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Introduction to EKGs and

EKG EmergenciesJason Lucas, PhD, PA-C

Cardiology Critical Care ServiceCo-Director, Advanced Cardiovascular Fellowship

Atlanta, GA

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• The basic EKG format

• Calculation of intervals

• Placement of the leads

• Correlation of the leads with heart regions

• Method of interpretation of the ECG

• Emergency rhythms

What you will learn:

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Normal Coronary Anatomy

http://www.radiologyassistant.nl/data/bin/w430/a5097978474479_coronary-anatomy-RAO1.png

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Conduction of the Heart

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The EKG Paper

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• One small block is 0.04 seconds.

• Five small blocks = one big block.

• One big block = 0.20 seconds.

• 25 small blocks = 1 second.

• Five big blocks = 1 second.

• 1500 small blocks = 1 minute.

• 300 big blocks = 1 minute.

Counting Blocks

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Measurement of the Boxes

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Counting Blocks

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Lead Placement

Indiana.edu

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Lead Placement

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The Rhythm

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The PathSinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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Cycle Initiation/Conduction:

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Cycle Initiation/Conduction:

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Repolarization of the ventricles generates a

current in the body and produces the T-wave on

the surface electrogram

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ECG Interpretation

What is your approach to reading an ECG?

•Rate

•Rhythm

•Intervals

•P wave

•QRS complex

•ST segment – T wave

•Axis

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Example Rhythm Strip

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Infarction Wave Abnormality EKG Segments Occlusion

Anterior ST Elevation V1, V2, V3, V4 Left Anterior Descending Artery

Inferior ST Elevation II, III, AVF Right Coronary Artery

Lateral ST Elevation I, AVL, V5, V6 Left Circumflex Artery

Posterior ST Depression, Tall R Wave V1, V2 RCA and/or LCX

Subendo Diffuse or Localized Changes,Non Q-Wave

Specific Regions

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Regions of the heart

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Putting it together

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Rate 60-100 bpm

P-P Regularity Regular

R-R Regularity Regular

P wave Present

P:QRS Ratio 1:1, associated

PR Interval Normal

QRS Width Normal

Normal Sinus Rhythm

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What is considered an EKG

Emergency?

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Cardioversion or Defibrillation

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Rate Varies, ventricular response can be fast or slow

P-P Regularity Chaotic atrial activity

R-R Regularity Irregularly irregular

P wave No discernable p-waves

P:QRS Ratio None

PR Interval None

QRS Width Normal, but can develop aberrant (wide) complexes

Atrial Fibrillation w/wo RVR

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Atrial RateVentricular Rate

Atrial Rate commonly 250-350 bpmVentricular Rate will vary with conduction

P-P Regularity Regular

R-R Regularity Usually regular, but may be variable

P wave “Saw-tooth” p-wave morphology

P:QRS Ratio Varies, can be 1:1, 2:1, 3:1, 4:1, etc.

PR Interval Varies

QRS Width Normal

Atrial Flutter

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Rate 20-40 bpm

P-P Regularity None

R-R Regularity Regular

P wave None

P:QRS Ratio None

PR Interval None

QRS Width Wide complex (≥ 0.12 s).

Ventricular Rhythms

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2nd-Degree Type II (Mobitz II)

https://www.google.com/search?q=third+degree+heart+block&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi_zJ_OzsnOAhWEXB4KHbaIC3UQ_AUICCgB&biw=976&bih=591#tbm=isch&q=second+degree+heart+block+type+II&imgrc=T3lPjYu9CEGCCM%3A

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2nd-degree type II (Mobitz II)

Second-degree type II (Mobitz II)

History •Always pathologic•Blockage occurs in the His bundle or the bundle branches

Symptoms •Asymptomatic, dyspnea, presyncope, syncope

EKG •Occasional loss of AV conduction for 1 beat

Treatment •Pharmacologic Therapy •Temporary Pacer (Internal/External) •Permanent Pacemaker (PPM) implantation•Biventricular pacemaker •Implantable cardioverter-defibrillator (ICD)

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Third degree heart block

(complete heart block)

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Third degree heart block

(complete heart block) Third Degree Heart Block

History •Always pathologic•Blockage occurs in the His bundle or the bundle branches •Cardiac function maintained by ventricular pacemaker or junctionalescape rhythm

Symptoms •Heart failure, presyncope, syncope

Physical Exam •Cannon a waves •BP fluctuations •Changes in 1st heard sound

EKG •No electrical communication between atria/ventricles•No P wave and QRS relationship

Treatment •Pharmacologic Therapy•Temporary Pacer (Internal/External) •Permanent Pacemaker (PPM) implantation•Biventricular pacemaker •Implantable cardioverter-defibrillator (ICD)

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Managment: Second degree II/3rd

degree AV block

• Unstable patients: – Immediate pharmacologic therapy:

• Atropine: 0.5 mg IV q 3-5 min, total dose 3 mg • Dopamine: 3 mcg/kg/min titrated to 20 mck/kg/min if needed • Dobutamine: 5 mcg/kg/min titrated to 40 mcg/kg/min if needed

– Temporary pacing (transcutaneous or transvenous) to increase HR and CO

• Hemodynamically Stable Patients: – First exclude reversible causes of AV block (ischemia,

hyperkamiea, AV nodal blocking drugs, hypothyroidism)– Consider permanent treatments:

• Permanent Pacemaker (PPM) implantation• Biventricular pacemaker • Implantable cardioverter-defibrillator (ICD)

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Temporary Pacer (External/Internal)

• Transcutaneous pacing (external pacing) – Indication:

• Bradycardia

– Technique: • Pads placed in the

anterior/posterior position and attached to defribillator/monitor

• Electrical capture: Pulse present with an EKG that shows wide QRS complex with a broad, tall T wave

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Temporary Pacer (External/Internal)

• Transvenous cardiac pacing (endocardial pacing) – Indications:

• Symptomatic bradycardiaunresponsive to drug therapy (atropine, epinephrine, dopamine) or transcutaneous pacing

– Technique: • Temporary solution: can be used as

bridge therapy to permanent pacing

• Pacing electrode threaded into the right atrium or right ventricle (or both)

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Pacemaker induced rhythm

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CRT-D

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Rate 200-250 bpm

P-P Regularity None

R-R Regularity Irregular

P wave None

P:QRS Ratio None

PR Interval None

QRS Width Variable with wide complexes

Polymorphic VT (Torsades)

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Rate Indeterminate

P-P Regularity None

R-R Regularity Chaotic Rhythm

P wave None

P:QRS Ratio None

PR Interval None

QRS Width None

Ventricular Fibrillation

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• Beyerbach, Daniel. Pacemakers and Implantable Cardioverter-Defibrillators: Practice Essentials, Overview, Evolution of the ICD. Clevland Clinic. 2016. http://my.clevelandclinic.org/services/heart/disorders/arrhythmia/heart-block

• Budzikowski, Adam. Third-Degree Atrioventricular Block Treatment & Management: Approach Considerations, Initial Management Considerations, Atropine and Transcutaneous/TransvenousPacing. June 2016. Medscape. http://emedicine.medscape.com/article/162245-overview

• Cazeau, Serve. Effects of Multisite Biventricular Pacing in Patients with Heart Failure and Intraventricular Conduction Delay. December 2015. http://emedicine.medscape.com/article/162007-treatment#d10

• Fang. Should Patients with Heart Block Receive Biventricular Pacing? 2015. Circulation. http://circep.ahajournals.org/content/8/3/722.full

• Sovari, Ali. Transvenous Cardiac Pacing: Background, Indications, Contraindications. February 2016. http://emedicine.medscape.com/article/80659-overview#a5

• Yalagadda, Chakri. Permanent Pacemaker Insertion: Background, Indications, Contraindications. Medscape. May 2014. http://emedicine.medscape.com/article/1839735-overview#a5

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Thank You!

Jason.Lucas@piedmont.org