Embark on a journey with Jennifer Carlquist, PA-C, and course director of The Urgent Care EKG Course as she shares 12 essential insights for navigating through EKGs in the urgent care setting.
1. When a patient has an irregular rhythm, it is important to look closely for P waves. If they are the same shape and distance from the QRS complex, you could be dealing with sinus arrythmia. This is usually caused by breathing.
2. If you have a patient with palpitations, you may find a clue to the cause by asking the patient when the palpitations happen. Often, palpitations only occur when the patient is about to go to sleep which could be caused by anxiety, although this is a diagnosis of exclusion.
3. When you have a patient with tachycardia, make sure you can explain why. Pulmonary embolus can cause tachycardia and will not always be associated with an s1q3t3.
4. If you have a very short PR interval, the first thing you should look for is a delta wave. This is what you will see with Wolff-Parkinson-White syndrome, which can be fixed with an ablation.
5. If a patient has experienced a recent stressful event such as the death of a spouse and has new onset heart failure, consider Takotsubo cardiomyopathy. This can present a myriad of EKG findings, including STEMI.
6. PVCs are not always benign. They can lead to heart failure if there are enough of them.
7. There is always a reason for sinus tachycardia, while supraventricular tachycardia (SVT) comes on suddenly for no good reason. It’s hard sometimes to tell the difference between the two, but when you start to sort through the history, that’s where it really starts to make sense. Sinus tachycardia will have volume loss, fever, anemia, or anxiety, while SVT patients will usually have none of those. The exception would be if a patient has anxiety after they started feeling the SVT, which is a whole different story.
8. When interviewing a patient about their palpitations, it is always helpful to ask if they have anxiety as well. If they do, ask them which came first: the palpitations or the anxiety. If the anxiety came first, then it is most likely anxiety causing the palpitations, although this would be a diagnosis of exclusion. If the patient feels palpitations and then anxiety comes on, that’s more likely arrhythmia based.
9. It is impossible to diagnose Takotsubo cardiomyopathy from an EKG alone. There are many different presentations of the condition, including STEMI, nonspecific STT-wave changes, T wave, and inversions that are symmetric. If you have a patient with a classic story that involves recent major stress in their life, then absolutely consider this diagnosis. It can be seen during their angiogram, where it will look like apical ballooning, and they will have a reduced ejection fraction.
10. ST-segment elevation can be very minimal and still deadly. It is important when you are screening for ST elevation to look closely at the TP segment. This is the most isoelectric line, and this is where you should draw your line to see if there’s any elevation or depression. As little as 1 mm can be significant for STEMI in the inferior leaves, so it really does matter here. Get serial ECGs.
11. When looking at the intervals at the top of the EKG, one of the most important numbers to look at is the QTC. The QTC should be <460 ms to be normal in women and <450 ms in men. If it is longer than that, consider adjusting the patient’s QT-prolonging medication. We do not usually see Torsades de Pointes until they get >500 ms, but it’s still a good idea to minimize risk by getting the patient off any QT prolongers you can.
12. Torsades de Pointes is lethal and most likely stems from a prolonged QT. Unlike in VT, the treatment is magnesium, but prevention is always the key. Amiodarone can also prolong the QT and can be proarrhythmic, so you may have to choose a different drug in some cases.
This course is ideal for PAs and NPs practicing in urgent care. Whether you’re new to practice or have many years of experience, you’re sure to learn practical, evidence-based tips you can use on your next shift. You can sharpen your EKG interpretation skills, improve your accuracy, become more proficient, and boost your clinical confidence with The Urgent Care EKG Course.
Visit https://www.ebmedicine.net/ekg to learn more.
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