Understanding EKGs

Dan - I just now saw your helpful hints for interpreting EKGs. Thank you so much for sharing what helped you!

I'd heard about the Dubin book but refuse to purchase it when he was arrested for child pornography and cocaine.

This is a 2-step approach remembered by 2 mnemonics:

Step 1: Evaluate all elements of the EKG systematically: A RARE PQRST.

Step 2: Differential diagnosis. Look for diseases that may have caused the abnormalities noted in step 1: DR III EEE !

This systematic approach to reading electrocardiograms (ECGs or EKGs) works every time, just like a machine. By using it, you will not miss any major abnormalities in electrocardiograms (EKGs).

What is the meaning of the mnemonics?

A RARE PQRST:

Age, e.g. a 60-yo patient is likely have a different pathology from a 30-yo patient

Rate, e.g. fast or slow?

Axis, e.g. left or right?

Rhythm, e.g. regular or irregular?

Evaluate each EKG element as follows:

P wave, e.g. peaked or absent?

Q wave, e.g. deep Q wave?

R wave, e.g. tall? look at QRS complex width for RBBB or LBBB

ST segment, e.g. elevation or depression?

T wave, e.g. peaked or inverted?

DR III EEE:

Drugs , e.g. Digoxin, tricyclic antidepressants

Rhythm and rate abnormalities, e.g. AV block of 1,2,3 degree, AFib, SVT?

Ischemia?

Infarct? Deep Q wave?

Infection, e.g. pericarditis

Enlargement, e.g. LVH, RVH, left or right atrium enlargement?

Electrolyte disturbances, e.g. hyperkalemia, hypokalemia, hypercalcemia,

Endocrine causes, e.g. hypothyroidism

How to use this approach in practice?

Look at the EKG and write down on a piece of paper:

A R A R E P Q R S T

D R I I I E E E

Circle the abnormalities you discover in step 1 — A RARE PQRST. Then, connect and try to explain these abnormalities by looking at the list of possible etiologies presented in step 2 — DR III EEE. That’s it!

I'm so delighted that you all love Dubin. dDd you know that he is a Plastic surgeon? How is that for a bit of trivia? Reading EKG's can replace reading the New York Times  crossword puzzle as they are not all easily interpreted and offer so many variables, but they are fun. Learning is fun  in any area you chose if that is what you transform learning into. Your journals always have good articles on a new EKG with an explanation and the AFPPA has two three hour , maybe two hour workshops, that will enhance your learning and help you to reach the cascades but never the pinnacle. Here is a question for the newly initiated EKG expert

Steve - Thanks for the comment! That's what my instructors keep saying: Practice, practice, practice and try to read as many as you can. I'm trying to ask as many questions as possible and I hope that in the field  I'm able to learn from such knowledgeable people as the nurse you described in your experiences. I will absolutely be practicing! Thanks.

Tim - We are using Dubin too, and it is really a wonderful teaching tool. It really puts everything into the simplest terms. I know I'll be using it as an important resource for some time. Thanks for the suggestion and your encouragement and congratulations on your ACLS completion! Good luck!

We used Dubin's book...highly recommend it if you are not already using it.  Today, we completed our ACLS training.  It was pretty incredible to be able to look at a monitor that showed V-Fib/V-Tach, A-Fib, SVT, and sinus bradycardia and know what to do next.  It only gets better!

funny u should say that, when I was a PA student 27 years ago I had a horrible time with EKG's, they made no sense to me. But with the help of two internists (from Philly, by the way) and lotsa pictures I felt much more comfortable. I would compare "the lines" with what was happening from the atrium to the ventricles. Remember, you have to read EKG's daily to get good at it. My nurse was an old time ICU/CCU nurse and brother she could read an EKG quickly and accurately. She had them read before grand rounds every day, every shift. The residents were on their best behavior around her. PRACTICE,PRACTICE,PRACTICE!!