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okay we've got a case here we've got a
55 year old male who presents the
emergency room with chest pressure for
two hours history of hypertension high
cholesterol diabetes type 2 and obesity
and he's got a family history of
coronary artery disease so you go ahead
and get an EKG on the patient and this
is what you receive so you decide to go
through methodically and figure out
exactly what it is that's going on on
this EKG so the first thing that we do
as you may recall is rate rhythm and
axis so what is the rate and remember
for the rates we look over the entire
picture we find an area that looks
fairly regular and I think this is
probably a good one as any and we see
there's two points that are cycling and
we count the number of boxes so we go
here for the number of boxes we go one
box two boxes and just almost three
boxes so next what we do is we take the
number of boxes and we put it into our
equation and you will know that if it is
one box it equals 300 beats per minute
if it is - it's 150 if it is three it's
a hundred if it is four it is
seventy-five if it is five it is equal
to 60 so we simply take the number of
boxes and we divide it into three
hundred and that will give us the rate
and so since looking at this it's
slightly shorter than three boxes the
rate is going to be slightly higher than
100 beats per minute which sounds
reasonable in this patient so rates is
over 100 beats per minute the next thing
that we have to look at is rhythm and
for that we are going to look at the QRS
complexes and right before it we're
going to look for P waves and the best
place to look for P waves is in lead two
because that's looking at the right
atrium and you can see P waves there
preceding each QRS complex here's a
rhythm strip which is almost always
lead to and you can see here clearly
that we have P waves before each QRS
complex so we're dealing with a sinus
rhythm and since this is greater than
100 this is sinus tachycardia so the
next thing that we want to do is look at
access and we want to see where is the
major ventricular axis in the situation
when we have contractions so let's go
through the leads lead 1 is going to be
going in this direction lead AVR is
going to be going to the right and so
it's going to be going up in this
direction AVL is going to be going up in
this direction lead to here is going to
be in this direction lead 3 is going to
be in this direction and of course AV F
is down in this direction and so what
you're trying to do here is look at the
major extreme so which ones have the
highest amplitude and which ones have
the most extreme amplitude and that'll
tell you generally what direction things
are going in and of course they should
be isoelectric or have the lowest
amplitude in the perpendicular direction
the other way of looking at it is just
going to the x and y axis which is lead
1 here and Y would be here in AVF so if
we're looking here in this direction we
see that the amplitudes are very low so
the QRS complexes are very low and so
that tells us that the axis is going to
be perpendicular to lead 1 whereas if we
look at AV F we see that there is a
definite negative amplitude here which
tells us that it's going to be going the
opposite direction of AV f so generally
just looking at one an AV f you can tell
that the axis is going to be going
generally in the up direction so which
up direction is that going to be it
could be here to the opposite of 2 or
the opposite of 3 so when we look at 2 &
3 we can see here that they're both high
in negative amplitude but 2 seems to be
the greatest in terms of negative
amplitude and so the direction that we
would see in this situation is probably
going to be somewhere opposite to lead
to so somewhere in that
range and that would make sense in terms
of axis so we've gone through rate we've
gone through rhythm and we've gone
through axis now we're kind of in
teasing you with this because obviously
the biggest issues that we can see here
clearly in this patient is not rate
where them access issues but it's this
thing it's the ST segment elevation that
we're seeing especially here in AVL and
we're seeing it in LEED v4 we're seeing
it in LEED v2 v3 as well and then the
key point here is that we're seeing
reciprocal ST segment depression in lead
Roman numeral 3 and in AVF so this is a
disaster this is a ST segment elevation
myocardial infarction that is evolving
in somebody with high risk factors so
the question this is what do we do with
this well join us in our next video
while we talk about what is the
management of somebody with an ST
segment elevation mi that comes in
because you need to know that before
they come in because it's very
nerve-racking in the meantime you want
to be able to recognize these things on
EKG and I want to implore you to visit
make cram comm where we have an
outstanding EKG class that goes through
methodically over these EKGs and so you
will not miss these very important signs
that you see on EKG thanks for joining
us
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you
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