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okay we've got a case here we've got a

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55 year old male who presents the

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emergency room with chest pressure for

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two hours history of hypertension high

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cholesterol diabetes type 2 and obesity

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and he's got a family history of

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coronary artery disease so you go ahead

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and get an EKG on the patient and this

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is what you receive so you decide to go

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through methodically and figure out

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exactly what it is that's going on on

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this EKG so the first thing that we do

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as you may recall is rate rhythm and

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axis so what is the rate and remember

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for the rates we look over the entire

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picture we find an area that looks

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fairly regular and I think this is

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probably a good one as any and we see

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there's two points that are cycling and

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we count the number of boxes so we go

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here for the number of boxes we go one

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box two boxes and just almost three

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boxes so next what we do is we take the

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number of boxes and we put it into our

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equation and you will know that if it is

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one box it equals 300 beats per minute

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if it is - it's 150 if it is three it's

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a hundred if it is four it is

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seventy-five if it is five it is equal

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to 60 so we simply take the number of

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boxes and we divide it into three

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hundred and that will give us the rate

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and so since looking at this it's

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slightly shorter than three boxes the

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rate is going to be slightly higher than

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100 beats per minute which sounds

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reasonable in this patient so rates is

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over 100 beats per minute the next thing

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that we have to look at is rhythm and

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for that we are going to look at the QRS

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complexes and right before it we're

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going to look for P waves and the best

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place to look for P waves is in lead two

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because that's looking at the right

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atrium and you can see P waves there

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preceding each QRS complex here's a

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rhythm strip which is almost always

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lead to and you can see here clearly

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that we have P waves before each QRS

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complex so we're dealing with a sinus

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rhythm and since this is greater than

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100 this is sinus tachycardia so the

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next thing that we want to do is look at

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access and we want to see where is the

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major ventricular axis in the situation

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when we have contractions so let's go

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through the leads lead 1 is going to be

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going in this direction lead AVR is

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going to be going to the right and so

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it's going to be going up in this

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direction AVL is going to be going up in

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this direction lead to here is going to

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be in this direction lead 3 is going to

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be in this direction and of course AV F

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is down in this direction and so what

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you're trying to do here is look at the

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major extreme so which ones have the

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highest amplitude and which ones have

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the most extreme amplitude and that'll

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tell you generally what direction things

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are going in and of course they should

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be isoelectric or have the lowest

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amplitude in the perpendicular direction

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the other way of looking at it is just

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going to the x and y axis which is lead

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1 here and Y would be here in AVF so if

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we're looking here in this direction we

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see that the amplitudes are very low so

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the QRS complexes are very low and so

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that tells us that the axis is going to

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be perpendicular to lead 1 whereas if we

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look at AV F we see that there is a

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definite negative amplitude here which

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tells us that it's going to be going the

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opposite direction of AV f so generally

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just looking at one an AV f you can tell

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that the axis is going to be going

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generally in the up direction so which

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up direction is that going to be it

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could be here to the opposite of 2 or

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the opposite of 3 so when we look at 2 &

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3 we can see here that they're both high

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in negative amplitude but 2 seems to be

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the greatest in terms of negative

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amplitude and so the direction that we

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would see in this situation is probably

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going to be somewhere opposite to lead

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to so somewhere in that

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range and that would make sense in terms

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of axis so we've gone through rate we've

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gone through rhythm and we've gone

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through axis now we're kind of in

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teasing you with this because obviously

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the biggest issues that we can see here

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clearly in this patient is not rate

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where them access issues but it's this

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thing it's the ST segment elevation that

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we're seeing especially here in AVL and

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we're seeing it in LEED v4 we're seeing

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it in LEED v2 v3 as well and then the

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key point here is that we're seeing

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reciprocal ST segment depression in lead

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Roman numeral 3 and in AVF so this is a

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disaster this is a ST segment elevation

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myocardial infarction that is evolving

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in somebody with high risk factors so

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the question this is what do we do with

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this well join us in our next video

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while we talk about what is the

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management of somebody with an ST

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segment elevation mi that comes in

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because you need to know that before

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they come in because it's very

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nerve-racking in the meantime you want

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to be able to recognize these things on

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EKG and I want to implore you to visit

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make cram comm where we have an

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outstanding EKG class that goes through

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methodically over these EKGs and so you

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will not miss these very important signs

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that you see on EKG thanks for joining

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us

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[Music]

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you

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[Music]