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Okay we've got a case here we've got a
55 year old male who presents the

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emergency room with chest pressure for
two hours history of hypertension high

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cholesterol diabetes type 2 and obesity
and he's got a family history of

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coronary artery disease so you go ahead
and get an EKG on the patient and this

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is what you receive so you decide to go
through methodically and figure out

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exactly what it is that's going on on
this EKG so the first thing that we do

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as you may recall is rate rhythm and
axis so what is the rate and remember

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for the rates we look over the entire
picture we find an area that looks

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fairly regular and I think this is
probably a good one as any and we see

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there's two points that are cycling and
we count the number of boxes so we go

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here for the number of boxes we go one
box two boxes and just almost three

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boxes so next what we do is we take the
number of boxes and we put it into our

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equation and you will know that if it is
one box it equals 300 beats per minute

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if it is - it's 150 if it is three it's
a hundred if it is four it is

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seventy-five if it is five it is equal
to 60 so we simply take the number of

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boxes and we divide it into three
hundred and that will give us the rate

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and so since looking at this it's
slightly shorter than three boxes the

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rate is going to be slightly higher than
100 beats per minute which sounds

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reasonable in this patient so rates is
over 100 beats per minute the next thing

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that we have to look at is rhythm and
for that we are going to look at the QRS

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complexes and right before it we're
going to look for P waves and the best

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place to look for P waves is in lead two
because that's looking at the right

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atrium and you can see P waves there
preceding each QRS complex here's a

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rhythm strip which is almost always
lead to and you can see here clearly

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that we have P waves before each QRS
complex so we're dealing with a sinus

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rhythm and since this is greater than
100 this is sinus tachycardia so the

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next thing that we want to do is look at
access and we want to see where is the

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major ventricular axis in the situation
when we have contractions so let's go

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through the leads lead 1 is going to be
going in this direction lead AVR is

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going to be going to the right and so
it's going to be going up in this

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direction AVL is going to be going up in
this direction lead to here is going to

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be in this direction lead 3 is going to
be in this direction and of course AV F

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is down in this direction and so what
you're trying to do here is look at the

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major extreme so which ones have the
highest amplitude and which ones have

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the most extreme amplitude and that'll
tell you generally what direction things

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are going in and of course they should
be isoelectric or have the lowest

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amplitude in the perpendicular direction
the other way of looking at it is just

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going to the x and y axis which is lead
1 here and Y would be here in AVF so if

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we're looking here in this direction we
see that the amplitudes are very low so

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the QRS complexes are very low and so
that tells us that the axis is going to

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be perpendicular to lead 1 whereas if we
look at AV F we see that there is a

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definite negative amplitude here which
tells us that it's going to be going the

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opposite direction of AV f so generally
just looking at one an AV f you can tell

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that the axis is going to be going
generally in the up direction so which

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up direction is that going to be it
could be here to the opposite of 2 or

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the opposite of 3 so when we look at 2 &
3 we can see here that they're both high

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in negative amplitude but 2 seems to be
the greatest in terms of negative

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amplitude and so the direction that we
would see in this situation is probably

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going to be somewhere opposite to lead
to so somewhere in that

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range and that would make sense in terms
of axis so we've gone through rate we've

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gone through rhythm and we've gone
through axis now we're kind of in

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teasing you with this because obviously
the biggest issues that we can see here

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clearly in this patient is not rate
where them access issues but it's this

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thing it's the ST segment elevation that
we're seeing especially here in AVL and

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we're seeing it in LEED v4 we're seeing
it in LEED v2 v3 as well and then the

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key point here is that we're seeing
reciprocal ST segment depression in lead

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Roman numeral 3 and in AVF so this is a
disaster this is a ST segment elevation

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myocardial infarction that is evolving
in somebody with high risk factors so

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the question this is what do we do with
this well join us in our next video

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while we talk about what is the
management of somebody with an ST

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segment elevation mi that comes in
because you need to know that before

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they come in because it's very
nerve-racking in the meantime you want

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to be able to recognize these things on
EKG and I want to implore you to visit

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make cram comm where we have an
outstanding EKG class that goes through

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methodically over these EKGs and so you
will not miss these very important signs

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that you see on EKG thanks for joining
us

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you