ECG 101

ECG 101

Inferior posterior STEMILikely RV infarct

Avoid GTN and morphineMay need a fluid load

The eyes may be the window to the soul

But the ECG is the window to the heart, lungs, toxicology, electrolytes, body temperature and sometimes even the brain

Pattern recognition

An ECG is put under your nose

Immediately

InterpretTime

Name stamp

Covers nurse/HCA’s arseMakes you read it

We know who to educate if it’s wrong

Be systematic

One system

Patient’s name

Presenting complaint

ECG machine RR interval big squares: 300, 150, 100, 75, 60, 50

total number of complexes across the page x 6

Rate

ECG machine RR interval big squares: 300, 150, 100, 75, 60, 50

total number of complexes across the page x 6

Rate

SVT

Rhythm

RhythmAtrial flutter with 2:1 block

Atrial flutter with 2:1 block

Same patient after treatment for sepsis

AAtrial flutter with variable block

Frontal axis

Frontal axis

Sinus tachycardia with R atrial abnormality (P pulmonary) and extreme R axis deviation

Why else do we care about axis?

CQC

Why else do we care about axis?

CQC

Incomplete Trifasicular block:RBBB, LAD and 1˚HB

Incomplete trifascilar blockRBBB, LAD and 1˚HB

1 myocyte away from complete heart blockDon’t send this post syncope patient home

Then proceed through the complexes

p waves

p waves

P mitrale: mitral stenosis

PR interval

PR interval

1˚HBLown-Ganong-Levine syndrome

with short PR interval

Mobitz type 2 2˚HB

PR depression II, V5, V6,PR elevation aVR

Saddle shaped ST elevation II, v5, V6Inverted saddle shaped ST elevation aVR

= pericarditits

QRS complex

QRS complexWide complex tachy, probably VT

LBBB

RBBB

QRS complex

QRS complex

Hyperkalaemia

Sodium channel blockadeeg tricyclic overdose

QRS complex

QRS complexSevere hyperkalaemia

Killer Qs

Pathological Qs

> 40 ms (1 mm) wide > 2 mm deep > 25% of depth of QRS complex Seen in leads V1-3

Killer Qs

Pathological Qs

> 40 ms (1 mm) wide > 2 mm deep > 25% of depth of QRS complex Seen in leads V1-3

Q waves 2˚ to MIMay still be thrombolysable

HOCM

ST segment

ST segment

LBBB

LVHBrugada

ST segment

R

ST segment

R

Right ventricular infarct

Posterior STEMI

ST segment

ST segment

Inferior-posterior-high lateral STEMI

ST segment

ST segment

Paced rhythm with Sgarbossa+ve anterior ST depression and

> 5mm ST elevation in III

LBBB

Original Sgarbossa Criteria

Concordant ST-segment elevation ≥ 1 mm in any lead (5 points) Concordant ST-segment depression ≥ 1 mm in lead V1 – V3 (3 points)

Discordant ST-segment elevation ≥ 5 mm in any lead (2 points)

ST segment

ST segment

Critical left main coronary occlusion or extensive triple vessel disease

avoid clopidogrel

T waves

T waves

Hyperactue Ts in ischaemia

Wellens’ Type A

Wellen’s type B

Repeat ECGs

13 minutes later, pain free:

Repeat ECGs

Same patient 13 minutes later, pain free:

Biphasic T in V2T wave inversion aVL

Deep anterior T wave inversionWellen’s syndrome (type B)

Don’t put a Wellen’s patient on a treadmillthey tend to drop dead

T waves

T wavesAnterior and inferior TWIRight heart strain

PE

Lateral T wave inversion due to LVH

Lateral T wave inversion due to LBBB

T waves

T wavesAnterior and lateral T wave inversion

HOCM

Flattened T wavesIschaemia

T waves

T wavesLateral and high lateral

T wave inversion due to ischaemia

T wave inversion due to subarachnoid haemorrhage

(rare)Hyperkalaemia

QTc

Long QT syndrome (genetic)

Drugs incl amiodarone, digoxin, macrolides, antipsychotics, tricyclics, SSRIs, loratidine

HypothermiaHyperCaHypoK, hypoMag

Myocardial ischaemiaICH

+ others

> 440ms in men or > 460ms in women

QTc

Long QT syndrome (genetic)

Drugs incl amiodarone, digoxin, macrolides, antipsychotics, tricyclics, SSRIs, loratidine

HypothermiaHyperCaHypoK, hypoMag

Myocardial ischaemiaICH

+ others

> 440ms in men or > 460ms in women

Prolonged QT

Prolonged QTleading to

Torsades de pointes

Just to reinforce …

Just to reinforce …

Anterior-septal marked ST depression(reciprocal ST elevation)

and prominent S R waves (reciprocal Qs)

=probable posterior STEMI

Posterior STEMI

Posterior STEMI

Confirm by moving V4-6 to the posterior chest

Methodical readRecord your interpretationTimeName stampFurther actions esp repeat ECGs q10min x 3 for CP

eg Trodat Printy 4910 http://www.selfinkingstamps.co.nz/shop/trodat-4910-26x9mm/

$20 delivered

References and images

Most facts checked with and images obtained from

Life in The Fast Lanehttp://lifeinthefastlane.com/