EKG of CARDIAC

EMERGENCIES

JAMES NKURUNZIZA
OMP CARDIOLOGY
ECG IN EMERGENCIES
► ACUTE CORONARY SYNROMES

► BRADYAARTHYMIAS

► TACHYAARTHYMIAS

► PE

► PERICARDITIS AND TAMPONADE

The Normal Conduction System
 The standard EKG has 12 leads
3 Standard Limb Leads (I, II, III)

3 Augmented Limb Leads(Avf, aVL, aVR)

6 Precordial Leads (V1-V6 or C1-C6)

Leads placement
Systematic Approach
► Rate
► Rhythm
► Axis
► Wave Morphology
 P, T, and U waves and QRS
complex
► Intervals
 PR, QRS, QT
► ST Segment
 The Normal Adult EKG

► Majority QRS complexes are positive (have tall R waves)

 Except AVR & V1-2; r-wave progression across the precordium
 T wave in V1 should be small, flat or flipped
 Rate
► Rule of 300

► 10 Second Rule
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
What is the heart rate?

(300 / 1.5) = 200 bpm

What is the heart rate?

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

33 x 6 = 198 bpm
ACS ECGs
Anatomic location of STEMI
Anterior Septal (Left Anterior
Descending)
Anterior Lateral (Left Circumflex)
Inferior (Right Coronary Artery)
Normal Complexes and Segments
Measurements
EKG Changes: Ischemia →
Acute Injury→ Infarction
► Patient presents 4 hours post onset of chest pain; What is
your knee jeck reflex with this?
► 1. Thrombolyse
► 2. Transfer to PCI center
► 3. Bed rest
► 4. MONA
► 5. NSAIDs
► Diagnosis?

► Which vessel do you think is involved?

► Diagnosis?

► What will you do?

► Diagnosis
► What unusual thing happened
► What will you do?
► Diagnosis
► What will you do?
► What will you be concerned about?
► Proximal LAD Occlusion: Large territory of
infarction: This patient developed VF in
cathlab. Successfully cardioverted
► Infero-postero-lateral MI
► Large territory prone to major
complications: Acute MR, AV block, etc
► RV infacrtion: Hypotension, clear lungs, raised
JVP
► Avoid: Nitroglycerin
► Give IVF
► ECG at presentation with crushing chest pain
► ECG 2 HOURS POST ACTILYSE
TACHYCARDIAS
► 192 BPM; Narrow complex, regular tachycardia
► ECG diagnosis: VT
► SVT
► 162 BPM; wide; regular tacycardia
► VT or SVT
► AF
►A flutter
►
► ECG diagnosis: Sinus tachy
► Atrial flutter
► Atrial fibrillation
► VT
► ECG diagnosis:
► AF
► A flutter
► Sinus tachy
► VT
► MI
Antidromic atrioventricular re-entry tachycardia
(AVRT)
Example 9
Sudden Cardiac Death: unexpected death within
1 hour of symptoms
Final, common pathway: Vtach/fib 90%
BRADYCADRIAS

Sinus node dysfunction

AV blocks
 1ST DEGREE AV BLOCK

• PR greater than 200 msec

• No hemodynamic complications
• Could progress to higher AV blocks
 2ND DEGREE AV BLOCK
MOBITZ TYPE 1
(WENCKEBACH)

• PR interval progressively lengthens with each beat until it is

completely blocked
• If bradycardic, could have decreased cardiac output
• Treatment:
- Only if brady (Atropine)
- Rare pacemaker
 2ND DEGREE AV BLOCK
MOBITZ TYPE 2

• Rare, occurs with large ant MI

•PR interval fixed and p waves occur in a regular ratio to QRS
(atrial rate is regular) until conduction is blocked
 AV block: 2nd degree, “fixed
ratio” blocks
► Seconddegree heart block with a fixed ratio
of P waves: QRS complexes (e.g. 2:1, 3:1,
4:1).

► Fixed
ratio blocks can be the result of either
Mobitz I or Mobitz II conduction.
AV block: 2nd degree,
“high-grade” AV block
 High Grade AV block definition
► Second degree heart block with a
P:QRS ratio of 3:1 or higher, producing
an extremely slow ventricular rate.

► Unlike
3rd degree heart block there is still
some relationship between the P waves and
the QRS complexes.
 3RD DEGREE AV BLOCK
(COMPLETE)

•Atria and ventricles are independent of each other;

no relationship present
•Symptoms could include lightheadedness or syncope from
decreased rate
► ECG diagnosis:
► Sinus brady
► 1st degree AV block
► 2:1 AV block
► Complete heart block
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