ecg for final part 2 whh
TRANSCRIPT
ECG for Final Part II
WHH
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Topics will be covered• ECG basics• How to identify normal ECG• How to identify abnormal findings in ECG
– Atrial hypertrophy - Hyperkalaemia– Atrial fibrillation - Hypokalaemia– Atrial flutter- Pericarditis– Heart blocks– Chambers enlargement– IHD– AMI
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Topics will not be covered• Signs and symptoms of the diseases with
abnormal ECG • Treatments of those diseases
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What is ECG?• ECG is a medical device capable of
recording the electrical activity of the heart from electrodes placed on the skin in specific locations.
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Standard ECG leads• Limb leads
Bipolar limb leads – I, II, IIIUnipolar limb leads – aVL, aVR, aVF
• Chest leadsV1 - V6
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Right Arm
Right Leg
Left Leg
Left Arm
• Limb leads are typically placed on the inside of the wrists and ankles
• To help reduce artifacts you can use the upper arms and thighs
• Do not place limb leads on the torso
Limb leads
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Chest Leads look at the heart in Chest Leads look at the heart in a horizontal plane.a horizontal plane.
• V1: right sternal edge (4th)V1: right sternal edge (4th)• V2: Left sternal edge (4th)V2: Left sternal edge (4th)• V4: the patient’s apex V4: the patient’s apex
beatbeat• V3: half-way b/t V2 and V4V3: half-way b/t V2 and V4• V5: anterior axillary lineV5: anterior axillary line• V6: mid-axillary lineV6: mid-axillary lineV5 and V6 are in the same V5 and V6 are in the same
horizontal plane as V4horizontal plane as V4ChestLeads
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Interpretation of an ECGPatient identificationStandardization1.Rate2.Rhythm3.Axis4.P wave5.PR interval6.QRS complex7.ST segment8.T wave9.U wave10.QT interval
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Conduction system of heart
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Wave. Interval. Complex.• One letter = wave
– Eg = P, T• Need to check height and width
• Two letters = interval– PR interval
• Need to check length
• 3 letters = complex– QRS complex
• Need to check height, width and shape
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• Name• Age • ID number• DOB• Father’s name
Patient identification and standardization
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• Regular RhythmRate = 300÷numbers of large square
• Irregular RhythmNumbers of R in 6 sec x 10 (6s method)
Rate determination
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Regular Rhythm
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Irregular Rhythm
Using 6-sec ECG rhythm strip to calculate heart rate: 7×10 = 70 bpm.
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P wave• Atrial depolarization• Best seen at Lead II• Normal Height <2 ⅟2 small square Width <2 ⅟2 small square
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Atrial Fibrillation• P wave (-)• Fibrillatory wave (+)
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Atrial Flutter• Cavo-tricuspid focus• Saw tooth appearance
Atrial Ventricle Wave HR
1 1 300
2 1 150
3 1 100
4 1 75HEXAGON
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P wave
P pulmonale = RAH
P mitrale = LAH
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PR interval• Conduction time
• Normal0.12-0.2 s (2 – 5 small square)
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AV blocks
Conduction from atrium to the ventricles via
the AV node may be either
– Delayed – as in 1st degree block (or)
– Blocked – as in 2nd and 3rd degree blocks
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– 1st degree HB
– 2nd degree HB
Mobitz type 1 (Wenkebach phenomenon)
Mobitz type 2
– 3rd degree HB (complete HB)
Different types of Heart Blocks
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1st Degree HB• Prolong PR interval only
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2nd degree HB• Mobitz type 1(Wenckebach Block)Progressive Increase PR f/b dropped beat
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2nd degree HB• Mobitz type 2Normal PR f/b dropped beat
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Mobitz Type 2 AV Block
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3rd Degree HB• AV dissociation• PR - Variable• PP - Equal or multiple of interval• RR – Equal• QRS is bizarre
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3rd Degree HB
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3rd Degree HB• 3rd Degree HB or Complete HB
• Does it really matters???
YESIt’s emergency condition
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3rd Degree HB• Adam Stokes attack• Due to Transient ventricular asystole• Cardiac Output decreased to zero
Syncope
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QRS complex• Ventricle depolarization
• Normal0.1s ( 2-2⅟2 small square)
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QRS nomenclature• If 1st deflection is negative Q wave• 1st positive deflection = R wave• Negative deflection after R wave =S wave• Positive deflection after R wave = R prime(R’)• Negative deflection after S wave=S prime (S’)
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AXIS DETERMINATION
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Left axis deviation – positive QRS in lead I
Right axis deviation - positive QRS in lead aVF
Rule of Thumb
AVF
AVF
I
I
CAUSES: LAD
• LVH• And others
Always Abnormal
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CAUSES: RAD
• RVH• And others
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Ventricle hypertrophy• Left ventricle hypertrophy• Right ventricle hypertrophy
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Chest-lead voltage criteria: – S in V1 or V2 + R in V5 or V6 > 35 mm(7.1sq)– R in V5 or V6 >25 mm (5.1sq)
Feature of LVH
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Note
The deep S waves in V1 and tall R waves in V5
and V6.
S V1 + R V5 > 35 mm
Left ventricular strain pattern in V5 and V6
Left ventricular hypertrophy
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• Right axis deviation• R wave larger than S wave in V1
(Tall R in V1)• S wave larger than R wave in V6
(Deep S in V6)
Feature of RVH
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Right Ventricular Hypertrophy
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ST segment• Ventricle repolarization
• ST- isoelectric
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Causes of ST depression• Angina
• NSTEMI
• LVH
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ST depression
• A – upward may be normal• B – down sloping strain / digoxin effect• C – planar ischaemia***
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Angina Pectoris• Imbalance between myocardial oxygen
demand and supply• ST depression and/or T inversion
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Causes of ST elevation
• AMI
• Pericarditis
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Acute Myocardial Infarction• Hyper acute T • ST elevation – myocardial injury• T inversion – myocardial injury• Q wave – myocardial necrosis
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Q wave• NormalLateral leads (I,aVL,V5,V6)III alone mb present1:1:4 =Physiological Q(height <1 ssq, width < 1ssq,Q <1/4 R)
-Old MI
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Standard ECG leads• Limb leads
Bipolar limb leads – I, II, IIIUnipolar limb leads – aVL, aVR, aVF
• Chest leadsV1 - V6
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Infarction Leads
Inferior II,III,aVF
Lateral I,aVL,V5,V6
Septal V1,V2
Anterior V1-V4
Localizing the Infarct
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Inferior Infarction
• Right coronary artery
• Leads II, III, aVF
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Inferior Infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
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Lateral Infarction
• Left circumflex artery
• I, aVL, V5, V6
• Usually associated with another infarction
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Lateral Infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left circumflex artery
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Anterior Infarction
• Left anterior descending artery
• V2-V4
• V1-V4 = antero-septal infarction
• V1-V6 = extensive anterior infarction
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Anterior Infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
LADA
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Pericarditis
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T wave• Normal1/8 R < T < 2/3 R
• Tall T– Peak T wave (> 50% of preceding R)– Hyperkalaemia(Tall T , Small P, Wide QRS)
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U wave• Slow repolarization of papillary muscle
• Normal – V1, V2
• Prominent U wave – hypokalaemia
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Interpretation of an ECGPatient identificationStandardization1.Rate2.Rhythm3.Axis4.P wave5.PR interval6.QRS complex7.ST segment8.T wave9.U wave10.QT interval
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P wave : Duration: 0.08 sec ( 2 small squares ) Height: < 2.5 mm ( 2 small squares )
PR interval: Duration: 0.12 - 0.20 sec (3-5 small squares)
QRS Complex : Duration: 0.07–0.10 sec(2 – 2½ small squares)
ST segment : Isoelectric
T wave : 1/8 previous R < T < 2/3 previous R
Important intervals and durations
QUIZ TIME
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THIS IS NOT THE END
This only a beginning and certainly not the end
We look forward for more learning experiences
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