EKG

Welcome to our initial EKG rounds kick-off!

EKG1.jpg

A recurring theme that I’m going to harp on over and over is to have a system to look at EKG’s.


Even when you see obvious abnormalities take the time to go through your system because you will miss things if you just go with an overall gestualt.  I recommend starting with the Rate.  You can usually trust the computer to interpret the rate correctly (though we will definitely review some where the computer gets it wrong).  However, I find myself very commonly muttering 300, 150, 100… as I go through how many big boxes it takes to cycle through.  In this case we’re just under 3 big boxes so this is probably about 110 bpm.


Next up is Rhythm.  We know it’s tachycardic and one of the first break points in tachycardia is wide vs narrow.  This one clearly counts as wide.  In fact it’s REALLY wide; look at your next 10 patients with LBBB and usually their QRS will be about 3 little boxes wide.  This one pushes 4-6 little boxes.  Looking further at rhythm we see there are no P waves.  So, we’re looking at a very wide complex ventricular tachycardia at about 110.  Alarm bells should be ringing.  How many times is V tach in the 110’s?  Paying careful attention to the rate helps unlock that there’s another piece to this EKG.


We’ve looked at Rate, Rhythm, P (and non-existent PR segments), as well as QRS.  We need to look at the ST segments.  We note that the computer is reading this as a STEMI and certainly we could forgive the computer for looking at some of the chest leads and coming to that conclusion.  We don’t really see elevation of the J point however.  Instead we see large ST segments that in a lot of leads essentially mirror the QRS.  There’s a mathematical term for a wave that follows that pattern, a Sine wave.  And in emergency medicine that term is synonymous with Hyperkalemia which this patient indeed has.   Any time you see complexes this wide you’d better either be reaching for Calcium or at least pulling up an old EKG.  We’re going to go through a lot of hyperkalemic EKG’s in this venue as they can be highly variable in appearance, but obviously important to recognize to stave off the impending arrest.elcome to our initial EKG rounds kick-off! A recurring theme that I’m going to harp on over and over is to have a system to look at EKG’s.  Even when you see obvious abnormalities take the time to go through your system because you will miss things if you just go with an overall gestualt.  I recommend starting with the Rate.  You can usually trust the computer to interpret the rate correctly (though we will definitely review some where the computer gets it wrong).  However, I find myself very commonly muttering 300, 150, 100… as I go through how many big boxes it takes to cycle through.  In this case we’re just under 3 big boxes so this is probably about 110 bpm.


Next up is Rhythm.  We know it’s tachycardic and one of the first break points in tachycardia is wide vs narrow.  This one clearly counts as wide.  In fact it’s REALLY wide; look at your next 10 patients with LBBB and usually their QRS will be about 3 little boxes wide.  This one pushes 4-6 little boxes.  Looking further at rhythm we see there are no P waves.  So, we’re looking at a very wide complex ventricular tachycardia at about 110.  Alarm bells should be ringing.  How many times is V tach in the 110’s?  Paying careful attention to the rate helps unlock that there’s another piece to this EKG.


We’ve looked at Rate, Rhythm, P (and non-existent PR segments), as well as QRS.  We need to look at the ST segments.  We note that the computer is reading this as a STEMI and certainly we could forgive the computer for looking at some of the chest leads and coming to that conclusion.  We don’t really see elevation of the J point however.  Instead we see large ST segments that in a lot of leads essentially mirror the QRS.  There’s a mathematical term for a wave that follows that pattern, a Sine wave.  And in emergency medicine that term is synonymous with Hyperkalemia which this patient indeed has.   Any time you see complexes this wide you’d better either be reaching for Calcium or at least pulling up an old EKG.  We’re going to go through a lot of hyperkalemic EKG’s in this venue as they can be highly variable in appearance, but obviously important to recognize to stave off the impending arrest.

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