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ELECTROCARDIOGRAM
ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM

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ELECTROCARDIOGRAM

ELECTROCARDIOGRAM

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    • 1. Electrocardiographic Cases Crisbert I. Cualteros, M.D.
    • 2. Sinus Rhythm
    • 3. SR frequent PVDs PRWP lat wall ischemia
    • 4. ECG Indications
      • determine cardiac rate
      • define cardiac rhythm
      • diagnose old or new MI
      • identify intracardiac conduction disturbances
      • aid in the diagnosis of IHD, pericarditis, myocarditis, electrolyte abnormalities and pacemaker malfunction
    • 5.
      • V1 = 4th ICS, R sternal border
      • V2 = 4th ICS, L sternal border
      • V3 = halfway between V2 and V4
      • V4 = 5th ICS, L MCL
      • V5 = 5th ICS, anterior axillary line
      • V6 = 5th ICS, L mid-midaxillary line
      • V3R = halfway between V1 and V4R
      • V4R = 5th ICS, R MCL
      Lead Locations
    • 6. Correspondence Anteroseptal wall V1-V3 Lateral wall V5, V6 Anterior wall V3, V4 Septal wall V1, V2 High lateral wall I, aVL Inferior wall II, III, aVF Area Leads
    • 7. Area Leads RV wall V3R and V4R Posterior LV wall Mirror image of V 1/2 Diffuse/global/massive Almost all leads Inferolateral wall V5, V6, II, III, aVF Anterolateral wall V3-V6, I, aVL
    • 8.  
    • 9. RRAHIM
      • Components of ECG interpretation
      • R ate
      • R hythm
      • A xis
      • H ypertrophy
      • I schemia and Infarction
      • M iscellaneous (normal variants)
    • 10.  
    • 11.  
    • 12.  
    • 13.  
    • 14.  
    • 15.  
    • 16. Rate
      • Mnemonic: 300, 150, 100, 75, 60, 50
      • Formula: 1500 / # of small boxes
      • 300 / # of big boxes
      • Bradycardia = <60 bpm
      • Normal Rate = 60-100 bpm
      • Tachycardia = >100 bpm
    • 17. What is the rate? 1500/28 or 300/5.6 53 bpm
    • 18. What is the rate? 1500/12 or 300/2.4 125 bpm
    • 19. Rhythm
      • Identify the P wave
      • Check relation of P wave to QRS
        • Normal: P wave is before QRS
        • SVT, heart blocks: P wave after QRS or burried
      • Check PR interval ( 0.12 - 0.20s )
        • Shortened: WPW
        • Prolonged: 1 st and 2 nd degree AV block
    • 20.
      • Check QRS duration (< 0.10 s )
          • Widened: bundle branch blocks
      • Check relation of R-R and P-P int
          • PP < RR: complete heart block
          • PP > RR: AV dissociation
    • 21. Common Rhythm Interpretations
      • Sinus rhythm
      • Supraventricular arrhythmias
          • Atrial fibrillation
          • Atrial flutter
          • Supraventricular tachycardia (SVT)
      • Heart Blocks
          • First-degree AV block
          • Second-degree AV block
            • Mobitz Type I (Wenckebach)
            • Mobitz Type II
    • 22.
          • Third-degree AV block
          • Left or Right Bundle Branch Block
            • Complete
            • Incomplete
      • Ventricular Arrhythmias
          • Premature Ventricular Depolarization (PVD)
          • Ventricular Tachycardia (V-tach)
            • Sustained
            • Non-sustained
          • Ventricular fibrillation (V-fib)
    • 23. Axis Determination
      • get the average QRS vector from the isoelectric baseline in Leads I and AVF
          • if the average QRS vector is above baseline -> (+) QRS deflection
          • if the average QRS vector is below baseline
          • -> (-) QRS deflection
    • 24. Axis -- -- indeterminate + -- RAD -- + LAD + + Normal Axis AVF Lead 1
    • 25.  
    • 26. Normal (-30 to +90) RAD Indeterminate LAD
    • 27. Axis
      • - 90 AVF
      • indeterminate LAD
      • ± 180 0 I
      • RAD normal
      • (-30 to +90)
      • + 90
    • 28. What is the axis?
    • 29. Axis Differentials WPW syndrome WPW syndrome LPFB LAFB Pulmonary embolism LBBB Lateral wall MI Inferior wall MI RVH (COPD, cor pul) LVH (HTN) N variant: thin, tall N variant: short, fat RAD LAD
    • 30. Hypertrophy
      • Six Possibilities
      • No hypertrophy
      • LVH
      • RVH
      • LAE
      • RAE
      • combination
    • 31. LVH criteria
      • 3 Methods
      • 1) S wave in V1 +
      • R wave in V5/6 > 35mm
      • 2) R in AVL > 11mm
      • 3) Romhilt and Estes Criteria (best)
    • 32. SR, LVH with Strain Pattern, Old Anteroseptal Wall MI
    • 33. RVH Criteria
      • RAD of ≥ +110, with any of the ff:
          • V1: R wave > S wave
              • COPD
              • RBBB
              • True posterior infarction
              • WPW
          • Deep S wave in V5-6
              • COPD
          • ST depression and T wave inversion in V1-3
    • 34. LAE (p mitrale)
      • 2 Methods
      • V1: wide terminal component of P wave ≥ 1 mm wide (0.04 s) and ≥ 1 mm deep
      • Any lead: P wave wider than 0.12s or with a ≥ 1 mm notch in the middle
    • 35. ST, RAD, LAE, RVH
    • 36. RAE (p pulmonale)
      • 2 Methods
      • V1: tall initial component of P wave ≥ 2mm wide and ≥ 2 mm tall
      • Any Lead: P wave ≥ 2.5 mm tall
    • 37. RRAHIM
      • Components of ECG interpretation
      • Rate
      • Rhythm
      • Axis
      • Hypertrophy
      • Ischemia and Infarction
      • Miscellaneous (normal variants)
    • 38. Myocardial Ischemia
      • 1 mm ST-segment depression
      • Symmetrically/inverted T waves
      • Abnormally tall T waves
      • Normalization of abnormal T waves
      • Prolongation of QT interval
      • Arrhythmias, BBB, AV blocks or electrical alternans
    • 39. SR, Anterolateral Wall Ischemia
    • 40. Myocardial infarction
      • Criteria (any)
      • ST elevation
          • ≥ 2 Chest leads: ≥ 2 mm elevation or
          • ≥ 2 Limb leads: ≥ 1 mm elevation
      • Q waves ≥ 0.04s (1 small square)
    • 41. Timing of MI/ECG 0-6 hours 6-24 h 24 -72 h 72 h – 6 weeks > 6 wk
    • 42.
      • Differentials for ST elevation
      • Acute pericarditis
      • Ventricular aneurysm
      • Severe LV wall hypokinesia
      • Early repolarization changes
      • Variant (prinzmetal) angina
    • 43.
      • Q waves
        • never significant in aVR
        • not significant in V1 unless with abnormalities in other precordial leads
        • not significant in III unless with abnormalities in II, aVF
        • more reliable if associated with ST changes
        • Not significant in V1-V3 if (+) LBBB , but significant if (+) RBBB
    • 44.
      • Criteria for Pathologic Q waves
      • ≥ 0.04 sec in duration
      • ≥ 25% of the R wave amplitude
    • 45. Recent Anteroseptal Wall MI
    • 46. SR, Acute Inferior Wall MI
    • 47. RRAHIM
      • Components of ECG interpretation
      • R ate
      • R hythm
      • A xis
      • H ypertrophy
      • I schemia and Infarction
      • M iscellaneous (normal variants)
    • 48.
      • Hypokalemia
          • V2, V3: u wave as tall or taller than T wave
      • Hyperkalemia
          • Chest leads: height of T wave > 10 mm
          • Limb leads: height of T wave > 5 mm
      • Hypocalcemia
          • Prolonged QT interval, longer than ½ the RR interval
      • Hypercalcemia
          • Shortened QT interval
    • 49.  
    • 50.
      • Poor R wave Progression (PRWP)
          • Height of Rwave in V3 < 3 mm
          • Differentials
            • Old anteroseptal wall MI
            • LVH
            • Normal variant: heart rotated clockwise
            • LBBB
      • Early Repolarization Changes (ERP)
          • V2-V4: ST segment elevation of 2-3 mm
            • Normal variant, usually in males < 40y
            • Differentials
              • Acute anteroseptal wall MI
              • Acute pericarditis
    • 51. SR, ERP
    • 52. SR, ERP
    • 53. SR, PRWP
    • 54. Hyperkalemia tall, peaked T waves usually >10 mm in the chest leads
    • 55. Hypokalemia abnormally tall U waves most prominent in V2 and V3
    • 56.
      • Low-voltage QRS
          • QRS in all limb leads is < 5 mm
      • Artifacts
          • Irregular spikes or undulations on the ECG baseline not found in other segments
          • Causes
            • Patient movement (shivering)
            • Poor electrode contact
    • 57. Atrial Fibrillation
      • Criteria
      • No P waves
      • Irregular fibrillatory waves
      • Irregularly irregular ventricular rhythm
      • Acute if < 48h
    • 58.
      • Top 5 causes of AF
      • (EVICT)
      • E thanol (Holiday Heart Syndrome)
      • V alvular heart disease (MS)
      • I HD
      • C ardiomyopathy
      • T hyrotoxicosis
    • 59.  
    • 60. AF with RVR PRWP NSSTTWC
    • 61.  
    • 62. AF with MVR, RBBB
    • 63. AF with RVR, lateral wall ischemia
    • 64. AV Nodal Blocks
      • First Degree AV Block
          • P-R interval > 0.21 sec
          • One-to-one AV conduction
    • 65. Sinus Bradycardia with first degree AV block
    • 66. AV Nodal Blocks
      • Second Degree AV Block
          • Sinus rhythm
          • Some P waves not followed by QRS complx
            • Mobitz I (Wenckebach)
              • Increasing PR interval -> dropped beat
    • 67.
        • Mobitz II
            • PR interval prolonged but constant
      • Third Degree AV Block or
      • Complete Heart Block
          • AV dissociation
          • P waves seen marching through the QRS
          • PP interval < RR interval
          • Idioventricular rhythm
    • 68. SR with 2 nd degree AV block (Wenckebach)
    • 69. 3 rd degree AV block
    • 70. Intraventricular Blocks
      • Complete RBBB
          • QRS duration ≥ 0.12 seconds
          • QRS in V1 has an rsR’ configuration or is a solitary R wave
    • 71. Intraventricular Blocks
      • Complete LBBB
          • QRS duration ≥ 0.12 seconds
          • QRS is notched and splintered
          • QRS has a QS or rS deflection in V1
    • 72. .
    • 73. SR with cRBBB
    • 74. ST with cRBBB
    • 75. V-Tach
      • Criteria
      • ≥ 3 consecutive QRS complexes…
          • of uniform configuration
          • of ventricular origin
          • > 100 bpm
    • 76.
      • Monomorphic
      • Sustained VT:
        • > 30 s
        • Hemodynamic compromise
        • Requires intervention for termination
      • Non-sustained
      V-Tach Morphology
    • 77.
      • Polymorphic
      • beat to beat variation in QRS complexes
      V-Tach Morphology
    • 78. SupraV Tach
      • Criteria
      • regular succession of QRS complexes with normal duration and configuration
      • rate 150 – 250 bpm
      • P waves not identifiable (superimposed on QRS) or preceed / succeed the QRS complex
    • 79.  
    • 80.  
    • 81. Sinus Rhythm
    • 82. Second-degree AV block, type II
    • 83. Third Degree AV Block
    • 84. Acute Inferior Wall MI
    • 85. AF with RVR
    • 86. AF with SVR
    • 87. Anteroseptal Wall MI
    • 88. Atrial Flutter with 2:1 conduction
    • 89. Digoxin Effect
    • 90. ERP
    • 91. First-Degree AV block, SB
    • 92. Frequent PVCs in Bigeminy
    • 93. Hyperkalemia
    • 94. Left Bundle Branch Block
    • 95. Right Bundle Branch Block
    • 96. SVT
    • 97. Ventricular Fibrillation
    • 98. Ventricular Tachycardia
    • 99. Ventricular Tachycardia
    • 100. WPW Syndrome
    • 101.  
    • 102. SR LAE LVH with strain Pattern ERP vs Acute injury pattern in the anteroseptal wall
    • 103. SR, LAH, LAE, IVCD, LVH, lateral wall ischemia and/or strain. NSSTTWC, inferior wall. ERP vs. acute injury, anteroseptal wall. 66 male (+) HTN (+) DM 5 pack years cc: fever, cough body malaise 150/80, 88, 20 trop I negative SR, LAE, with an acute injury pattern in the anteroseptal wall
    • 104. D.R., 41 male (-) medical problem (-) smoker (-) alcoholic cc: 2 months productive cough low-grade fever 120/80, 104, 36 imp: PTB III meds: combivent ranitidine levofloxacin
    • 105. Atrial flutter/atrial fibrillation with NSSTTWC
    • 106. Thank You! http://crisbertcualteros.page.tl

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