial tachycardia
Myocardial ischemia
Myocarditis
Non-paroxysmal junctional tachycardia
Pacemaker rhythms: Normal pacemaker function
Pacemaker malfunctions: Failure of capture, pacemaker-mediated tachycardia, etc.
Paroxysmal atrial tachycardia (PAT)
Pediatric ECG
Pericardial effusion / tamponade
Pericarditis
Persistent ST elevation (LV aneurysm morphology)
Polymorphic ventricular tachycardia
Poor R wave progression (PRWP)
Preexcitation
Premature complexes, atrial
Premature complexes, junctional
Premature complexes, ventricular
Pulmonary disease, chronic
Pulmonary embolism
QRS widening
Quetiapine toxicity
Raised intracranial pressure
Right atrial enlargement
Right axis deviation
Right bundle branch block
Right ventricular hypertrophy
Right ventricular MI
Right ventricular outflow tract tachycardia
Right ventricular strain
R-wave peak time
Shivering artifact
Short QT syndrome
Sinus rhythm
Sinus arrhythmia
Sinus bradycardia
Sinus node dysfunction (Sick sinus syndrome)
Sinus node exit block
Sinus node reentrant tachycardia
Sinus pause / arrest
Sinus tachycardia
Sodium channel blocker overdose
ST elevation in aVR (LMCA/3VD)
STEMI, anterior
STEMI, high lateral
STEMI, inferior
STEMI, lateral
STEMI (old)
STEMI, posterior
STEMI, right ventricular
Subarachnoid haemorrhage
Supraventricular tachycardia (SVT)
Tako Tsubo Cardiomyopathy
Torsades de Pointes
Tremor artifact
Tricyclic overdose (sodium-channel blocker toxicity)
Triple vessel disease
Trifascicular block
Ventricular aneurysm
Ventricular fibrillation
Ventricular flutter
Ventricular tachycardia: Fascicular VT
Ventricular tachycardia: Monomorphic VT
Ventricular tachycardia: Overview of VT
Ventricular tachycardia: Right Ventricular Outflow Tract (RVOT) tachycardia
VT versus SVT with aberrancy
Wellens Syndrome
Wolff-Parkinson White Syndrome
Joe Rauscher, AAS, BS, NRP, FPC
MD Candidate, St. George's University

jrausch1@sgu.edu
http://www.sguemc.com
secretary@sguemc.com
http://www.facebook.com/groups/sguemc/
St. George's University

Emergency Medicine Club
12-Lead Morphology
Axis V1 V5 QRS Other changes
Sinus tachycardia
most common; 44% of patients
Complete/incomplete RBBB
associated with increased mortality; 18% of patients
Right ventricular strain pattern
T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF)
This pattern is seen in up to 34% of patients and is associated with high pulmonary artery pressures
Right axis deviation
16% of patients
Extreme right axis deviation may occur (0 and -90)
Gives an appearance of left axis deviation
Dominant R wave in V1
Manifestation of acute right ventricular dilatation.
Right atrial enlargement (P pulmonale)
Peaked P wave in lead II > 2.5 mm in height
Seen in 9% of patients
SI QIII TIII Pattern
Deep S wave in lead I, Q wave in III, inverted T wave in III.
This “classic” finding is neither sensitive nor specific for pulmonary embolism
Only 20% of patients with PE
Clockwise rotation
Shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation
Atrial tachyarrhythmias
AF, flutter, atrial tachycardia
Seen in 8% of patients
Non-specific ST segment and T wave changes, including ST elevation and depression
Up to 50% of patients with PE
Pulmonary Embolus
Widespread concave ST elevation and PR depression throughout
Limb leads (I, II, III, aVL, aVF)
Precordial leads (V2-6)
Reciprocal ST depression and PR elevation
Lead aVR (± V1)
Sinus tachycardia is also common in acute pericarditis due to pain and/or pericardial effusion
Pericarditis
K = 9.2
Serum potassium
> 5.5 mEq/L
is associated with
repolarization abnormalities
:

Peaked T waves (usually the earliest sign of hyperkalaemia)

Serum potassium
> 6.5 mEq/L
is associated with
progressive paralysis of the atria
:

P wave widens and flattens
PR segment lengthens
P waves eventually disappear

Serum potassium
> 7.0 mEq/L
is associated with
conduction abnormalities and bradycardia
:

Prolonged QRS interval with bizarre QRS morphology
High-grade AV block with slow junctional and ventricular escape rhythms
Any kind of conduction block (bundle branch blocks, fascicular blocks)
Sinus bradycardia or slow AF
Development of a sine wave appearance (a pre-terminal rhythm)

Serum potassium level of
> 9.0 mEq/L
causes
cardiac arrest
due to:

Asystole
Ventricular fibrillation
PEA with bizarre, wide complex rhythm
Hyperkalemia
K = 7.0
Special Thanks:
Dr. Edward Burns
Sydney Rescue Helicopter Base
Life in the Fast Lane
Dr. Tomas Garcia
12-Lead ECG: The Art of Interpretation (2015)
Catalina Lionte, Cristina Bologa and Laurentiu Sorodoc
Toxic and Drug-Induced Changes of the Electrocardiogram, Advances in Electrocardiograms - Clinical Applications, PhD. Richard Millis (Ed.) (2012)
Circumflex (LCx)
Circumflex (LCx)
Circumflex (LCx)
Circumflex (LCx)
LAD
LAD
LAD
LAD
RCA
RCA
RCA
ST Elevation
V1, V2
ST Elevation
II, III, aVF
ST Elevation
V3, V4
ST Elevation
I, aVL (V5, V6)
ST Elevation
II, III, aVF, V4R
ST Elevation
I, aVL, V3, V4, V5, V6
Reciprocal Changes
None/
Inferior
Reciprocal Changes
Lateral
, Anterior
Reciprocal Changes
None
/Inferior
Reciprocal Changes
Inferior
Reciprocal Changes
Inferior
Reciprocal Changes
Lateral
Diagnosis of Exclusion
s in Lead I
q in Lead III
Must Exclude Criteria for
RAE, RVH, RAH, P-pulmonale
Diagnostic Criteria
LAD (-30 to -90)
qR or R in Lead I
rS in Lead III
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