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Old 01-14-2014, 22:55   #1
Sdiver
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EKG/ECG Practice

Trapper John had mentioned in another thread about putting up some more EKG/ECG strips.

So let's start with this one ....

Here is the ECG from our 63 yo F patient complaining of neck and arm pain... BEFORE you jump in and write STEMI (that is too obvious), I want to know what you think the RHYTHM is.

I'm NOT going to give you Pt. Hx or scenario, just read the rhythm and give me your interpretation.

Be as precise and specific as possible.
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Old 01-15-2014, 06:07   #2
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Took me a few minutes to realize what a STEMI is. It's been about 7 years since I looked at a strip so it seems they have some new terms like ST elevated myocardial infarction. We called it the "tombstone" sign.

As I had taken 12 leads for guys physicals, we never had to learn how to read them and sometimes doctors would give us classes on them. I never could remember which angle I was looking at, so never really got the feel for reading the 12 lead.

That said, the only other thing I was seeing was the pr interval seems a bit long. 1st degree AV block?
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Old 01-15-2014, 06:58   #3
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Quote:
Originally Posted by miclo18d View Post
That said, the only other thing I was seeing was the pr interval seems a bit long. 1st degree AV block?
I agree with that assessment - the PR interval appears long but fixed, without any dropped p waves.
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Old 01-15-2014, 08:15   #4
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First thing that struck me was the inverted T-wave in lead I. The second is what appears to be a broad T-wave in all leads, and elevated S-T interval (short S-T interval with a long S-T segment?) The obvious MI aside, I get the impression of a left ventricular hypertrophy too.

Is this patient on digoxin? I am thinking there may be some pharmacological induced ECG changes too, but not sure.
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Old 01-15-2014, 10:21   #5
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Originally Posted by Trapper John View Post
First thing that struck me was the inverted T-wave in lead I. The second is what appears to be a broad T-wave in all leads, and elevated S-T interval (short S-T interval with a long S-T segment?) The obvious MI aside, I get the impression of a left ventricular hypertrophy too.

Is this patient on digoxin? I am thinking there may be some pharmacological induced ECG changes too, but not sure.
In this thread, don't worry about meds or Hx or Dx, just give me your interpretation of the posted strip.

Remember, be as precise and specific as possible in reading it off.
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Old 01-15-2014, 12:50   #6
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Quote:
Originally Posted by Sdiver View Post
In this thread, don't worry about meds or Hx or Dx, just give me your interpretation of the posted strip.

Remember, be as precise and specific as possible in reading it off.
FTFSI Just couldn't help myself
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Old 01-15-2014, 14:21   #7
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Rate = 52, rhythm=reg, PRI= >.20 about .28 seconds, QRS = <.12, Every QRS has a P, Every P has a QRS, Elevation >3mm in leads II, III, AvF. Invereted T in I, V1, V2, AvR, AvL.

Sinus Brady W/ 1st Degree HB and Inferior STEMI

I think.

There are numerous sites to learn / re-learn about EKG.

http://www.slideshare.net/Jedimurl/1...e-easy-2725398
http://www.emergencyekg.com/interactive_learning.cfm
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Old 01-15-2014, 17:56   #8
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Originally Posted by Trapper John View Post
FTFSI Just couldn't help myself
Now worries. It happens.


Quote:
Originally Posted by PedOncoDoc View Post
I agree with that assessment - the PR interval appears long but fixed, without any dropped p waves.
Correct, there are no dropped P waves, but ... has anything else dropped or is there anything "extra" that cane be seen ???


Quote:
Originally Posted by adal View Post
Rate = 52, rhythm=reg, PRI= >.20 about .28 seconds, QRS = <.12, Every QRS has a P, Every P has a QRS, Does it ???Elevation >3mm in leads II, III, AvF. Invereted T in I, V1, V2, AvR, AvL.

Sinus Brady W/ 1st Degree HB and Inferior STEMI

I think.

There are numerous sites to learn / re-learn about EKG.

http://www.slideshare.net/Jedimurl/1...e-easy-2725398
http://www.emergencyekg.com/interactive_learning.cfm
It's always good to practice up on EKGs and these are a couple of good sites to do so on.

Not reading/practicing on strips, you could miss a thing or two.

*HINT .... Get your calipers out.
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Old 01-15-2014, 18:04   #9
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*HINT .... Get your calipers out.
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Old 01-15-2014, 18:05   #10
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Sooo....I don't and probably won't ever own a pair of calipers.

Now I see my error.

3rd degree HB. That explains the brady better.

It is hard to see without a longer strip that I would usually run in conjunction with a 12 lead. It's hard to dx off that short run the 12 lead uses.
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Old 01-15-2014, 18:22   #11
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First thing that I did - you owe me for a new LED screen...
*Sigh* ... Okay.

That's why I use a EKG ruler or a piece of paper with marks on it.
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Old 01-15-2014, 20:49   #12
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Sooo....I don't and probably won't ever own a pair of calipers.

Now I see my error.

3rd degree HB. That explains the brady better.

It is hard to see without a longer strip that I would usually run in conjunction with a 12 lead. It's hard to dx off that short run the 12 lead uses.
You've done this before haven't ya? Kidding aside - very good analysis. But, I thought complete HB gives the classic camel hump T-wave presentation?

I still say left ventricular hypertrophy. Possible LBB. Need to hit the books on this one some more. I wonder if the absent Q wave in lead 1 is significant?
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Old 01-16-2014, 08:28   #13
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Originally Posted by Trapper John View Post
You've done this before haven't ya? Kidding aside - very good analysis. But, I thought complete HB gives the classic camel hump T-wave presentation?

I still say left ventricular hypertrophy. Possible LBB. Need to hit the books on this one some more. I wonder if the absent Q wave in lead 1 is significant?
3rd degree heart block has consistent intervals between p waves and between QRS complexes that are independent from each other, hence the recommendation to get out the calipers. When taking exams on which I had to analyze rhythms I would take a piece of paper and place a mark above 2 consecutive p waves and move from p-wave pair to p-wave pair to see if they were consistent, and would do the same for the QRS complexes.

I would've preferred to see a longer rhythm strip in conjunction with the 12-lead to firm up this diagnosis - sometimes the switch from lead to lead on the printout can make identifying 3rd degree block more difficult than it should be.
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Old 01-16-2014, 15:17   #14
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Old 01-16-2014, 16:25   #15
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Originally Posted by PedOncoDoc View Post
3rd degree heart block has consistent intervals between p waves and between QRS complexes that are independent from each other, hence the recommendation to get out the calipers. When taking exams on which I had to analyze rhythms I would take a piece of paper and place a mark above 2 consecutive p waves and move from p-wave pair to p-wave pair to see if they were consistent, and would do the same for the QRS complexes.

I would've preferred to see a longer rhythm strip in conjunction with the 12-lead to firm up this diagnosis - sometimes the switch from lead to lead on the printout can make identifying 3rd degree block more difficult than it should be.
Yeah, Sdiver and I had this chat on another forum. I may have jumped the gun a bit. However, with a longer strip it would be easier. I have been looking at my pts EKG strips with renewed vigor, however.

I use paper strips also, if... I have the time. Most of the time I'm on my way to a cath lab with the obvious stuff and we try to work in the extra credit when we can.

This was a great example of slow down and do it like we are SUPPOSED to.
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