1. EKG Interpretation Susan P. Torrey, MD, FACEP, FAAEM Associate Professor of Emergency Medicine Tufts University School of Medicine Faculty, Baystate Medical Center Springfield, Massachusetts

2. A systematic review of every EKG Rhythm Rate Axis Intervals –PR –QRS –QT Chamber enlargement, esp. LVH Ischemia or infarct

3. Rate – method #1

4. Rate – method #2

5. Rate – method #3 Rate = 300 ÷ # “big boxes” between R-R 300 – 150 – 100 – 75 – 60 – 50

6. 1 – rate and rhythm?

7. 2 – rate and rhythm?

8. 3 – rate and rhythm?

9. Axis Left RightNormal

10. Axis

11. axis?

12. Axis

13. 4 – axis?

14. Axis

15. 1 - axis ?

16. Axis

17. 1 - axis ?

18. Axis

19. 5 – axis?

20. Axis

21. 6 – axis?

22. Axis

23. Intervals

25. Atrial enlargement Right atrial enlargement –Tall P in II “P-pulmonale” –Tall initial P in V 1 Left atrial enlargement –Wide, notched P in II –Inverted terminal P in V 1

26. Increase in QRS (conduction – poison – masqueraders) RBBB LBBB Severe LVH Hyperkalemia TCA toxicity (other Na channel blockers) Hypothermia Wolff-Parkinson-White

27. RBBB – depolarization 3 2 3

28. 7 – RBBB

29. RBBB – EKG criteria prolonged QRS ( ≥ 0.11 sec ) V 1 – tall R wave V 6 – wide terminal S wave expect to see: –repolarization changes (V 1-3 )

30. Tall R wave in V1 RBBB RVH Old posterior MI WPW – type A ↑ QRS Right axis Old inferior MI Delta waves, etc.

31. 8 - Old inf-post MI

32. 4 - RVH

33. 6 – WPW, type A

34. LBBB - depolarization

35. LBBB – EKG criteria prolonged QRS (>0.12 sec ) V 6 – tall monophasic R (no septal Q) expect to see: –poor R wave progression right chest leads –ST elevation in V 1-3 –repolarization changes (T inversion lateral)

36. 9 – LBBB

37. 1 – severe LVH

38. Chamber enlargement LVH –Deepest S in V 1-2 + tallest R in V 5-6 > 35 mm, or –R in aVL ≥ 12 mm +/- associated repolarization changes strain pattern in lateral leads left axis deviation eventually, widen QRS and poor R wave progress ST elevation in anterior leads (V 1-3 )

39. 10 - hyperkalemia

40. 11 – TCA toxicity

41. TCA toxicity after Na

42. Wolff-Parkinson-White x x short PR delta wave increase QRS

43. 5 – WPW

44. 12 – hypothermia

45. QT interval changes ↑ QT interval –Hereditary conditions –Hypocalcemia –? hypokalemia –Notorious drug and medications effects ↓ QT interval –Hypercalcemia

46. Normal QT < ½ preceding R-R

47. A systematic review of every EKG Rhythm Rate Axis Intervals –PR –QRS –QT Chamber enlargement, esp. LVH Ischemia or infarct

49. 13 – Unknown #1

50. 14 – Unknown #2

51. 15 – Unknown #3

52. 16 – Unknown #4