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ECG for Final Part 2 WHH
- 1. ECG for Final Part II WHH HEXAGON
- 2. 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 HEXAGON
- 3. Topics will not be covered • Signs and symptoms of the diseases with abnormal ECG • Treatments of those diseases HEXAGON
- 4. 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. HEXAGON
- 5. Standard ECG leads • Limb leads Bipolar limb leads – I, II, III Unipolar limb leads – aVL, aVR, aVF • Chest leads V1 - V6 HEXAGON
- 6. 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 HEXAGON
- 7. Chest Leads look at the heart inChest 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 apexV4: 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 line V5 and V6 are in the sameV5 and V6 are in the same horizontal plane as V4horizontal plane as V4 Chest Leads HEXAGON
- 8. Interpretation of an ECG Patient identification Standardization 1.Rate 2.Rhythm 3.Axis 4.P wave 5.PR interval 6.QRS complex 7.ST segment 8.T wave 9.U wave 10.QT interval HEXAGON
- 9. Conduction system of heart
- 10. HEXAGON
- 11. 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 HEXAGON
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- 14. • Name • Age • ID number • DOB • Father’s name Patient identification and standardization HEXAGON
- 15. • Regular Rhythm Rate = 300÷numbers of large square • Irregular Rhythm Numbers of R in 6 sec x 10 (6s method) Rate determination HEXAGON
- 17. Irregular Rhythm Using 6-sec ECG rhythm strip to calculate heart rate: 7×10 = 70 bpm. HEXAGON
- 18. P wave • Atrial depolarization • Best seen at Lead II • Normal Height <2 ⅟2 small square Width <2 ⅟2 small square HEXAGON
- 19. Atrial Fibrillation • P wave (-) • Fibrillatory wave (+) HEXAGON
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- 21. 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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- 23. P wave P pulmonale = RAH P mitrale = LAH HEXAGON
- 24. PR interval • Conduction time • Normal 0.12-0.2 s (2 – 5 small square) HEXAGON
- 25. 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 HEXAGON
- 26. – 1st degree HB – 2nd degree HB Mobitz type 1 (Wenkebach phenomenon) Mobitz type 2 – 3rd degree HB (complete HB) Different types of Heart Blocks HEXAGON
- 27. 1st Degree HB • Prolong PR interval only HEXAGON
- 28. HEXAGON
- 29. 2nd degree HB • Mobitz type 1(Wenckebach Block) Progressive Increase PR f/b dropped beat HEXAGON
- 30. HEXAGON
- 31. 2nd degree HB • Mobitz type 2 Normal PR f/b dropped beat HEXAGON
- 32. Mobitz Type 2 AV Block HEXAGON
- 33. 3rd Degree HB • AV dissociation • PR - Variable • PP - Equal or multiple of interval • RR – Equal • QRS is bizarre HEXAGON
- 35. 3rd Degree HB • 3rd Degree HB or Complete HB • Does it really matters??? YES It’s emergency condition HEXAGON
- 36. 3rd Degree HB • Adam Stokes attack • Due to Transient ventricular asystole • Cardiac Output decreased to zero Syncope HEXAGON
- 37. QRS complex • Ventricle depolarization • Normal 0.1s ( 2-2⅟2 small square) HEXAGON
- 38. 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’) HEXAGON
- 39. HEXAGON
- 41. Left axis deviation – positive QRS in lead I Right axis deviation - positive QRS in lead aVF Rule of Thumb AVF AVF I I
- 42. CAUSES: LAD • LVH • And others Always Abnormal HEXAGON
- 43. CAUSES: RAD • RVH • And others HEXAGON
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- 47. Ventricle hypertrophy • Left ventricle hypertrophy • Right ventricle hypertrophy HEXAGON
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- 49. 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 HEXAGON
- 50. 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 HEXAGON
- 51. • 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 HEXAGON
- 53. ST segment • Ventricle repolarization • ST- isoelectric HEXAGON
- 54. Causes of ST depression • Angina • NSTEMI • LVH HEXAGON
- 55. ST depression • A – upward may be normal • B – down sloping strain / digoxin effect • C – planar ischaemia*** HEXAGON
- 56. Angina Pectoris • Imbalance between myocardial oxygen demand and supply • ST depression and/or T inversion HEXAGON
- 57. Causes of ST elevation • AMI • Pericarditis HEXAGON
- 58. Acute Myocardial Infarction • Hyper acute T • ST elevation – myocardial injury • T inversion – myocardial injury • Q wave – myocardial necrosis HEXAGON
- 59. Q wave • Normal Lateral leads (I,aVL,V5,V6) III alone mb present 1:1:4 =Physiological Q (height <1 ssq, width < 1ssq,Q <1/4 R) -Old MI HEXAGON
- 60. HEXAGON
- 61. Standard ECG leads • Limb leads Bipolar limb leads – I, II, III Unipolar limb leads – aVL, aVR, aVF • Chest leads V1 - V6 HEXAGON
- 63. Infarction Leads Inferior II,III,aVF Lateral I,aVL,V5,V6 Septal V1,V2 Anterior V1-V4 Localizing the Infarct HEXAGON
- 64. Inferior Infarction • Right coronary artery • Leads II, III, aVF HEXAGON
- 65. Inferior Infarction I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Right coronary artery HEXAGON
- 66. Lateral Infarction • Left circumflex artery • I, aVL, V5, V6 • Usually associated with another infarction HEXAGON
- 67. Lateral Infarction I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Left circumflex artery HEXAGON
- 68. Anterior Infarction • Left anterior descending artery • V2-V4 • V1-V4 = antero-septal infarction • V1-V6 = extensive anterior infarction HEXAGON
- 69. Anterior Infarction I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 LADA HEXAGON
- 71. T wave • Normal 1/8 R < T < 2/3 R • Tall T – Peak T wave (> 50% of preceding R) – Hyperkalaemia (Tall T , Small P, Wide QRS) HEXAGON
- 72. U wave • Slow repolarization of papillary muscle • Normal – V1, V2 • Prominent U wave – hypokalaemia HEXAGON
- 73. Interpretation of an ECG Patient identification Standardization 1.Rate 2.Rhythm 3.Axis 4.P wave 5.PR interval 6.QRS complex 7.ST segment 8.T wave 9.U wave 10.QT interval HEXAGON
- 74. HEXAGON
- 75. 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
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- 97. 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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Editor's Notes
- While there are 4 limb electrodes / cables, it is important to remember that the electrode attached to the right leg plays no part in the formation of any lead – it is only there to stabilise the ECG. Although the fronts of the wrists and ankles are common positions for the attachment of cables to electrodes, all parts of the limb will give an identical electrical signal. However, it is NOT good practice to place limb electrodes on either the abdomen or shoulders.
- Augmented Leads Leads aVR, aVL, and aVF make up the augmented leads (FIG. 2-4). Each letter of an augmented lead refers to a specific term: a augmented, V voltage, R right arm, L left arm, F foot (the left foot). STANDARD CHEST LEADS The chest leads are identified as V1, V2, V3, V4, V5, and V6 (FIG. 2-5). Each electrode placed in a “V” position is positive.