ecg practical approach
DESCRIPTION
ECG PRACTICAL APPROACH. Dr. Hossam Hassan Consultant Emergency Medicine. Objectives. To emphasize simplicities Practical approach Interpretation & clinical scenario are inseparable Systematic approach. Conduction System. Nomenclature. Magic numbers of Dr. Hossam. 3. 5. Rate - PowerPoint PPT PresentationTRANSCRIPT
ECG PRACTICAL ECG PRACTICAL APPROACHAPPROACHDr. Hossam HassanDr. Hossam Hassan
Consultant Emergency MedicineConsultant Emergency Medicine
Objectives Objectives
• To emphasize simplicities
• Practical approach
• Interpretation & clinical scenario are inseparable
• Systematic approach
Conduction SystemConduction System
Nomenclature Nomenclature
Magic numbers of Dr. HossamMagic numbers of Dr. Hossam
Systematic approachSystematic approach
• Rate• Rhythm• axis
• P-wave• PR interval• QRS complex• ST segment• T-wave
Rate Rate
• The interval between 2 successive R-wave
• How many big squares?
• Divide 300 / # big squares
• Normal 60 – 100/min
Rhythm Rhythm
Sinus Rhythm
Every P=wave is followed by QRS complex
P-wave is upright in lead II
NSRNSR
Types of Sinus RhythmTypes of Sinus Rhythm
• NSR
• Sinus Tachycardia
• Sinus Bradycardia
• Sinus arrhythmia
Sinus tachycardiaSinus tachycardia
Axis Axis
• Normal axis
• Right axis deviation
• Left axis deviation
RADRAD
LADLAD
P-waveP-wave
• Atrial depolarization
• Atrial contraction is a result
• Normally a dome-like structure
Abnormalities of P-waveAbnormalities of P-wave
• Peaked p-pulmonle– Pulmonary HTN– PE– Pulmonary valve stenosis
• M-shaped M-mitrale– Mitral valve stenosis– Left atrial hypertrophy
• Inverted 2nd atrial / junctional ectopy
P-pulmonaleP-pulmonale
PR intervalPR interval
• Definition
From the start of P to beginning of QRS
• Represent the delay in transmission in AV node
• Normally 0.12 – 0.20 msec
Abnormalities of PR intervalAbnormalities of PR interval
• Prolonged >
1st degree HB
• Short <
Pre-excitation syndromes– WPW Syndrome– LGL Syndrome
Junctional rhythm
QRS ComplexQRS Complex
• Amplitute
• Duration
• Shape
• Q-wave
• R-wave
QRS AMPLITUTEQRS AMPLITUTE
• LVH By voltage criteria – S-wave in V 1 or V 2 + R-wave in V5 or V6
LVH & STRAIN PATTERNLVH & STRAIN PATTERN
Causes of LVHCauses of LVH
• HTN
• Aortic stenosis
• HOCM
• Aortic regurgitation
• Mitral regurgitation
QRS DURATIONQRS DURATION
• Ventricular depolarization
• Ventricular contraction is a result
• Normally < 0.12 msec
< small squares
Causes of wide QRSCauses of wide QRS
• Ventricular tachycardia
• BBB– Left BBB– Right BBB
L BBBL BBB
R BBBR BBB
Shape Shape
• Upstroke & downstroke of R-wave
• Delta wave
Q-waveQ-wave
• 1st negative deflection after the P-wave
• Normally 1mm wide & 2 mm deep
• Lead III , V5 & V6
Pathological Q-wave
Wider & deeper
>1/4 of the ensuing R-wave
Old MI
+ve R-wave in V1+ve R-wave in V1
Causes +ve R-wave in V ICauses +ve R-wave in V I
• RVH
• R BBB
• Posterior MI
• Type A WPW
ST-SegmentST-Segment
• From the end of S-wave to the beginning of T-wave
• Normally iso-electric
• Abnormalities– Elevated– depressed
Elevated ST segmentElevated ST segment
• Acute MI
• Pericarditis
• Early repolarization pattern in the young
Infarct localizationInfarct localization
• Inferior– Lead II , III , aVF
• Septal – V I , V II
• Anterior– V3 , V4
• Lateral– Lead I , AVL,V5 , V6• Posterior MI
- Prominent R wave in V1,V2 with depressed ST segment
Acute inf MIAcute inf MI
Anteroseptal MIAnteroseptal MI
Anterior MIAnterior MI
Lateral MILateral MI
Depressed ST SegmentDepressed ST Segment
• Unstable angina
• Left ventricular strain pattern
LVH & strain patternLVH & strain pattern
T-waveT-wave
• Ventricular repolarization• Dome like structure• Abnormalities
– Peaked / tented t-wave• Hyperkalaemia• Subendocadial ischemia
– Inverted • LV Strain pattern• Dynamic t-wave changes of ischemia
DYNAMIC T-WAVE CHANGESDYNAMIC T-WAVE CHANGES
Hay….. Hay….. wake up we wake up we
are doneare done