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ECG Workshop the Fundamentals

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ECG Workshop the Fundamentals ECG Workshop The Fundamentals Darrell E. Jones, DO David Kassop, MD, FACC ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Darrell E. Jones, DO Physician, U.S. Army Special Operations Command, Fort Bragg, North Carolina; Assistant Professor, Uniformed Services University of the Health Sciences, Department of Family Medicine, Bethesda, Maryland; Adjunct Faculty, Womack Army Medical Center (WAMC) Family Medicine Residency Program, Fort Bragg, North Carolina Dr. Jones serves as the chief of primary care for family member and soldier care. He earned his osteopathic medical degree from Nova Southeastern University College of Osteopathic Medicine in Davie, Florida, in 2005, and he completed his family medicine residency at WAMC. He is one of the few physicians to serve at the Military Free-Fall School in Yuma, Arizona, where he gained unique knowledge of high-altitude medicine and free-fall and skydiving injuries. Dr. Jones deployed to Afghanistan twice in three years and spent 13 months supporting Operation Enduring Freedom. He served for two years as the student coordinator and director of medical simulation for the WAMC family medicine program, and he received the Family Medicine Faculty of the Year Award for two consecutive years. For the past 10 years, Dr. Jones has moonlighted in multiple emergency departments, treating 2,500 patients annually. In addition, he has presented at the Uniformed Services Academy of Family Physicians annual conference for the past three years and volunteers as an adjunct member of the faculty for the WAMC Family Medicine Residency Program. David Kassop, MD, FACC Chief of Cardiology, Division of Medicine, Womack Army Medical Center, Fort Bragg, North Carolina; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland Dr. Kassop is a Medical Corps Officer, Active Duty, in the U.S. Army, with more than 10 years in service. He earned his undergraduate degree from the United States Military Academy (West Point) in 2003, and earned his medical degree from the USUHS in 2007. At Walter Reed National Military Medical Center in Bethesda, Maryland, he completed a cardiovascular disease fellowship and an internal medicine residency. He is board certified in cardiovascular disease and internal medicine through the American Board of Internal Medicine (ABIM), and specializes in invasive cardiology and advanced cardiovascular imaging. Dr. Kassop is a fellow of the American College of Cardiology and the American College of Physicians. He has co- authored more than 10 peer-reviewed publications and has presented at national and international medical society conferences. Learning Objectives 1. Compare and contrast the findings of ECG tests in different patient cases. 2. Relate the implications of ECG readings to potential cardiac disease. 3. Compare the findings of an ECG to a patient’s clinical presentation. 4. Compare the results of multiple ECG findings from the same patient. ECG Basics Module 1: Introduction Why is this important? • Patient care • Clinical competence • Expectation as a primary care provider • Credentialing • Accessible diagnostic test that can provide a wealth of information… Why is this important? • Rapid diagnosis in ACS • Structural heart disease (cardiomyopathies, valvular disease, congenital heart disease) • Pericardial disease • Evaluation of arrhythmias and conduction disorders • Channelopathies (LQTS, Brugada, CPVT) • Drug toxicity, electrolyte disturbances • Clinical disorders (PE, CNS disorders, dextrocardia) • Pacemaker function Why is this important? • Normal ECG • > 95% likelihood normal LV systolic function • low risk of structural heart abnormalities • Normal vs. Abnormal • Normal variant vs. Pathologic Approach to Reading ECGs Always be Systematic • Utilize a comprehensive algorithm • The order of the algorithm is less important than doing it the same way every time • Look at all the wave features in all the leads • Analyze your rhythm strip(s)! Approach to Reading ECGs • Clinical context is key • Beware of bad data, to include lead placement and artifact • ALWAYS COMPARE TO PRIOR ECGs • When in doubt, describe what you see • Never be afraid to ask for help! Interpretation Algorithm • Rate • Rhythm • Axis • Intervals • Blocks • Hypertrophy/enlargement • Injury/ischemia/infarct • Other Electrophysiology • Heart has inherent electrical properties • Depolarization of SA node electrical signal cardiac muscle cells contract • Contraction propagates through the heart mechanical contraction • Once depolarization completes, the cardiac muscle re-polarizes • Sum of myocyte potentials are measured by surface ECG Demonstration of Electrophysiology The Leads Two groups: • Limb leads • Record cardiac depolarization in relation to a vector between 2 points on the body • Can be further categorized to augmented leads • Precordial leads • Record the depolarization from the heart to the chest wall Limb Leads Precordial Leads Rhythm Strip misalud.com Standards • Time/ Intervals Time • Chart speed 25 mm/sec • 40 ms/small box Voltage 200 ms/large • 5 large boxes/second 0.1 mV • Voltage • 10 small = 1 mV = full 40 ms (.04 sec) standard 200 ms The P’s and Q’s of ECG RR ST PR QT T wave: Ventricular Repolarization QRS Complex: Ventricular Depolarization P wave: Atrial depolarization EKG Practice Rate • Rate: Normal HR is between 60 and 100 bpm • HR = 300/N {300, 150, 100, 75, 60, 50, 43, 37} 300 100 75 150 • Or, count the # of beats on the rhythm strip and multiply by 6 (10 second strip) • Rate > 100 is tachycardia • Rate < 60 is bradycardia Rhythm • Fast or Slow? • Bradycardia – look for AV block • Tachycardia – Supraventricular or Ventricular • Wide or narrow? • Clues to where the beats are coming from • Wide may be coming from the ventricle or due to aberrant conduction • Narrow means it is coming from above the AV node • Regular or Irregular? • Irregularly irregular v. regularly irregular Rhythm • Sinus Rhythm • P wave before every QRS complex AND… • P wave axis normal (upright in leads I, II, III) • Anything that is not sinus rhythm is an arrhythmia • Define the underlying rhythm • Evaluate for ectopy (PVC, PAC) EKG Practice EKG Practice EKG Practice AV Blocks First degree: PR interval is constant and longer than 200 ms Second degree: Type 1 (Wenkebach) Progressive lengthening of the PR interval before dropping the QRS complex Type 2 Fixed PR interval with periodic dropping of the QRS complex Third degree: AV dissociation (P not matching up with QRS)) EKG Practice EKG Practice EKG Practice Axis Graph Axis • Criteria • Normal -30 to +90 (… to +110 if <40 y/o) • Determine if net QRS voltage in limb leads is (+) or (-) • If QRS is (+) in I and AVF, then axis normal • (+) in I, (-) in AVF; left axis deviation, if II also neg • (-) in I, (+) in AVF; right axis deviation Differential Diagnosis • Left axis deviation: • LAFB, LVH, inferior MI, LBBB (in some cases), ostium primum ASD, severe hyperkalemia • Right axis deviation: • LPFB, RVH, lateral MI, RBBB (in some cases), ostium secundum ASD, chronic lung disease/PE, dextrocardia, limb lead reversal Interpretation Algorithm • Rate • Rhythm • Axis • Intervals • Blocks • Hypertrophy/enlargement • Injury/ischemia/infarct • Other EKG Practice EKG Practice Intervals • PR interval: 120 - 200 ms (3 - 5 small boxes) • QRS complex: < 120 ms (< 3 small boxes) • Wide QRS indicates: • Bundle branch block • Abnormal depolarization (PVC) • Severe LVH • Ventricular rhythms • QT interval: <.45 sec at normal rate • Pearl: QT should
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