1 small box = 0.04 seconds

1 large box = 5 small boxes = 0.20 seconds

1 small vertical box = 0.1 mV

1 large vertical box = 5 small vertical boxes = 0.5 mV

Identify the Q

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#4 Represents the Q

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Identify the PR Interval

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#2 Represents the PR Interval

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Identify the PR segment

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#3 Represents the PR segment

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Identify the QRS Complex

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#9 Represents the QRS Complex

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Identify the QT interval

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#6 Represents the QT interval

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Identify the R

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#8 Represents the R

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Identify the P wave

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#1 Represents the P Wave

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Identify the S

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#5 Represents the S

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Identify the ST Segment

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Identify the T wave

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#11 Represents the T Wave

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Which of these show positive deflection?

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P, R, and T show positive deflection. Q and S show negative deflection.

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Which of these show negative deflection?

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Q and S show negative deflection. P, R, and T show positive deflection. 

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What is considered a pathological Q wave?

A Q Wave is pathological if it is:

- wider than 0.03 seconds

- >1/3 of the total QRS height

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Here, the Q wave is pathological because it is at least 0.04 seconds (the width of a small box).

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Here in the lower example, the Q wave is pathological because the Q is greater than 1/3 the height of the QRS complex.

The J point is where the S wave meets the beginning of the ST segment.

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In "textbook" EKGs, the ST segment starts at the isoelectric line. However, often the J point can't be identified due to ST elevation. In normal patients, the J Point can be 1-3 mm from the isoelectric lines due to left ventricular hypertrophy or early repolarization:

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ST elevation is associated with infarction (think STEMI)

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ST depression is associated most commonly with ischemia. It can also be caused by:

- Left Bundle Branch Block

- Digitalis

- Ventricular hypertrophy

- Acute posterior MI

- Pulmonary embolus

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What is the heart rate of this six-second strip?

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60 bpm

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There are 6 complexes. 6 X 10 = 60 bpm.

What is the heart rate of this six-second strip?

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80 bpm.

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There are 8 complexes. 8 x 10 = 80 bpm

What is the heart rate of this six-second strip?

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120 bpm

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There are 12 complexes. 12 x 10 = 120 bpm

What is the heart rate of this six-second strip?

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50 bpm.

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There are 5 complexes. 5 x 10 = 50 bpm.

P-Mitrale presents as a double-humped, M-shaped P wave that is >.12 seconds. It is a classic finding of Left Atrial Enlargement. 

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P Pulmonale shows as a tall, peaked P wave that is more than 2.5 mm high. It is strongly associated with Right Atrial Englargement and COPD. 

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How do you recognize atrial fibrillation?

The hallmarks of atrial fibrillation are:

- Irregular rhythm

-Fibrillatory P Waves (not obviously seen, may appear absent)

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The hallmarks of atrial flutter are:

-Sawtooth appearance

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Hallmarks of first-degree AV block:

-Prolonged PR interval

-Regular rhythm

-Normal and uniform P Waves

-Normal QRS complexes

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Hallmarks of Second Degree (Wenckebach) AV Block:

- P-R intervals become progressively longer until one P wave is completely blocked and produces no QRS. This cycle repeats.

- *** think: longer, longer, longer, drop, then you have Wenckebach

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In Mobitz II (Wenckebach), heartbeats display a PR interval that increases with every beat before "dropping" a beat:

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Notice that the PR interval is normal in the first beat, but increases with each beat before dropping the QRS complex.

In Mobitz II 2nd Degree AV Block, the PR interval does not prolong but the rhythm still "drops" QRS complexes:

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Notice that although arrows point to "dropped" QRS complexes, the PR intervals are all normal and do not vary or prolong between beats.

In a Third Degree AV block, the P wave and the QRS are both normal but have no relationship between them. 

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Hallmarks of a Right Bundle Branch block:

- a wide QRS: >0.12 seconds

- a "slurred S wave" in Leads I and V₆

-a RSR' (rabbit ear) pattern in V₁

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You can see the wide, "slurred" S wave in Leads I and V_6. 

In V₁, you will see a "rabbit ear" R wave, meaning that you have two peaks on R: 

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Hallmarks of Left Bundle Branch Block:

- Wide QRS: >0.12 seconds 

- Broad, monomorphic R waves in Leads I and V₆

- Broad, monomorphic S waves in V₁

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A Left Bundle Branch Block is associated with:

- CAD

- Pressure overload (e.g. due to hypertension, aortic stenosis, or hypertrophic cardiomyopathy)

- Volume overload (e.g. due to mitral or aortic regurgitation)

- Dilated cardiomyopathy

- Primary disease of the conduction system

Left ventricular hypertrophy can be caused by:

- outflow obstruction (e.g. hypertension)

- volume overload (dilitation)

Hallmarks of Left Ventricular Hypertrophy:

- S wave in V₁ or V₂ >30 mm

- R wave in V₅ or V₆ >30 mm

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In V₂ here you can see deep S waves (>30 mm) and extremely high R waves (>30 mm) in V₅ indicating Left Ventricular Hypertrophy.

Hallmarks of Ventricular Tachycardia:

- The QRS are wide (>0.12) and the HR is very fast (100-200).

- PR interval absent.

-Rhythm regular

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Hallmarks of Ventricular Fibrillation:

- No discernable P wave, QRS, or T wave

- Extremely fast, irregular rhythm

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• Hypovolemia
• Hypoxia
• Acidosis
• Hypo/hyperkalemia
• Hypothermia
• Drug overdose
• Cardia tamponade
• Tension pneumothorax
• Coronary thrombosis
• Pulmonary embolism

Treatment of asystole:

- Treat underlying cause

- Epinepherine 1 mg q3-5 minutes

- Atropine 1 mg q 5 minutes, 3 mg total max dose

Premature Ventricular Complexes when the ventricles depolarize too early, resulting in abnormalities in the shape of the QRS complex. The PVCs can either be unifocal, meaning that every abnormal PVC looks the same, or multifocal, where some PVCs look different from each other. 

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Here is an example of a unifocal PVC. The third and eighth beats show abnormally shaped QRS complexes, but both PVCs are shaped the same.

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Here is an example of a rhythm with multifocal PVCs. The second and fourth beats are both PVCs, but they are shaped very differently from each other, making them multifocal PVCs.

Bigeminy means "every other beat." If a patient has every other beat a Premature Ventricular Contraction, that is classified as bigeminy. Trigeminy means "every third beat." If a patient has every third beat a Premature Ventricular Contraction, that is classified as trigeminy. 

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In this EKG, every other beat is a unifocal PVC, so this rhythm would be classified as bigeminy.

Junctional rhythms occur when the SA node does not fire, so the AV node kicks in. Since the P wave reflects the firing of the SA node, junctional rhythms show inverted or flat P waves.

Hallmarks of Junctional Rhythms:

- Inverted or flat P wave

- Heart rate 40-60 beats per minute

- Regular rhythms, normal QRS complexes

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What abnormalities are seen in this EKG strip? How would you classify this rhythm?

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This rhythm is Ventricular Fibrillation. Hallmarks of Ventricular Fibrillation:

- No discernable P wave, QRS, or T wave

- Extremely fast, irregular rhythm

What abnormalities are seen below? What conditions would you expect this patient to have?

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This strip shows P Pulmonale. P Pulmonale shows as a tall, peaked P wave that is more than 2.5 mm high. It is strongly associated ith Right Atrial Englargement and COPD. 

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What abnormalities are seen in this EKG? How would you classify this?

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What abnormalities are seen below? What conditions would you expect this patient to have?

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This patient shows P-Mitrale. P-Mitrale presents as a double-humped, M-shaped P wave that is >.12 seconds. It is a classic finding of Left Atrial Enlargement.

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What abnormalities are seen in this EKG strip? How would you classify this rhythm?

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This rhythm is Ventricular Tachycardia. This pattern shows the hallmarks of Ventricular Tachycardia:

- The QRS are wide (>0.12) and the HR is very fast (100-200).

- PR interval absent

-Rhythm regular

What abnormalities are seen in this EKG? How would you classify this rhythm?

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What abnormalities are seen in this EKG strip? How would you classify this rhythm? 

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(6 second strip)

This strip shows a junctional rhythm. This shows the hallmarks of Junctional Rhythms:

- Here the P wave is flat

- Heart rate 40-60 beats per minute

- Regular rhythms, normal QRS complexes

How would you classify this abnormality? What is the most common cause of this abnormality?

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This EKG shows ST depression. The most common cause of ST depression is ischemia.

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What abnormalities are seen on this EKG? How would this rhythm be classified?

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This rhythm is a first degree AV block. The rhythm is regular, the P waves and QRS complexes are normal, but the PR interval is very elongated (>.20 seconds)

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What abnormalities are seen in this EKG strip? How would you classify this rhythm? 

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What abnormality is seen here? What conditions are associated with this pattern?

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This EKG shows ST elevation.

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What abnormalities are seen in this EKG strip? How would you classify this rhythm?

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This is Ventricular Fibrillation. It shows the hallmarks of Ventricular Fibrillation:

- No discernable P wave, QRS, or T wave

- Extremely fast, irregular rhythm

What abnormalities are seen in this EKG strip? How would you classify this rhythm?

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This is a juctional rhythm. You can tell because the strip shows an inverted P wave with a normal QRS and T wave and normal rhythm.

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Junctional rhythms occur when the SA node does not fire, so the AV node kicks in. Since the P wave reflects the firing of the SA node, junctional rhythms show inverted or flat P waves.

Hallmarks of Junctional Rhythms:

- Inverted or flat P wave

- Heart rate 40-60 beats per minute

- Regular rhythms, normal QRS complexes

What abnormalities are seen in this EKG strip? How would you classify this rhythm?

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This is a Second Degree (Wenckebach) Type 1 heart block. You can tell because the PR intervals get longer, longer, and longer, then an entire beat is dropped.

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Hallmarks of Second Degree (Wenckebach) AV Block:

- P-R intervals become progressively longer until one P wave is completely blocked and produces no QRS. This cycle repeats.

- *** think: longer, longer, longer, drop, then you have Wenckebach

What abnormalities are seen in this EKG strip? How would you classify this rhythm?

[image]

This strip shows atrial fibrillation. The hallmarks of atrial fibrillation are:

- Irregular rhythm

-Fibrillatory P Waves (may appear absent, but here are very obviously seen)

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An Accelerated Junctional Rhythm is a Junctional Rhythm where the heart rate is between 60-100 bpm. In normal junctional rhythms, the heart rate is 40-60 bpm.

Junctional rhythms occur when the SA node does not fire, so the AV node kicks in. Since the P wave reflects the firing of the SA node, junctional rhythms show inverted or flat P waves.

Hallmarks of Accelerated Junctional Rhythms:

- Inverted or flat P wave

- Heart rate 60-100 beats per minute

- Regular rhythms, normal QRS complexes

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This strip shows flat P waves. Using the rule of 10, the Heart Rate is 80 bpm