ECG Interpertation - Brown Flashcards by Amanda Kroymann

Identify this condition based on symptoms and the rhythm strip presented:

pt complains of palpitations, shortness of breath with exertion, fatigue, and edema

exam reveals irregular pulse, variable BP, crackles on ascultation

Atrial Fibrillation

Rate: Variable, usually fast > 100 bpm
Rhy: Irregularly irregular (chaotic)
P-wave: Not consistently present or reproducible
PR: Not measurable
QRS: Normal (narrow,

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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Identify this condition based on symptoms and the rhythm strip presented:

pt reports feeling light-headed and having fainted

signs: rapid HR

Paroxysmal Supraventricular Tachycardia

Rate: 140 - 250 bpm*
Rhy: Very Regular
P-wave: Lost in the T-wave, not typically observed on rhythm strip
PR: Not measurable
QRS: Normal (narrow,

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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What pathology is present?

Rate: Variable, usually fast > 100 bpm

Rhy: Irregularly irregular (chaotic)

P-wave: Not consistently present or reproducible

PR: Not measurable

QRS: Normal (narrow,

Atrial Fibrillation

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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Differential Diagnosis for a Wide-QRS Complex

in order of descending mortality

hyperkalemia
ventricular tachycardia
idioventricular rhythm, including heart block
drug effects and overdose (tricyclics)
Wolff-Parkinson-White
Bundle Branch Blocks & IVCD
PVCs
Aberrantly conducted complexes

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What pathology is present?

Rate: Atrial rate 250 – 400 Ventricular rate Varies

Rhythm: Regular or Irregular

P-waves: Saw tooth deflection (F waves)

PR: Not measurable

QRS: Typically normal

Atrial Flutter

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

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Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

Rhythm Determination on an ECG

Is the distance between one QRS complex the same as the others?

If yes - the rhythm is regular

If no - the rhythm is irregular

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Insignificant Q Waves

do not meet the criteria for significance
typically found in leads: I, aVL, V4-V6

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Criteria for Diagnosis of MI: Injury Pattern

ST segment elevation (1 mm or greater)
T wave peaks initially then inverts later

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Criteria for Diagnosis of MI: Infarction Pattern

Presence of SIGNIFICANT Q WAVES

Q wave that is 1/3 total height of QRS
wider than 40 ms

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What pathology is described and shown on the ECG below:

QRS > 120 ms

rSR’ pattern V1-V2

slurred S-wave in I and V6

Right Bundle Branch Block

QRS > 120 ms
Axis is RAD or normal
rsR’ pattern V1-V2
slurred S-wave in I and V6
NSSTT changes in V1 and V2

Describe the specific diagnostic criteria for Bundle branch blocks.

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Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

Axis Determination

on the ECG look at Limb Lead 1 and determine if the net deflection of the QRS complex is positive, negative or equal
on the ECG look at Limb Lead aVF and determine if the net deflection of the QRS complex is positive, negative or equal
determine where the lines cross

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Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

ECG: Right Axis Deviation

right bundle branch block
right ventricular hypertrophy
high lateral wall MI
right anterior fascicular block

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ECG Waveforms

(PQRST)

P wave: atrial depolarization

QRS wave: ventricular depolarization, also atrial repolarization occurs

J Point: end of the QRS wave and start of the ST segment

T Wave: ventricular repolarization

U Wave: late repolarization variant, can be a normal variant or assoicated with hypokalemia or hypomagnesiumemia

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R-Wave Progression

uses the precordial chest leads V1-V6
r-wave (myocardial rotation) progresses from V1 through V6
start small V1
transition occurs V3,V4
get big V6

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Identify the common variances within normal ECGs.
Describe the specific diagnostic criteria for normal ECGs .

“Normal” ECG

P waves upright in: I, II, V2-V6
Small Q waves in: I, aVL, V4-V6
Deep Q waves in: aVR occassionally III and V1
T waves upright in: I, II, V3-V6
T waves inverted in: aVR
T waves variable in: III, aVL, aVF, V4-V6

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Identify the pathology described below and shown on the ECG:

PR interval < 120 ms, normal P waves

Wide QRS complex

Presence of “delta-wave”

Wolff Parkinson White

“delta-wave” intial slurring of QRS

can also have secondary ST-T changes

What pathology is present?

Rate: 140-250 bpm

Rhythm: regular

P-Wave: not typically observed

PR: not measurable

QRS - normal (narrow < 0.12 sec)

Paroxysmal Supraventricular Tachycardia

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

QT Interval

measures a complete ventricular cycle (depolarization and repolarization)
start of QRS to end of T wave
normal is heart rate dependent
- HR of 60 - 400 ms
- HR of 100 - 320 ms
as HR increases, QT interval decreases
QT is probably prolonged if it exceeds more than HALF of the R-R interval

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

QRS Interval

QRS

normal < 3 boxes)
beginning of QRS to end (J-Point)
length of time for ventricular contraction
prolonged interval
- bundle branch blocks
- IVCD
- WPW
- LVH
- RVH
- ventricular tachycardia
- PVCs
- idoventricular rhythm

Develop a simple method that will allow you to consistently assess unknown ECGs for common pathologies.*
*

Gestalt - general impression (i.e. this is bad)
Determine the Heart Rate
Determine the Rhythm
Measure the Longest Interval (PR, QRS, QT) in the limb leads
Determine the Axis
Asses the R-Wave Progression

Evaluate this rhythm strip:

Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

Paroxysmal Supraventricular Tachycardia

Rate: 140 - 250 bpm*
Rhy: Very Regular
P-wave: Lost in the T-wave, not typically observed on rhythm strip
PR: Not measurable
QRS: Normal (narrow,

Reentry process, presents abruptly for numerous reasons

Symptoms: light-headedness, syncope, racing heart; worsen angina and heart failure

Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals

ECG: Left Axis Deviation

left bundle branch block
left ventricular hypertrophy
inferior wall MI
left anterior fascicular block

How to differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.

Is the rhythm regular?

yes: PVST or atrial flutter
no: atrial fibrillation or atrial flutter

Are P-waves (F-waves) present?

yes: atrial flutter
no: PVST or atrial fibrillation

Criteria for Diagnosis of MI: Ischemia

ST segment depression (2 mm or greater)
T wave inversion (symmetrical)

What pathology is described and shown on the ECG below? QRS \> 120 ms Wide S waves V1-V4 Wide R waves in I and V6

Left Bundle Branch Block * QRS \> 120 * Axis is normal or LAD * wide monomorphic S waves V1-V4 * wide monomorphic R waves in I and V6 * NSSTT changes in most leads *Describe the specific diagnostic criteria for Bundle branch blocks.*

*Identify the common variances within normal ECGs. Describe the specific diagnostic criteria for normal ECGs.* what to note/evaluate on each ECG lead

* location and morphology of P waves * QRS pattern (presence of Q-waves) * ST segment (elevation or depression) * T wave changes \*\*Review all leads except aVR

Differential Diagnosis of ST-Elevation

* Acute STEMI * Printzmetal's Angina * Ventricular Aneurysm * Pericarditis * Normal Variant - early repolarization

Evaluate this rhythm strip:

**Atrial Flutter** Rate: Atrial rate 250 – 400 Ventricular rate Varies Rhythm: Regular or Irregular P-waves: Saw tooth deflection (F waves) PR: Not measurable QRS: Typically normal *Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.*

Evaluate this Rhythm Strip:

**Atrial Fibrillation** Rate: Variable, usually fast \> 100 bpm Rhy: Irregularly irregular (chaotic) P-wave: Not consistently present or reproducible PR: Not measurable QRS: Normal (narrow, Symptoms: palpitations, SOB, fatigue, DOE, CP, edema Signs: irregular pulse, variable BP, crackles edema Causes: organic heart disease, valvular disease, thyroid, HTN *Differentiate between atrial fibrillation, atrial tachycardia, and atrial flutter.*

System to Evaluate Rhythm Strips

* Determine Heart Rate * Determine Rhythm * Presence of P-wave (location and morphology) * a single P-wave should proceed each QRS complex * should bear a family resemblance to all other P-waves * Measure PR and QRS intervals

*Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals* Heart Rate Determination on an ECG

Paper speed is 25 mm/sec or 300 big boxes per second take 300 divided by the number of big boxes from 1 QRS to the next i.e. in this example: 300/3.8 = ~80

*Analyze the basic ECG components required to assess pathology to include, heart rate, rhythm, axis, and intervals* PR Interval

PR: * normal: 120-200 ms (3-5 boxes) * beginning of P wave to the beginning of the QRS complex * best measured in limb lead 2 * conduction through the AV node * short PR interval: * pre-excitation syndrome (WPW, LGL) * PACs * long PR interval - lots of causes * refered to as "First Degree AV Block"