The only EKG book. 9th Ed

Chapter 9. How Do You Get to Carnegie Hall?1

The following EKGs will allow you to try out your new skills. Use the method we outlined in the previous chapter. Don’t overlook anything. Take your time. Ready? Here we go!


Answer to EKG 1: Sinus tachycardia. Note also the presence of left axis deviation.

EKG 2:

Answer to EKG 3: The QRS complexes are wide and distorted. In leads V5 and V6, the QRS complexes are notched, and there is ST-segment depression and T-wave inversion. This patient has left bundle-branch block. The rabbit ear configurations in the QRS complexes in V5 and V6 are unusual for left bundlebranch block.


Answer to EKG 4: The broad, abnormal QRS complexes may immediately attract your attention, but notice the pacer spikes before each one. The spikes are preceded by a P wave (look at leads II, III, aVF, V1, and V2). This pacemaker fires whenever it senses a P wave, ensuring ventricular contraction.

EKG 5:

Answer to EKG 5: There are deep Q waves in leads III and aVF. This tracing shows an inferior infarct.

EKG 6:

Answer to EKG 6: The QRS complexes are greatly widened, with beautiful rabbit ears in lead V1. This patient has right bundle-branch block.

EKG 7:

Answer to EKG 7: The rate is very fast and regular, and the QRS complexes are narrow. Retrograde P waves can be seen in lead III if you look carefully. This patient has AV nodal reentrant tachycardia.

EKG 8:

Answer to EKG 8: The rhythm is irregularly irregular, and the QRS complexes are narrow. This patient is in atrial fibrillation.

EKG 9:

Answer to EKG 9: Are you confused by what appears to be extreme right axis deviation? Actually, in this instance, the EKG electrodes were accidentally reversed—the right arm and left arm electrodes were placed on the wrong arms. When you see a tall R wave in lead aVR and a deep S wave in lead I, check your electrodes.

EKG 10:

Answer to EKG 10: Everywhere you look, you see dramatic ST-segment elevation. This EKG shows an evolving infarct affecting the entire heart!

EKG 11:

Answer to EKG 11: You are staring at the classic saw-toothed pattern of atrial flutter.

EKG 12:

Answer to EKG 12: Left ventricular hypertrophy satisfying many criteria.

EKG 13:

Answer to EKG 13: Wolff-Parkinson-White syndrome with delta waves and a short PR interval.

EKG 14:

Answer to EKG 14: Extreme bradycardia resulting from hypoxemia in a patient with sleep apnea.

EKG 15:

Answer to EKG 15: Atrial fibrillation with a rapid ventricular response. You can’t see the fibrillating baseline, but the rhythm is clearly irregularly irregular.

EKG 16:

Answer to EKG 16: Ventricular tachycardia.

EKG 17:

Answer to EKG 17: How do the P waves and QRS complexes relate to each other? They don’t—this is third-degree heart block.

EKG 18:

Answer to EKG 18: Again, look at the relationship of the P waves to the QRS complexes. There are two P waves for every QRS complex—this is 2:1 AV block.

EKG 19:

Answer to EKG 19: The rhythm is normal sinus. The key finding is ST segment elevation in V1, V2 and aVR with reciprocal changes in the inferior leads and aVL - this patient is having a STEMI.

EKG 20:

Answer to EKG 20: What is the rhythm that you see? It is irregular with one P wave for every QRS complex. This is a normal EKG, and what you are seeing is a sinus arrhythmia.

EKG 21:

Answer to EKG 21: The most important finding here is diffuse ST-segment elevation without the upward bowing you typically see with an STEMI. This patient had acute pericarditis. You might also have picked up that the second beat is a bit premature—it is a PAC.

EKG 22:

Answer to EKG 22: Let’s finish up with this one. Did you catch the right bundle-branch pattern with ST-segment elevation most prominent in lead V2? This patient has Brugada syndrome.

Practice, practice, practice! An old joke, and I’m truly sorry.

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