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Pratical Guide To Ecg Interpretation

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Pratical Guide To Ecg Interpretation

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patriciavfreitas
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A Practical Guide To ECG Interpretation Ken Grauer, MD, F.A.A.F-P. Professor, Department of Community Health and Family Medicine Assistant Director, Family Practice Residency Program College of Medicine, University of Florida, Gainesville ACLS Affiliate Faculty fr Florida Dr, Graver can be reached by: Mail: Dr. Ken Brauer Family Practice Residency Program 625 SW. 4th Avenue PO, Box 147001 Gainesville, Florida 32614 Fax (282) 332-9154 e-mail: grauer@fpmg health.ufl edu Web site: http://orwew.med.ufl.edu/chfm/people/arauer Second Edition NA Mosby St ovis Botinoe Bovton Calebad Chicago Minneapelic Now York Phileptis Potend london Mian Syéney Tokyo. Tota NA Mosby aes aig cr WH A Times Mirror ue Company Vice President and Publisher: Don Ladig Acquisitions Editor: Jennifer Ri Developmental Editor: Tamara Myers Project Manager: Mark Spann Design Manager. Judi Lang Designer: Studio Montage ‘Manufacturing Manager: Karen Boehme Cover Art: AKA Design Second Edition Copyright © 1998 by Mosby-Year Book, Inc. Previous edition copyrighted 1983 All rights reserved, No part of this publication may be reproduced, stored in a retrieve system, of transmitted, in any form or by any means, electronic, mechanical i photocopying, recording, or otherwise, without written permission of the publisher Permission to photocopy or reproduce solely for internal or personal use is permitted for ibveres or other users registered with the Copyright Clearance Center, provided that the base fee of $4.00 per chapter plus $.10 per page is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. This consent does not extend to other kinds of copying, such as copying for genera distribution, for advertising or promotional purses, fr creating new collected works, or for resale. ion by Studio Montage, Graphic Word, Inc. Priting/binding by Von Hoffmann Press Mosby-Year Book, Ine. 11830 Westline Ind St. Louis, MO 63146 rial Drive ISBN 1-55664-557-0 000102/987654321 To Fredia Wofford McCraven and E.G. Wofford ' for welcoming me into't family « enily About the Author Ken Grauer, M.D,, FA.A.EP, is 2 professor in the Department of Community Health and Family Medicine, College of Medicine, University of Florida and assistant directo ofthe Family Practice Residency Program in Gainesville, He is board certified in family practice, and is ACLS Affiiate Faculty fr Florida (and former National ACLS Affiliate Faculty, He is also a former contributor to the American Heart Association ACLS Textbook who served on the Task Force for ACLS Post- Testing. He has recently worked on a Position Paper on ECG Interpretation for primary care physicians. In addition to the second edition of this book, Or. Grauer is the author of ECG Interpretation: Packet Reference (Mosby, 1982), He is also the principal authar ofthe following books and teaching resources: Clinical Electrocardiography: A Primary Care Approach (Second edition—Blackwell Scientific Publications, 1992|; ACLS: Rapid Review and Case Scenarios (Fourth edition, Mosby Lifeline—1996); Arrhythmia Interpretation: ACLS Preparation and Clinical Approach (Mosby Lifeline~ 1997); ACLS: Rapid Study Card Review (Third edition, Mosby Lifeline—1997);, ACLS Rapid Reference (Third edition, Mosby Lifeline—1997); and ACLS Teaching Kit: An Instructor's Resource {Mosby-Year Book, 1990). His ACLS materials have been featured on the Mosby Lifeline CD-ROM products, ACLS Infobase: The ACLS Omnibus Resource, and ACLS Review (User's Manuel and Instructor's Version}. Dr Graver has lectured widely and is primary author of numerous articles on cardiology for family physicians, including several “ECG of the Month columns that have been published for well over a decade in various primary care journals. He has been featured on more than twenty medical audiocassettes published by Audio-Digest and the AAFP Home-Study Self-Assessment Program. He has served on the Editorial Board of the following journals: Family Practice Fecenitication, Procedural Skils and Office Technology, and Internal Medicine Alert, Emergency Medicine Alert and ACLS Alert Dr, Grauer is well known throughout Florida and nationally for teaching ACLS courses and ECG/Arrhythmia workshops to diverse medical audiences including nurses, paramedics, medical students, physicians in training, and physicians in practice. He has been recognized locally, statewide, end nationally with tegching awards and proudly carries as his trademark the ability ‘0 simplify otherwise complicated topes into a concise, practical, and easy-to-remember format. vir Acknowledgments ributions were instrumental to the pre | am indebted tothe following people whose co paration of this book: Mark Spann—uho stepped in at the eleventh hour and exerted his mastery to help save this wark. Thank you Mark Jennifer Roche—for her faith my work, Thenk you, Jenifer! Anita Wofford-Grauer—for accepting my need to spend the “etemity” it took to write this book. Thank you for your lve and support Rick Griffin and Stephanie Ivey—for their friendship and welcome at the best] restau- rant in Gainesville [and the world!} Ivey's Grill—hich continues to provide me with 2 peaceful, pleasant, and creatively inspiring environment for my writing (and endless well as forthe tofu and frit to keep my coronaria clean, Thanks also to my ers and waitresses at lve’, who truly make up the bestand friendliest staff rewriting}. favorite w anywhere! Maria Alvarez and Ray Parris—those best teachers (end great friends) at the Maria Alvarez Imperial Dance Studio, who have forever been instrumental in helping me to maintain my sanity (and still have fun by dancing) for the long hours I spent writing this and other books, Barney Marriott, MD, end William P. Nelson, MD—for teaching me more about ECGS than can ever say The Cardiology staff at Alachua General Hospital (Burt Silverstein, MD; Steve Roark, MD: Mike Cillon, MD, James O'Meara, MD, and Berard Gros, MD}—for their tremendous support of me, and for teaching cardiology to our residents To all of the other excellent cardiologists who have inspired me, and from whom I have teamed. To aif those who have knowingly (end unknowingly) provided me with tracings and other nuggets of information through the yeers. ‘And last but far from least—to all the nurses, medical students, residents, and other para- rmecical personnel who through the years have allowed me to learn by teaching them. 1x Preface to the New Edition Why a Second Edition? In 1992, at the time we wrote the Preface and How to Use this Book sections forthe first edition cf our ECG book, we asked why? Why write another book on electracardiogrephy when literally hundreds of books on this topic already exist? In 1998, as we now write the How to Use this Book section for the new edition of our book, we again ask why? Why write a second edition of this ECG book? ‘ur answer to this question is multifaceted. We have greatly expanded the scope of our content to even more thoroughly cover ECG Interpretation. New features of this second edition include: * Comprehensive Discussion of Cardiac Arrhythmias. This subject is covered completely — so that this second edition serves equally well as @ text an Arrhythmia Interpretation as it does for 12-Lead ECG Interpretation. Discussion of the AV blocks, AV dissociation, MAT (ultitocal atrial tachycardia), raythms of cardiac erest, and a practical clinical approach to diagnosis of tachyarrhythmias are examples of new subject material added. * Clinical Correlations. n the hope of making this second edition as relevant as possible 10 the everyday practice of our readers, we have greatly expanded our use af clinical cor- relations throughout this book. For exemple, far each ofthe major cardiac rhythms we have added a Clinical Notes section that addresses assessment and key menagement issues. Discussion has been added onthe clinical significance ofthe various bundle branch blacks and hemiblocks; on the clinical meaning and various modalities used to diagnose LH and RVH,; 09 relevence ofthe term Poor A Wave Progression: and on the use of the ECG in acute myocardial infarction (with respect tits effect on the coronary circulation and site af inferction, correlation with the history and cardiac enzyme results, and use of reperfu- sion therapy). In addition, clinical integration has been greatly expanded with regard to haw the ECG is used in assessment of electrolyte disorders, patients with a pericardial frc: tion rub, chen with heart murmurs, and the patient with a cardiac pacemaker. + Addition to the Essential Liss. There are now six Essential Lists (i... the Causes of a Regular SVTis a new list) Discussion of clinical use ofthese lists has been expanded, + Additional Practice Tracings. Much greater opportunity is provided in this second edi- tion for practice and reinforcement of the key concepts covered—which are always followed with detailed explained answers. The other major feature thet we have enhanced is the text's readebility end user- friendliness. improved features include: Rapid Locator Guide. This feeture is found on the very last page just inside the back cover. On it are listed the most commonly referred to Figures and Tables inthis new edi- tion—thus enabling our readers to find in an instant the specific page where this material i found. Frequent Cross References. Specific page reference is made throughout this new edition to other places in this book where material related in content to what is currently being read can be found. Additional Schematic Tracings and User-Friendly Tables/Figures. We have increased our already liberal use of concept enhancing illustrations and tabular material- {rom our first edition, Schematic illustrations are regularly correlated with actual 12-lead ECGs and chythm strips. ‘We hope you enjay the new edition of our ECG book. It was written with YOU in mind! Ken Graver, MD x1 How to Use this Book ‘As noted in the Preface, the first question is why?—why write this book electrocerdiography? ‘As was the case forthe first edition, the secret les in the approach. Despite hundreds of books already written on the topic, the need remains for a comprehensive yet practical approach to electrocardiography for the beginning and novice student. Practical Guide to ECG Interpretation hs been written expressly with the needs of this audience in mind. The approach in this text is diferent. We don't stress endless memorization of litle-used (and al-t90-easly-orgotten) facts. Instead we stress application of practical concepts encaun- tered in the daly practice of most medical care providers, New features enhancing this second edition were discussed in detail in our Preface. Part | (Philosophical Overview/Review of Fundamentals) opens with a brief Philesophical Overview of electrocardiography (Chapter 1). We stress that the reader need not ba a cardiologist (or even a physician) to obtain a high degree of proficiency inthe art of inter- pretation. Knawledge and application of a systematic approach, awareness of the clinical setting, availability ofa prior tracing, and common sense are the key ingredients to being @ suc- cessful electrocardiographer. ‘We then move to our Review of Fundamentals in an attenpt to unify the knowledge base of our readers. Much of this material may be basic to those with prior experience, Nevertheless, appreciation of these concepts is essential to understanding the balance of our book. Partl (The Systematic Approach) comprises the core content of the book, It begins with ‘an Overview of the Descriptive Analysis (Chapter 2) There follows comprehensive discussion and review of Rate & Rhythm (Sections A through D in Chapter 3); the PR Interva/(Chapter 4) the RS Interval and Bundle Branch Block (Chapter 5}: WPW [Addendum to Chapter); the QT Interval (Chapter 6); Axis and Hemiblocks (Chapter 7), Chamber Enlargement (Chapter 9); and ORST Changes {Chapter 10), Review exercises and Putting It (the Systematic Approach) All Together are presented in Chapters 8 and 11. We hape most readers will went to read on to Part I: “For Those Who Want to Know More.” This section begins with Chapter 12 on Infarction and Ischemia, which many may believe is our most important chapter. In addition to emphasizing ECG diagnosis of acute infarc- tion and ischemia, this chapter reviews the coronary circulation, stresses clinical application of thrombolytic therapy (and use of the initial ECG to determine which patients are mast likely to benefit ftom this treatment), and includes tips on recognizing silent infarction and diagnosing posterior and right ventricular infarction by ECE. Chapter 13 introduces the Six Essential Lists in electrocardiography. Awareness of the contents of these lists greatly facilitates the task of the interpreter There follows discussion of Electrolyte Disturbances (Chepter 14) and Pericarditis |Chapter 15) Part IV puts on Finishing Touches. It includes chapters on Recognizing Lead ‘Misplacement (Chapter 16); When the Patient is a Child (Chapter 17); if the Patient has a Pacemaker|Chapter 18); What Can We Learn from Comparison Tracings? (Chapter 20}, and Does the Computer Know Better? (Chapter 21). We believe the two sections in Chapter 19 {Section 19A—A Brief Look at the AV Blocks; and Section 198—When 12 Leads are Better than One) will offer real challenge ta any reader actively involved in arthythmia interpretation, Those who apply the principles set forth in these two sections will make a quantum leap in their ability to interpret cardiac arhythmias. ‘The text concludes with Part V (Putting Yourself to the Test). A total of 45 basic review and challenge tracings for interpretation are included in Chapters 22 and 23. Each practice tac ing is accompanied by a shart clinical scenario to add realism, You are asked to systematically interpret these tracings and then to compare your answers with the detailed explanations that follow, Clinical relevancy is stressed. Accompanying each tracing are Questions to Further Understanding, which seek to bridge the gap between ECG theory and clinical (and practical) application. Chapter 24 then closes with parting advice an Where Do We Go From Here? XIII Ve eee gees sete eeveesHow To USE THIS Boor Note: itis not essential to weit until the end of the book ta do the practice trac- ings in Chapters 22 and 23. On the contrary, appreciation of clinical relevancy may be enhanced by periodically trying your hand at a few of these basic review and challenge tracings as you read through the book. Refer back to pertinent chapters in the text when questions arise. Then put yourself to the test again after reviewing the relevant material or completing the text. In the hope of serving you better, please note the street address, fax, and e-mail address on the title page. Feel free to write, fax, or e-mail your feedback on how you like this book, as ‘well as any questions or comments you may have. Contents Abbreviations, xvii Part I Getting Started 4 Philosophical Overview/Review of Fundamentals, 1 Part II The Systematic Approach 2 Overview of the Descriptive Analysis, 22“ 3 Rete and Rhythm, 30 4 The PR Interval, 92 55 The GRS Interval/Bundle Branch Block, 96 6 The QT interval, 118 7 Axis (and Hemiblocks), 123 8 Review, 144 9 Chamber Enlargement, 152 10 ORST Changes, 170 11 Putting It All Together (Writing the Descriptive Analysis), 190 Part III For Those Who Want to Know More 12 ECG Indicators of Myocardial infarction, 202 13 The Six Essential lists, 225 14 Electrolyte Disturbances, 248 15 Pericarditis, 256 Part IV. 16 Recognizing Lead Misplacen 17 When the Patients a Chi 18 If the Patient nas a Pacemaker, 264 19 Advanced Arrhythmia Concepts, 287 20 What Can We Learn from Comparison Tracings? 356 21 Does the Computer Know Better? 374 ishing Touches Part V_ Putting Yourself to the Test 22 Basic Review Tracings, 380 23 Challenge Tracings, 428 24 Where Do We Go From Here? 482 Index, 484 Rapid Locator Guide, Inside back cover xv Abbreviations We intentionally use numerous abbreviations throughout this book. We have chesen to do so because: «Abbreviations occupy a ubiquitous presence in the field of electracerdiography. They are part of the vernacular spoken by medical personnel, as well as the standard for written interpretations. Rare is the cardiologist who will meticulously (and legibly) write out intraventricular conduction defect, right atrial enlargement, or left ventricular hypertro- phy each time these abnormalities occur. I's just so much easier (and clearer) to write IVCD, RAE and LVH, ‘+ We fee! readability of our book is enhanced by using abbreviations instead of writing each term out + Learning is facilitated by becoming used tothe terms and abbreviations used in everyday practice. For clarification and easy reference, we've therefore listed those abbreviations you'll encounter throughout this book: . A AIVR—accelerated idioventricular rhythm AV —atrioventicu AV block—atrioventricular block AV node—atrioventricular (or junctional} node AV nodal chythm—atrioventricular (or junctional) rhythm i AVNRT—AV nodal reentry tachycardia (= PSVT) B BBB—bundle branch block c CCU—coronary care unit chw—consistent with cw—elockwise cow—counterclockwise (CNS—central nervous system COPD—chronic obstructive pulmonary disease CSM—carotid sinus massage (= CSP) CSP-—tarotid sinus pressure (= CSM) CvA—cerebral vascular accident DIEIFIGM £03—electrocardiogram ED—emergency department EKG—electrocardiogram (ie, from the German “ElektroKardioGraph"} EMD—electromechanical dissociation ETT—exerise tolerance (stress| test 1 tBBB— complete left bundle branch black XVII PuELOSOPHICAL OVERVIEM/REYIEN OF FUNDAMENTALS ee ee ® Philosophical Overview ‘The most appropriate place to start a book on rap interpretation ofthe 12-lead ECG is at the beginning ~ with the definition of an electrocardiagram. Simply stated, an ECG.is “the graphic: representation ofthe hear’ electrical activity.” It is nothing more, and nothing less. In our expe- rience, when health care providers are disappointed by the inability of an ECG to provide the information they seek, itis most often because this basic definition is forgotten.® i Al that an ECG does is reflect the hearts electrical activity. kt says nothing about the relation between this electrical activity and the clinical situation at hand, That's the job of the interpréter, Thus, the identical 12-leed vecing might be interpreted very differently depending on what the clinical scenario happens to be. For example, ST segment elevation or T weve inversion may be interpreted as strongly suggestive of acute infarction or ischemia if seen on the ECG of a middle-aged adult with new-onset chest pain. However, the very same ST segment and/or T wave changes might be interpreted es normal if they appeared instead on an ECG obtained from an otherwise heelthy child or asymptomatic young adult, Thus, even when seemingly abnormal find- ings are identified, a single ECG— viewed by itseff-says litle i anything] about the likely clinical significance of these abnormalities. Moreover, this single ECG ~ viewed by itself -provides litle {or no} information as ta whether any ofthe abnormalities seen are new (i. acute) oral. From the above introductory comments it should be apparent that in adltion to assessment of the ECS itself, optimal interpretation also entail: 4. Clinical correlation, including knowledge of the patient’s age and the reason for obtaining the ECG in the first place (e.g. new-onset chest pain, assessment for chamber enlargement in a patient with hypertension, of simply “routine” as a baseline part ofthe physical examination in an asymptomatic patient ‘AND 2. Availability of a prior tracing for comparison. This becomes especially important when the current tracing shows abnormalities that could be of new onset (and which might explain a change in the patient's clinical condition) Components of ECG Interpretation ‘The KEY to ECG interpretation is restraint. The key to resent is using a systematic approach. Doing so nat only protects you from focusing on obvious abnormalities (and overlooking more subtle findings in the process, but also keeps you organized. Even without knowing the clinical significance of some ofthe findings detected, maintaining @ systematic approach in your inter pretetion wil be of invaluable assistance for helping to recognize when "something's amiss” with the tracing i We have found it easiest to approach the art of ECG interpretation by dividing it into two principle components: 1. Descriptive Analysis 2. The Clinical Impression CLINICAL NoTe - Most errors in interpretation arise from failure to keep these {wo components separate in your mind! Descriptive analysisis simply a statement of what is found on the ECG. It includes assess- tment of the tracing for the parameters of rete, rhythm, axis, chamber enlargement, and ORST The elacvical acti ofthe hear orginets at a cela eve, Oring the resting state, incvidul myocar cel se said tobe poled hey arénegtivaly cargd on the al ita and postive charged an the ouside srtacl of te col With eecicelstimiation ofthe cl tbatonas depolarized th ire eget of thecal interir becomes pos tively eharged). With organized spread ofthe wave of dapolarizationatoss the mass of cardiac cell, mechanical cnttactinof the het ruse oceurs Some tinea, epoar2ee myocar ells tum to tir resting satiety gun become negatively charged on hiner dig the ores know 3 epleriztion, Recrtng ofthese eect a eves asthe mass of ara allt the sia and varies depolarae and repolarie| produces the C6. KEY Cuintcat Point incuropiion tis unfairote asttin inte tess tie Evaouum(.a,withourkroweige of the patients age and presenting complaint). i iit alo oon exceedingly ditto datamine anyee8 | abnormalities seen are new or old i wrlesa porvacing fomtie patient is available for comparison. t KEY Cuinicat Pornt - ‘An all to0 common pitfall to inter pretation is the tendency of jumping ‘head to one’s conclusion fle. the clinical impression) — without fist systematically completing the de- ‘scrptve analysis. The most helpful advice we can offer fr avoiding this pitfall is to exercise restraint atthe time of your interpretation: 1. Alwaysbe systematic in your approach 2. Always aim to complete your descriptive analysis ideally by WAITING DOWN your findings). Do this before you begin to formulate

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