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EKG Course Flashcards

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0
Q

Anterior MI

A

LAD

V1-6 STE

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1
Q

Where are STE for septal, anteroseptal and anterolateral MI?

A

Septal V1-2
Anteroseptal V1-4
Anterolateral V3-6, I aVL

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2
Q

Inferior MI

A

RCA occlusion
STE II, III, aVF
reciprocal changes in aVL
always consider possibility of posterior and/or right ventricular involvement

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3
Q

Lateral wall MI

A

Usually left circumflex
STE I aVL V5-6
isolated STE I and aVL is a high lateral MI

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4
Q

How do you know thrombolytics have worked?

A

STE elevation resolves by 70%
Accelerated idioventricular rhythm
Inversion of t-waves within 4 hours of lytics

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5
Q

Distinguishing features between STEMI and aneurysm?

A

Aneurysm - no reciprocal changes

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6
Q

Right ventricular MI

A

Inferior wall STEMI
STE V1 and STD V2 or
isoelectric V1,3 and STD V2 or
STE III»STE II also suggests right ventricular MI

Do right sided leads. Take V,5,6 and put on right side of chest. See elevation in right sided leads.

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7
Q

What are the findings of STE in presence of LBBB or pacemaker?

A

Sgarbossa criteria (only requires one lead):

A. concordant STE >=1mm in any lead
B. concordant STD>=1mm in V1,2 or 3
C. discordant STE >=5mm (lower specificity)

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8
Q

Approach to LBBB and suspected ACS

A

hemodynamic instability or acute heart failure or sgarbossa criteria

or patient has ST:S ratio <=-0.25 (ST deviation in opposite direction of QRS > 25%)

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9
Q

What criteria are used to diagnose STEMI in RBBB?

A

no special criteria

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10
Q

Clues to isolated posterior STEMI

A

in leads V1-2: large R waves, STD, upright t waves

4-5% of STEMIs are isolated posterior

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11
Q

How do you place leads to pick up posterior STEMI?

A

Wrap leads around left mid back area

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12
Q

What do de winter t waves look like?

A

de winter t waves
sharp upsloping from j point
1-3mm of ST depression upsloping at j point in precordial leads
LAD occlusion

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13
Q

What are the EKG changes for Wellen’s syndrome?

A

deep t wave inversions

biphasic t wave pattern in mid precordial leads V2,3 or 4; suggests proximal LAD stenosis

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14
Q

What is the significance of early t wave inversion in aVL?

A

the normal EKG lead aVL is normally isoelectric ST segment or upright t wave

acute inferior wall MIs: common ‘reciprocal’ changes: ST segment downsloping in aVL or t-wave inversion in aVL

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15
Q

With inferior wall STEMI, sometimes reciprocal aVL changes can precede the development of inferior lead abnormalities. What symptoms are common for inferior wall MIs?

A

Burning, nausea, belching

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16
Q

When are flipped t waves is aVL a normal variant?

A

LBBB and LVH

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17
Q

Approach to flipped t waves in aVL?

A

Serial EKGs and cardiac enzymes

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18
Q

What does aVR look like in a normal EKG?

A

isoelectric or t wave inversion

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19
Q

What changes in aVR predict LMCA occlusion, prox LAD occlusion or triple vessel dz?

A

STE in aVR

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20
Q

What size of aVR STE is concerning?

A

1mm

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21
Q

In what situations are elevations in aVR meaningless?

A 
no ischemic ST changes elsewhere on EKG 
SVT
uncontrolled HTN (get BP down 15% and repeat)
LVH with strain
can also be a normal variant in LBBB
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22
Q

What are the vessels potentially in trouble when we observe: STE in aVR? STE in both aVR and aVL? STE in both aVR and V1? STE in aVR>=STE V1?

A

STE aVR - LMCA, prox LAD, triple vessel

STE aVR and aVL - LMCA

STE aVR and V1 - prox LAD or LMCA; if STE in aVR>V1 - LMCA

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23
Q

What are hyperacute t-waves?

A

Straightening of upslope of t wave. Observe and repeat EKGs

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24
What are the types of bradycardia?
Sinus - upight P waves in I, II, III aVF Junctional Ventricular
25
What questions do you need to ask about tachycardias?
Narrow or wide? Reg or Irreg? Atrial activity?
26
What is the differential of a narrow regular rhythm?
``` Sinus SVT - P may be hidden or may follow QRS A Flutter - saw tooth in inferior leads - 2:1 conduction; 2 Ps for every QRS ```
27
What is the differential for narrow irregular rhythm?
A fib - no distinct atrial activity A flutter with variable conduction - regular atrial activity about 300 bpm MAT - distinct P waves that are changing MAT
28
Ddx of wide, regular tachycardia?
Sinus tachycardia with aberrant conduction - P waves present VT - usually >120 bpm - P waves often hidden SVT with BBB - P waves may be hidden
29
When you see a regular wide complex tachycardia, how should you manage?
Always assume VT and treat accordingly.
30
What is the ddx of an irregular wide complex tachycardia?
atrial fibrillation with BBB - rate 150-180 and QRS morphology are identical atrial fibrillation with pre-excitation (WPW) - rate may approach 300
31
What is polymorphic VT? Torsades?
rapid, regular QRS QRS morphology changes torsades is PMVT associated with prolonged QT
32
What is the treatment of polymorphic VT, torsades type?
shock patient and then use magnesium (not procainamide, amiodarone, lidocaine)
33
Accelerated idioventricular rhythm
slow VT ventricular rhythym 40-120 (<120) reperfusion rhythym do nothing
34
What EKG changes should by looked for in a patient that presents with syncope?
Ischemia Dysrhythmia Atrial fib with WPW Hypertrophic Obstuctive Cardiogenic Myopathy Brugada Long QT Pulmonary Embolism
35
What are the EKG findings for HOCM?
Tall narrow QRS waves (high LV voltage) high LV voltage can cause 'messed up' t waves tall R wave in V1 (mimics posterior MI) deep narrow Q waves in inferior, lateral leads
36
What are the EKG findings of Brugada? What are the risks associated with Brugada? Management?
``` IRBBB or RBBB type morphology EKG abnormalities V1, V2 elevations, 2 morphologies: - coved type - saddle morphology - can vary from day to day ``` Pattern or symptoms more prominent with fever, hot ambient temperature, anticholinergics and SSRIs polymorphic or monomorphic VT 10% mortality per year if symptomatic treated with ICD (only effective treatment)
37
How is RBBB and iRBB distinguished from Brugada?
RBBB usually has ST depression. Brugada has coved STE and t inversion
38
What are the findings of WPW?
look for shortened PR and then delta waves to avoid imagining delta waves shortened PR widened QRS delta wave
39
What types of dysrhythymias can WPW produce?
SVT - orthodromic (uses AV node to conduct down) narrow complex tachycardia. treat like any other SVT since treatments cut circuit at AV node - antidromic (uses accessory pathway to conduct down) - results in wide QRS, regular tachycardia - treat VT - try procainamide or amiodarone or shock patient A fib - polymorphic QRS, very rapid rate - shock or procainamide - AV node blockers such as amiodarone lead to V Fib
40
What is too long for a QT interval?
500 msec
41
What are the causes of prolonged QT?
hypomagnesemia hypokalemia hypocalcemia sodium channel blockers (TCA, Type 1A anti-arrthymics) elevated ICP, ACS, hypothermia, hereditary
42
What are the EKG findings associated with pulmonary embolism?
``` sinus tachycardia complete or IRBBB right ventricular strain pattern right axis deviation dominant R wave in V1 right atrial enlargement (peaked P in lead II) SI QIIITIII ```
43
Hypocalcemia prolongs the
ST segment leads to increased QT segment
44
What are the EKG findings for arrthythmogenic RV dsyplasia?
/ekg finding is very rare and thus, not discussed
45
If ventricular rate is normal for heart blocks, is treatment necessary?
No
46
2nd degree AV block with 2:1 conduction may be ... or ...
mobitz 1 | mobitz 2
47
Ventricular escape rhythm and 'hyperacute' t waves, bradycardia may be ...
hyperkalemia
48
What are the EKG signs of hyperkalemia?
``` peaked Ts widening of QRS prolonged PR flattening and eventual loss of PRs tachydysrhythmias advanced AV blocks and sinus pauses pseudo-ACS --> new BBB, ST changes sine wave ```
49
Whenever you look at EKG and think bizarre, think ...
hyperkalemia
50
What are the findings for LAFB?
``` narrow QRS left axis deviation rS pattern in II, III and aVf S wave in lead aVf > R wave in lead I qR in lead I aVL ```
51
What are the findings for left posterior hemiblock?
QRS normal right axis deviation rS pattern in I and aVL qR in inferior leads II, III aVf
52
How are non-conducted PACs distinguished from 2nd degree HB
PP interval is constant in HB PP interval is changing with PAC (premature atrial conduction) Most common cause of PACs is mild electrolyte abnormality
53
Treatment decisions for emergent dysrhythmias based on ...
what the ventricle is doing
54
What is the approach to classification of tachy dysrhythmias?
Narrow or wide? Regular or irregular? What is the atrium doing?
55
Ddx of narrow, regular tachy?
Sinus Aflutter 2:1 SVT
56
What do you tell narrow, regular apart?
What is the atrium doing? Ventricular rate 150 +/-20 consider flutter Look in all leads, esp V1 (on top of sinus node)
57
Atrial flutter often produces p waves that are ... in the inferior leads
inverted
58
Irregularly, irregular and wide QRS. Thinking?
BBB vs pre-excitation QRS morphology consistent --> likely A fib Rate not too excessive --> A fib
59
Ddx of irregularly, irregular tachy with narrow QRS?
A fib A flutter with variable conduction or M A T
60
How to distinguish A fib, MAT and A flutter?
p waves - about 300 --> A flutter no distinct p waves --> A fib p waves of differing morphologies --> MAT
61
Ddx of regular, wide complex tachycardia?
Sinus Tachy with aberrancy SVT with aberrancy VT
62
Always assume ... if ddx includes SVT and VT for wide complex tachycardia
VT
63
What are the clues to SVT?
Narrow, regular retrograde P waves HR>maximum
64
What is atrial trigeminy?
Every 3rd beat is a premature atrial complex
65
What is junctional trigeminy?
Every 3rd beat a premature junctional complex
66
What are causes of grouped beats?
``` premature contractions - bigeminy - trigeminy 2nd degree AV block - mobitz I - mobitz II ```
67
What are the causes of regularly, irregular tachycardia/rhythms?
2nd degree HB | bigeminy, trigeminy (premature beats)
68
Can't call something VT if it has a rate under ...
120
69
How to tell the difference between Afib with BBB vs Afib with accessory pathway?
Wide complex, irregularly irregular rhythms BBB - morphology is constant, HR is lower Afib with accessory pathway - varying morphology and HR can be very fast
70
EKG is good for ruling in VT but not for ..... VT
ruling out
71
What are some EKG signs that guarantee VT?
Steeple sign in V1 Axis is 'no man's land' - extreme right axis deviation Deep S wave in V6
72
Many reliable criteria ... VT and no reliable criteria ... VT
rule in, rule out
73
What is an algorithmic approach to wide complex tachycardia?
1. Is the WCT clearly sinus tach with aberrancy (P, QRS, P QRS ....) If NO: 2. Ventricular TAchycardia
74
What is the steeple sign?
Specific for VT. | V1 QRS goes straight up and straight dow
75
What signs are specific for VT?
- steeple sign - extreme right axis deviation - deep S wave in V6
76
What is Mattu algorithm for wide complex tachycardia?
/is it clearly sinus tach? --> treat underlying cause | /if no --> its v tach
77
How to define VT?
wide complex rate >120 retrograde P waves
78
When should one be wary of mimics of VT?
If HR <120, consider: - hyperkalemia - TCA, cocaine toxicity - reperfusion arrhythmias
79
Why do we need to be careful about treatment of slow VT?
treatment with lidocaine may induce asystole
80
What reperfusion rhythm can be mistaken for VT?
/accelerated ideoventricular rhythym
81
When QRS complexes are very wide, consider...
toxicology or metabolic issues | consider calcium or sodium bicarb first
82
What are causes of STE?
``` pericarditis LVH CNS problems --> altered MS ventricular aneurysm BER hyperkalemia LBBB Brugada ```
83
What factors rule in STEMI vs pericarditis?
STD except in V1 or aVR STE III>II Horizontal or concave upwards STE new Q waves
84
Pericarditis is only allowed to have concave ... ST elevations
upwards
85
What factors suggest AP?
friction rub | PR depression in multiple leads - only seen in viral AP and transient
86
PR depression is ... specific for AP
not
87
When in doubt between pericarditis or STEMI, get ....
serial ECGs
88
What is your baseline for determining STE or STD?
TP segment
89
What might low voltage and tachycardia indicate?
pericardial effusion
90
What features distinguish benign early repolarization from STEMI?
If STE in V6 - if ratio of STE to T wave less than 25% tends to predict BER. Concave upwards repolarization and notching Evolving changes favour STEMI
91
Is benign early repolarization benign?
Possible increased risk of sudden death over 5-30 years
92
What are EKG features of ventricular aneurysms?
Should not produce reciprocal changes Aneurysms should have Q waves Get serial EKGs Need time: - cardiac biomarkers - ECHO
93
How can LVH be distinguished from STEMI?
Look for criteria for LVH
94
What are criteria for LVH?
R in V5 or V6 + S in V1 > 35mm max R + max S in precordial leads >45mm R in aVL>11mm
95
What are the repolarization abnormalities that characterize LVH with strain?
ST depression in I, aVL, V4-6 +/- II and aVf Inverted t waves in same leads STE in V1-3 (and aVr) QRS widening
96
symmetric t wave inversions weigh in favour of .... asymmetric t wave inversions weigh in favour of ...
ischemia | LVH
97
Horizontal ST depression is ....
ischemia
98
Large PEs can produce ... inversions
T wave
99
PE may cause T wave inversions most commonly in the ... leads
anteroseptal and inferior leads. Present simultaneously think big PE
100
PE causes S..Q..T..
SIQIIITIII
101
Biphasic t-waves STE, fish hook at beginning of ST segment, high voltage is typical of..
young male, athletic
102
What EKG finding is pathogonomic for right ventricular MI?
Disproportionate ST elevation in lead III than in II
103
ddx of wide complex tachycardia?
``` ventricular tachycardia SVT with aberrancy Sinus tachycardia with aberrancy Atrial flutter with aberrancy WPW Accelerated intraventricular rhythm sodium channel blocker - eg. TCA, cocaine hyperkalemia torasades ```
104
ddx wide complex tachycardia with variable rate?
Sinus tach with sodium channel blocker Sinus tach with hyperkalemia Atrial fibrillation with aberrancy
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