ECG Tutorial Part 2 - Dr. Johnston Flashcards
1st degree AV block is what
PR segment is longer then 0.2sec
= due to the AV node problem
1st degree AV Block is seen when
- Atherosclerosis, HTN, DM, *
- Fibrosis like in Congenital HD*
- CAD ischemia
- Drugs like CCB, B.B, Anti-arrhymias
- Thyroid problem or adrenal insufficiency
- Inflammation or amyloidosis, hemochromatosis, sarcoidosis
- Valvular calcification
2nd degree AV Block types
- Mobitz type 1 (Wenckbach) : progressive PR prolongation before dropped QRS
= Grouped Beats, there is a pattern - Mobitz type 2
Mobitz type 1 (Wenckbach) is what and associated with
Mobitz type 1 (Wenckbach) : progressive PR prolongation before dropped QRS, “grouped beats” = pattern
= progressive lengthening of PR (since the impulse from SA to AV comes to early during refractory period)
= associated with Inferior wall MI
= transient
Mobitz type 1 (Wenckbach) :causes
- Digitalis toxicity
- Ischemic event (inferior MI)** seen in leads 2,3, AVF
- Myocarditis
- Right coronary artery disease
- Edema around AV node
Mobitz type 1 (Wenckbach) : looks like
Narrow QRS , longer and longer PR before the dropping of QRS
= 40-55bpm
What do you see in MI inferior wall
ST elevation : leads 2, 3, AVF
ST depression : leads 1, AVL
Mobitz type 2 associated with a prognosis
- Ischemic heart disease
- Anterior wall MI
- Conductive system degeneration
- LAD coronary artery disease
= worse prognosis then type 1, progressive and irreversible
Mobitz type 2 looks like and where is the block
PR stays the same in the length
Drops QRS at any point, wide QRS
20-40bpm
= anyplace distal to AV node, bundle of his, bundle branches, fascicularis branches
3rd degree AV Block is what and types (above and below AV node block)
A and V are not communicating at all and work independently
- Above AV block : Junctional rhythm ——> narrow QRS (40-55bpm)
- Below AV Block : Ventricular Pacemaker ——> Wide QRS (20-40bpm)
3rd degree AV Block TX
pacemaker if sustained
3rd degree AV Block causes
- Ischemic HD
- Infiltration disease
- Cardiac surgery : (Bypass, valve, myocarditis, degenerative)
3rd degree AV Block looks like
P and QRS have different HRs and not any pattern to when they show up next to each other
Oder of activation of wall in the ventricles
- Left ventricular septa ——> RIGTH ventricular septa
- To bottom RIGTH ventricular wall ——> upper RIGTH ventricular wall
- Bottom left V wall ——> upper left V wall
BBB ( Bundle Branch Block) looks like
- QRS is wider then 3 small boxes (0.12sec)
2. ST segment and T wave opposite of QRS (seen I premature ventricular contractions)
RBBB which leads should you look at
1, AVL, 6, V1, V2
RBBB what happens
After septum in activated
The left ventricle is activated first and then the right is activated
RBBB looks like what on EKG
QRS is wide and notched (R’)
ST in opposite direction
RIGHT LEAD = R, S, R’
Left side of heart is seen in what leads and what do you see in RBBB
1, V5, V6, AVL = wide R wave with and wide S wave present
RIGTH side of heart in what leads and looks like what in RBBB
V1* and V2* (can have notches), and V3
= R, S, R’
Wide fat QRS
LBBB what happens
Left septum does not activate
Right septum activates first traveling to left septum
Then RIGTH V and last Left ventricle
LBBB what do you see
- No Q wave in V5, V6 (left side heart) + inverted ST
2. DEEP Q and S wave in V1 and V2 (right side heart)
LBBB causes
- HTN
- Ischemia
- Aortic Stenosis
- Cardiomyopathy
- LAD ——> myocardial dysfunction
- RAD ——> Congestive cardiomyopathy
Leads to look at for LBBB
1 (wide R and R’), V6, ALV, V5, = all look the same **
V1/ V2 / V3 (very deep wide or narrow Q and S)**
Hemiblocks are what
Blocks after the bifurcation of the left bundle
Hemiblocks directions it can happen and what does each ekg look like
- Left Anterior (superior fascicle) = more common, upside down QRS, so its R, narrow S at inferior AVF, and normal 1
- Left Posterior (inferior fascicle), normal QRS at AVF and upside down at 1
- NO hemiblock, normal QRS in 1 and AVF
Left anterior Hemiblocks
Left posterior Hemiblocks
Axis
LAH : left axis (+1, -AVF), more then -60degrees
LPH : right axis (-1, +AVF), more ten 120 degrees
LAH : small Q and small R leads
- Small Q : 1, AVL
2. Small R : AVF, 2,3
LPH : small Q and small R leads
- Small R : 1, AVL
2. Small Q : AVF, 2,3
LAH causes
- LAD occlusion MI**
- conduction system disease
What can see the exact type of hypertrophy imaging
Echocardiogram
LAE
RAE
LVE = LVH
RVE = RVH
Left atrial enlargement
RIGTH atrial enlargement
Left ventricular enlargement = LV hypertrophy
RIGTH V E = Right ventricular hypertrophy
Atrial enlargement causes
- Dilitation : high Blood V in chamber
- Hypertrophy : High resistance to BF out of chamber
- V overload
Atrial enlargement leads to look at and which chamber enlarges first
first the right then left
LEADS : 1, 2, 3, V1 (dont need to know)
P wave normal EKG characteristics
- NOT 3mm high
2. Pointed, notched, wide, tall is not normal (normal = rounded)
V1 and 2 RAE looks like P wave
Lead 2 : pointed at top then wider at base
V1 : pointed and then dips down a little before PR segment finishes
V1 and 2 LAE looks like P wave
Lead 2 : 2 bumps looking like an M, only both are round humps
V1 : one round normal and then dips down before PR segment finishes (looks normal)
V1 and 2 LAE + RAE looks like P wave
dont need to know
Lead 2 : 2 humps at the top the first is pointed and the second one in round (M looking )
V1 : pointed iceberg and then dips down round and deeper then normal
RAE associated with 2 things
- Tricuspid valve disease
2. Lung : Pulmonary HTN, COPD, PE, asthma, mitral valve disease
LAE associated with what 2 things
Mitral stenosis
Mitral Regurgitation
Inverted P wave means
AV node junction origin P waves problem in leads 2 and 3
Ventricular Hypertrophy causes
Excess V during Diastole and need more P to eject blood during systole
LVH most common causes
HTN**
Aortic valve problems, hypertrophic cardiomyopathy, coarction or aorta
LVH EGK looks like and leads
Increased Voltage V5 and V6, AVL, 1 (high R)
Deep WRS in V1 and V2 (deep S)
Scoring system for LVH
Romhilt - Estes Scoring System (4-5 score is yes)
Sokolow Lyon Criteria
= R wave 2.5 boxes AVL ——> 5 boxes 1 and V6
ST sloping down line until it hits the T wave means
Stenosis some kind of straining
RVH causes
LUNG** = COPD
= Tetrology of Fallot
= tricuspid problem regurgitation
RVH axis and leads with high S and high R
RIGTH axis
- High R : leads V1, AVF,3
- high S : V6, 1, AVL
High K EGK
Rises RMP and slows conduction and widens QRS
= TALL peaked T waves, longer PR segment, can loose P wave (looks like a sine wave)
Low K EGK
Rises RMP = increases automaticity and more irregular firing
= U wave, prolong QT interval, flat or inverted T wave
Low Ca EGK
Prolong QT, flatten T wave = arrhythmia (Torsades de Pointes)
High Ca EGK
Shortens QT interval
Short ST segment
Acidosis EGK
More vulnerable to re-enter arrhythmias like tachy and such
Hypokalemia causes
= Dietetics , metabolic alkalosis, high aldosterone (Conn’s, Cushings)
= B-agonist overdose
= Diarrhea
= seen in hospital often
Hypokalemia U wave is seen in what leads
2, V3, V4
Hyperkalemia causes
= renal failure
= metabolic acidosis, DKA, cell breakdown
TX hyperkalemia
- Dialysis
- Insulin and glucose
- Na HCO3
- Albuterol
- Renin binding agents
Hypercalcemia causes
= hyoerparathyroidism
= malignancy
= TB, sarcoidosis (granulomatous disease)
= hyperthyroidism
Hypothermia EKG
Bradycardia
= J wave (Osborne wave) ——> wave going up from S wave looking like a tall peak T wave before the actual T wave (RAISED ST SEGMENT)
= looks like 2 ice bergs
PE EGK
SOB, CXR normal = Tachy = ST depression in lead 2 1. S1Q3T3**= deep S wave in lead 1, deep Q in lead 3 and inverted T in lead 3, and V1-V4**** 2. Transient RBBB****
WPW (Wolff-Parkinson’s)is what
White syndrome
= SHORT PR segment + sudden tachy
= slurred P wave to QRS ——> this is a Delta wave
= accessory AV conduction pathway is present ——> Bundle of Kent and this bypasses normal AV conduction **
Delta wave
After p wave ends concave (J) looking line up to the R
WPW (Wolff-Parkinson’s) associated problems these pt have and leads to look at
Tachycardia, palpitations, near fainting spells for months
= leads V1-V6
Brugada Syndrome prevalence
AD, Asian male, young age
Predisposed to sudden death and cardiac arrhythmias
= NA+ channel opathy
Brugada Syndrome EKG looks like
= elevated ST segments (ski slope looking on way down) before the inverted T wave
= lead V1, V2, V3
= can also see RBBB
Wellens syndrome EGK
T wave inversion big
V2, V3
= can happen in LAD disease
Long QT syndrome
Normal QT is less then 1/2 R—>R interval
If longer then that = predisposed to ventricular arrhythmia
Pericarditis EKG
Raised ST segment in like an convex way (upside down U in some way) or concave*
= in ALL leads , how you can tell its probable not an MI
