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General Impression Measurements Underlying Rhythm QRS Axis Atrial Enlargement/Ventricular Hypertrophy Bundle Branch Blocks Myocardial Infarction Miscellaneous Good Milfs Use Quality Ass Butter Merrily and Mightily
I. General Impression R-Wave Progression aVR Deflection II. Measurements Rate # of small boxes between concurrent R-Waves divided into 1500 Rhythm PRI 0.12sec-0.20sec QRS <0.12sec QTc <0.44sec with HR 60-100 k = 0.397 for men k = 0.415 for women
III. Underlying Rhythm P:R Ratio = 1:1 P-Wave Morphology Round & Upright R-Wave Morphology IV. QRS Axis Lead I & aVF: Positive, Negative, Equiphasic Lead I & aVF Positive: Normal Axis Lead I Positive & aVF Negative: Left Axis Deviation (LAD) Lead I Negative & aVF Positive: Right Axis Deviation (RAD) Lead I Negative & aVF Negative: Extreme Right Axis Deviation (ERAD) Out of All Limb Leads Find the one that is Isoelectric Lead I: 180 to 0 Lead II: -120 to 60 Lead III: 120 to -60 aVR: -150 to 30 aVL: 150 to -30 aVF: 90 to -90 Find the Lead that is Perpendicular to the Isoelectric Lead
Lead I & aVF Perpendicular Lead II & aVL Perpendicular Lead III & aVR Perpendicular
V. Atrial Enlargement/Ventricular Hypertrophy Atrial Enlargement Right Atrial Enlargement (RAE) Lead II P-Waves >2.5mm & Peaked V1 First half of P-Wave >1mm in height and width & larger than second half Left Atrial Enlargement (LAE) Lead II P-Waves notched and >.11sec in duration V1 Second half of P-Wave >1mm in height and width & larger than first half Ventricular Hypertrophy Right Ventricular Hypertrophy V1 R-Wave is equal or greater than size of S-Wave V1-V6 Reversal in R-Wave Progression and RAD Left Ventricular Hypertrophy (a.) R -Wave height in aVL >11mm (b.) {R-Wave height in Lead I + the SWave depth in Lead III} > 25mm (c.) {S-Wave depth in V1 + the height in V5} > 35mm VI. Bundle Branch Block Right Bundle Branch Block (RBBB) V1 & V2 QRS Complex has two R-Waves; double peaked rSR-Wave Lead I, V5, & V6 S-Wave is slurred and does not return sharply to the isoelectric line Left Bundle Branch Block (LBBB) Lead I, V5, & V6 QRS Complex >.12sec QRS Complex Upright T-Wave Inversion V1-V3 QRS Complexes Mostly Negative (e.g. Big Q-Waves) T-Waves are Upright VII. Myocardial Infarctions What youre looking for Significant Q-Wave At least 1mm wide and one third the height of the R-Wave ST-Segment Elevation Elevation > 1mm from the isoelectric line Start Lateral
High Lateral Lead I aVL V5 V6 Then Inferior Lead II Lead III aVF Lastly Anterior Septal (Normally has elevated ST-Segments) V1 V2 Anterior V3 V4 Posterior V1 & V2: Tall R-Waves without a RAD
VIII. Miscellaneous Electrolyte Imbalances Potassium Hyperkalemia Tall peaked T-Waves Wide flat P-Waves Widening of QRS Disappearing ST-Segments Merging QRS and T Hypokalemia Flat T-Waves Increasingly Prominent U-Waves Calcium Hypercalcemia Short QTc Hypocalcemia Prolonged QTc Digitalis Toxicity Sloping ST-Segments ST depression Diphasic or inverted T-Wave Short QT Interval
Pericarditis Elevated, concave ST-Segment Diffuse ST changes not correlated to coronary vessels