Key Points:
- Consistency saves lives: Use a repeatable ECG routine to reduce misses in chaotic settings. Many valid methods exist. Pick an order that fits your acute-care workflow and do it the same way every time.
- Life threats first: Prioritize instability, malignant rhythms, occlusion MI patterns, and toxic-metabolic conduction problems.
- Must-explain triggers: Wide QRS, extreme rate, marked QTc prolongation, regional ischemic patterns, and new conduction disease require a specific explanation.
- Patterns and dynamic changes beat a single tracing: Territorial coherence, reciprocity, and serial evolution are more reliable than any single snapshot using only millimetric thresholds. When in doubt, get serial ECGs.
- Correlate, then act: The goal is not perfect labeling. It is the correct time-sensitive decision.
This hub suggests a repeatable, bedside approach to ECG interpretation that prioritizes identification of critical, time-sensitive findings.
How to Use This Hub:
- Do a quick safety check for clinical instability and consider technical errors.
- Run steps 1–3 listed below in order.
- If you hit a must-explain trigger or ECG abnormality, click into the linked ECG STAT post to help you differentiate and interpret with attention to nuance and pitfalls.
Quick Safety Check (before deep analysis)
- Confirm calibration and tracing quality (artifact, baseline wander).
- Consider lead misplacement if the ECG looks anatomically implausible.
- Identify instability: hypotension, shock, ischemic chest pain, pulmonary edema, altered mentation, severe hypoxia, etc.
- If the ECG plausibly explains instability, treat first (cardioversion, pacing, reperfusion pathway), then refine.
Heart Rate & Rhythm
(Rapid Threat Sorting)
Confirm the rate, then classify the R–R pattern (regular, regularly irregular, irregularly irregular). Define what the atria are doing (P waves and atrial rate when visible), what the ventricles are doing (QRS rate and width), and the AV relationship (P:QRS, PR behavior, dissociation). If the rhythm diagnosis is not clear on a single ECG, use a longer rhythm strip or repeat the ECG rather than forcing a diagnostic label.
Review rate & rhythm basics here:
Intervals & Conduction
(Must-Explain Abnormalities)
Scan for must-explain findings: PR abnormalities, wide QRS, marked QTc prolongation, new axis deviation, abnormal voltage, poor R wave progression, and pathologic Q waves. Then screen ST-T for regional ischemic patterns, reciprocity, and abnormal T-wave morphology (hyperacute, peaked, new inversions). Measure ST deviation from the TP segment, and confirm the machine QTc when it may influence management.
Learn more about these here:
Clinical Correlation
(Commit to Action)
Interpret in context and prioritize time-sensitive threats: occlusion MI patterns and STEMI-equivalents, unstable tachy or brady rhythms, hyperkalemia or sodium channel blocker toxicity, high-grade conduction disease, and mechanical patterns such as tamponade or acute right heart strain when the story fits. Compare with prior ECGs, and use serial ECGs when symptoms or findings are dynamic. End with an actionable conclusion focused on the next step.
Dive deeper here:
Key Clinical Pearls:
- Stay Systematic: Maintain your framework even when the department is on fire. Chaos tempts shortcuts. Maintaining a systematic and focused approach is crucial to avoid errors and misdiagnoses in busy acute care environments.
- Compare to Prior ECGs: Subtle changes can be lifesaving clues. Whenever possible, compare the current STAT ECG with previous ones. Pay close attention to all 12 leads, looking for subtle but potentially fatal abnormalities.
- Serial ECGs Matter: Dynamic changes can make or break the diagnosis. If you’re uncertain, obtain serial ECGs to observe dynamic changes that could influence your management decisions.
- Use ECG STAT: The structured taxonomy reinforces your system and highlights must-know differentials.
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