EKG Basics for APPs
A systematic EKG read for APPs — rate, rhythm, intervals, ischemia, and the dangerous patterns to escalate stat.
Learning Objectives
- 1.Read an EKG systematically every time.
- 2.Calculate rate and identify the basic rhythm.
- 3.Recognize the dangerous patterns that require immediate escalation.
- 4.Apply EKG findings within APP scope (recognition/triage).
Overview
APPs don’t need to over-read like an electrophysiologist, but you must reliably recognize the EKG patterns that change disposition in minutes — STEMI, dangerous rhythms, and conduction disease. A consistent, systematic approach prevents misses.
Read it the same way every time
- 1.Rate — fast, slow, or normal?
- 2.Rhythm — regular or irregular? P waves present and related to QRS?
- 3.Axis — normal vs deviation (basic).
- 4.Intervals — PR, QRS width, QT/QTc.
- 5.Ischemia — ST elevation/depression, T-wave changes, Q waves.
- 6.Chambers — hypertrophy/enlargement clues. Then compare to a prior EKG.
Rate and rhythm basics
- •Rate: 300/large-boxes between QRS, or count complexes in a 6-second strip ×10.
- •Regular narrow-complex: sinus, SVT, atrial flutter (often ~150).
- •Irregularly irregular, no clear P waves: atrial fibrillation.
- •Wide-complex tachycardia: treat as VT until proven otherwise.
Ischemia patterns
- •ST elevation in contiguous leads → STEMI until proven otherwise (reciprocal changes support it).
- •ST depression / T-wave inversion → ischemia (NSTEMI/UA in the right context).
- •New Q waves → prior infarct. Always compare with an old EKG.
- •Special patterns to flag: Wellens (deep precordial T inversions), de Winter, hyperacute T waves.
Dangerous patterns — escalate stat
- •STEMI / dynamic ischemic changes with symptoms.
- •Wide-complex tachycardia (assume VT).
- •High-grade AV block (Mobitz II, complete heart block) or symptomatic bradycardia.
- •Peaked T waves / widening QRS suggesting hyperkalemia.
- •Markedly prolonged QT (torsades risk).
Escalate immediately
These patterns — especially with symptoms or instability — go to the physician now and activate the appropriate pathway (e.g., cath lab for STEMI). Don’t sit on them.
Scope note
Scope
APPs recognize and triage EKGs and act on dangerous patterns. Formal over-read/interpretation of the official record remains with the physician; when uncertain, escalate.
Common beginner mistakes
- •Not comparing to a prior EKG (new vs old changes everything).
- •Calling a wide-complex tachycardia "SVT with aberrancy" and undertreating — assume VT.
- •Missing hyperkalemia’s peaked T waves / QRS widening.
- •Anchoring on a normal EKG to exclude ACS — a normal EKG does not rule it out.
Nurse / MA workflow connection
- •Quality acquisition (lead placement, artifact) from the MA is prerequisite to a safe read.
- •A symptomatic patient during EKG acquisition should be escalated to you immediately.
Mini cases
Chest-pain patient’s EKG shows 2 mm ST elevation in II, III, aVF with reciprocal depression in I/aVL.
What is this and what now?
Show answer
Inferior STEMI. Activate the STEMI/cath-lab pathway and escalate to the physician immediately; begin guideline-based initial care per protocol. Don’t wait for troponin to "confirm."
An EKG shows a regular wide-complex tachycardia at 180 in a patient with known prior MI.
How do you treat the assumption?
Show answer
Assume VT (especially with structural heart disease). Escalate emergently and manage per the unstable/stable VT pathway — do not assume benign SVT with aberrancy.