Stretching Your ECG Skills Steven A. Wahls, MD, FAAFP Assistant - - PowerPoint PPT Presentation

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Stretching Your ECG Skills Steven A. Wahls, MD, FAAFP Assistant - - PowerPoint PPT Presentation

Apr 25, 2023 464 likes •778 views

Stretching Your ECG Skills Steven A. Wahls, MD, FAAFP Assistant Professor Residency Focused Faculty OHSU Department of Family Medicine 41st Annual NPO Education Conference October 12, 2018 Doubletree Lloyd Center, Portland Conflict of

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41st Annual NPO Education Conference October 12, 2018 Doubletree Lloyd Center, Portland

Stretching Your ECG Skills

Steven A. Wahls, MD, FAAFP Assistant Professor Residency Focused Faculty OHSU Department of Family Medicine

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Conflict of Interest:

  • Nothing to disclose
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Goals/ learning points

1.60 second review of what we are looking at… 2.Read ECGs 1.Remember your flow 2.Commit yourself to an interpretation 3.Have fun!

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https://commons.wikimedia.org/wiki

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From: Katzung B, Trevor, A: Basic & Clinical Pharmacology, 13th Ed. McGraw-Hill www.accesspharmacy.com

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Pinterest: Demystifying the 12 Lead ECG

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18-year-old pre-op ECG for knee

  • surgery. What does this ECG

show?

Wave-Maven

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Clues to limb lead reversal

Wilson’s central terminus

  • This directionless “zero lead” lead is calculated as the

average input from the three limb leads: WCT = 1/3 (RA + LA + LL). Quick guide to spotting LA/RA reversal

  • Lead I is completely inverted (P wave, QRS complex and

T wave).

  • Lead aVR often becomes positive.
  • There may be marked right axis deviation.

Quick guide to spotting LA/LL reversal

  • Lead III is completely inverted (P wave, QRS complex

and T wave)

  • The P-wave is unexpectedly larger in lead I than lead II (it

is usually the other way around).

http://www.frca.co.uk https://lifeinthefastlane.com

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A 65-year-old man complaining of weakness…

Wave-Maven

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  • Mild hyperkalemia

K> 5.5 mEq/L

  • repolarization abnormalities Peaked T

waves

  • Moderate hyperkalemia

K> 6.5 mEq/L

  • progressive paralysis of the atria: P wave

widens and flattens, increased PR, loss of P.

  • Severe hyperkalemia

K> 7.0 mE/L

  • Increased QRS width, sine wave
  • conduction abnormalities and bradycardia

LITFL

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55-year-old woman: why is she dyspneic?

Wave-Maven

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RAE

LITFL

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LAE

LITFL

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Wagner et al. (2007) LITFL

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75 year old man presented with

  • weakness. BP 220/80.
  • Dr. Smith’s ECG Blog

https://hqmeded-ecg.blogspot.com

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ESTES Criteria for LVH

("diagnostic" >5 points; "probable" 4 points)

Sokolov-Lyon criteria for LVH

  • Voltage: S wave depth in V1 +

tallest R wave height in V5-V6 > 35 mm

  • Non-voltage:
  • Increased RW peak time >50ms

V5 or V6

  • ST depression/ TW inversion

Left side leads

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32 year-old male runner presenting with shortness of breath and chest discomfort

  • ver last hour…

Wave-Maven

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57 year old women complaining of pounding in her chest…

Wave-Maven

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35 year old Air Transport Pilot for routine screening

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ECG Changes seen in Athletes

http://bjsm.bmj.com/content/47/3/125

  • Sinus bradycardia (≥30 bpm)
  • Sinus arrhythmia
  • Ectopic atrial rhythm
  • Junctional escape rhythm
  • First-degree AV block (PR interval>200 ms)
  • Mobitz type I (Wenckebach) second-degree AV block
  • Incomplete RBBB
  • Isolated QRS voltage criteria for LVH
  • Early repolarization (ST elevation, J-point elevation, J waves, or

terminal QRS slurring)

  • Convex ST segment elevation & T wave inversion V1–V4
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You are reading ECGs and review this. What do you see, and what could cause it?

Wave-Maven

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Possible causes for LBBB

  • Aortic stenosis.
  • Dilated cardiomyopathy.
  • Myocardial infarction/ CAD
  • Primary conduction system disease
  • Acquired conduction system disease

(e.g. Lyme dis)

  • HTN
  • AI
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Read this ECG. What is your final impression?

Wave-Maven

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Elderly woman following a fall, with complaints of fatigue and weakness

Wave-Maven

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ECG missing its clinical data… Ideas?

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Wave-Maven

42 year old man with irregular pulse

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Wave-Maven

59 year old woman with history of palpitations

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Sources & Re-sources…

  • Nathanson L A, McClennen S, Safran C, Goldberger AL.

ECG Wave-Maven: Self-Assessment Program for Students and Clinicians.

  • Yanowitz, F G. ECG Learning Center.
  • Life in the Fast Lane
  • The clinical exercise physiology consortium
  • ECGPEDIA