ECG updateFOR PARAMEDICS & JUNIOR MEDICAL           OFFICERS                     DR LEE OI WAH
A POEM BY MOTHER TERESA :“ life is an opportunity benefit from it,  Life is a dream, realize it,  Life is a challenge, mee...
Heart, front view
The intrinsic conduction system of the heart andsuccession of the action potential through selected    areas of the heart ...
The Standard 12 Lead ECGThe standard 12-lead electrocardiogram is arepresentation of the hearts electrical activityrecorde...
Frontal and Horizontal Plane Lead Diagram
RV + Septal + LV= AC. ANTERIOR
FACTORS AFFECTING THE ECG1. ECG recorded with patient lying comfortable, relaxed in   bed. Explain procedure to apprehensi...
Schematic representation of normal ECG trace (sinusrhythm), with waves, segments, and intervals labeled.
1. Measurement2. Rhythm3. Conduction4. Waveform description
MEASUREMENT
CALCULATION OF THE HEART RATETime: Each small square = 0.04 seconds        Each large square = 0.2 seconds (5 small       ...
HEART RATECALCULATION OF THE HEART RATEHeart Rate: number of QRS complexes in 6 secs x 10
ECG NOMENCLATUREP WAVESRepresent sequential activation (depolarisation) of the    Right & Left atrial and therefore origi...
ECG NOMENCLATUREP WAVES May be:   Bifid and broad (notch & M-shaped) (>3 small    squares wide in left atrial hypertroph...
ECG NOMENCLATURE Normal P waves      Inverted P wavesAbsent P waves    Two P waves to each QRS
ECG NOMENCLATUREPR interval  Represent the time take for excitation to spread fromthe SA node down over the atria to the ...
ECG NOMENCLATUREPR interval     Normal: 0.12 secs - 0.20 secs        (3 small squares to <5 small squares).     May be: ...
ECG NOMENCLATURE    PR interval    Prolonged in:    # Drug effect (digitalis, beta blockers, Calcium Channel      Blocke...
PR interval
PR intervala) 2nd Degree Type 1      b)
PR intervalProlonged PR: > 0.20s    AV dissociation / 3rd degree HB:        Some PRs may appear prolonged, but the P waves...
J-pointQRS complexes (interval)      Represents the time taken for excitation (depolarisation)to spread through both the ...
QRS complexes (interval)      Will be:            Wide (3 or more small squares) in               bundle branch block  ...
QT INTERVAL Represents total time required for both  depolarisation and repolarisation of the ventricles  to occur. Measu...
QT INTERVAL CNS disease (especially subarrachnoid hemorrhage,  stroke, trauma) Coronary Heart Disease (some post-MI pati...
ST segment   Represents the interval of time between theend of the QRS complex (a juncture called the J-point) and the be...
ST segment   There may be:     Convex elevation in myocardial infarction     Concave elevation in pericarditis     Dep...
ST segment
ST segment ST segment depression is often characterized as "upsloping", "horizontal", or "downsloping".
T wave   Represent end of ventricular repolarisation of ventricles.   Should be in the same direction as the QRS complex...
ECG INTERPRETATIONWhat is the rate ?         …………………………………What is the rhythm ?       …………………………………Is there a “P” wave ?   ...
Ecg update(basic cardiology)
Ecg update(basic cardiology)
Ecg update(basic cardiology)
Ecg update(basic cardiology)
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Ecg update(basic cardiology)

  1. 1. ECG updateFOR PARAMEDICS & JUNIOR MEDICAL OFFICERS DR LEE OI WAH
  2. 2. A POEM BY MOTHER TERESA :“ life is an opportunity benefit from it, Life is a dream, realize it, Life is a challenge, meet it, Life is a struggle, accept it, Life is too precious, do not give up on it, Life is life, fight for it.”
  3. 3. Heart, front view
  4. 4. The intrinsic conduction system of the heart andsuccession of the action potential through selected areas of the heart during one heart beat.
  5. 5. The Standard 12 Lead ECGThe standard 12-lead electrocardiogram is arepresentation of the hearts electrical activityrecorded from electrodes on the body surface.
  6. 6. Frontal and Horizontal Plane Lead Diagram
  7. 7. RV + Septal + LV= AC. ANTERIOR
  8. 8. FACTORS AFFECTING THE ECG1. ECG recorded with patient lying comfortable, relaxed in bed. Explain procedure to apprehensive patient to ally anxiety and reduce muscle twitching. 82. Good contact between skin and electrode.3. ECG machine properly standardized - 1 mV to produce 1 cm deflection.4. Patient and ECG machine must be properly grounded to avoid alternating current interference.5. Any electronic equipment with patient can produce artifacts.
  9. 9. Schematic representation of normal ECG trace (sinusrhythm), with waves, segments, and intervals labeled.
  10. 10. 1. Measurement2. Rhythm3. Conduction4. Waveform description
  11. 11. MEASUREMENT
  12. 12. CALCULATION OF THE HEART RATETime: Each small square = 0.04 seconds Each large square = 0.2 seconds (5 small squares)QRS rhythm: When normal is usually regular.
  13. 13. HEART RATECALCULATION OF THE HEART RATEHeart Rate: number of QRS complexes in 6 secs x 10
  14. 14. ECG NOMENCLATUREP WAVESRepresent sequential activation (depolarisation) of the Right & Left atrial and therefore originate from the SAN, and it is common to see notched or biphasic P waves of right and left atrial activation. Usually precede the QRS complex • P duration < 0.12 sec • P amplitude < 2.5 mm
  15. 15. ECG NOMENCLATUREP WAVES May be:  Bifid and broad (notch & M-shaped) (>3 small squares wide in left atrial hypertrophy in leads I, II & aVL  Peaked (>3 small squares tall) in right atrial hypertrophy in leads II, III, aVF  Lost of inverted in ectopic rhythm and tachycardias  Lost in or dissociated from the QRS complex
  16. 16. ECG NOMENCLATURE Normal P waves Inverted P wavesAbsent P waves Two P waves to each QRS
  17. 17. ECG NOMENCLATUREPR interval  Represent the time take for excitation to spread fromthe SA node down over the atria to the AV node, downthro the bundle of His, and to the ventricular muscle. Measured from beginning of P wave to beginning ofQRS complex. Represent total time required for impulsefor depolarisation of atria (P wave) as well as timerequired for impulse to travel slowly through the AVjunction, through the bundle branches, just up to thepoint of ventricular depolarisation (QRS complex).
  18. 18. ECG NOMENCLATUREPR interval  Normal: 0.12 secs - 0.20 secs (3 small squares to <5 small squares).  May be: Short in: Infants, drugs (e.g steroids) Wolf Parkinson White syndrome and other pre-excitation syndromes ( accessory pathway bypassAV junction)
  19. 19. ECG NOMENCLATURE PR interval Prolonged in: # Drug effect (digitalis, beta blockers, Calcium Channel Blockers. # Hyper trophy, Atrial Dilatation, Degenaration (aging), Myocardial Infarction (Inf. MI) # First Degree Heart Block # Second Degree Heart Block # Third Degree Heart Block
  20. 20. PR interval
  21. 21. PR intervala) 2nd Degree Type 1 b)
  22. 22. PR intervalProlonged PR: > 0.20s AV dissociation / 3rd degree HB: Some PRs may appear prolonged, but the P waves and QRS complexes are dissociated (i.e., not married, but strangers passing in the night).
  23. 23. J-pointQRS complexes (interval)  Represents the time taken for excitation (depolarisation)to spread through both the ventricles (simultaneously)  Measure from beginning of QRS complex to its endpoint, called the J-point.  In normal sinus rhythm should be:  Preceded by a P wave  <0.12 seconds (< 3 small squares)
  24. 24. QRS complexes (interval)  Will be:  Wide (3 or more small squares) in  bundle branch block  in ventricular ectopics beats (VPCs) ventricular rhythms.  If early or abnormal, may be caused by:  An ectopic ventricular focus causing premature ventricular contractions (PVCs). A ventricular tachycardia: Broad complex: 0.12 seconds or more Usually arise from a single ectopic focus
  25. 25. QT INTERVAL Represents total time required for both depolarisation and repolarisation of the ventricles to occur. Measured from the beginning of QRS complex to the end of T wave. Normal QT interval : 0.35 to 0.45 second. Length of QTI normally varies according to age, gender& especially heart rate . Electrolyte abnormalities (K+, Ca++, Mg++) & certain antidysrhythmic drugs, tricyclics, phenothiazines can prolong QTI.
  26. 26. QT INTERVAL CNS disease (especially subarrachnoid hemorrhage, stroke, trauma) Coronary Heart Disease (some post-MI patients). Indicates a state of increased vulnerability to malignant ventricular arrhythmias, syncope, and sudden death. The prototype arrhythmia of the Long QT Interval Syndromes (LQTS) is Torsade-de-pointes, a polymorphic ventricular tachycardia characterized by varying QRS morphology and amplitude around the isoelectric baseline.
  27. 27. ST segment  Represents the interval of time between theend of the QRS complex (a juncture called the J-point) and the beginning of the T wave. Though not a true wave form, the ST segmentrepresents the interval during which themyocardium remains at rest in a depolarised stateand the beginning of ventricular repolarisation. Shape and position relative to baseline should beisoelectric and may be altered with episodes ofischemia, metabolic abnormalities, drug effects andother conditions.
  28. 28. ST segment  There may be:  Convex elevation in myocardial infarction  Concave elevation in pericarditis  Depression: Ischemia, digoxin toxicity, and left ventricular hypertrophy. In AMI, the ST segment elevation (or reciprocaldepression) occurs in the leads representing thesite of the infarction (12 lead ECG):  Anterior : Leads V2 - V5 (often in I and AVL)  Inferior : Leads II, II, AVF  Septal : Leads V1 - V4  Lateral : Leads I, AVL, V4 -V6
  29. 29. ST segment
  30. 30. ST segment ST segment depression is often characterized as "upsloping", "horizontal", or "downsloping".
  31. 31. T wave  Represent end of ventricular repolarisation of ventricles.  Should be in the same direction as the QRS complex.  Slightly rounded and asymmetrical and usually exhibit asmooth takeoff from the end of the ST segments.  If inverted, may be a sign of myocardial ischemia,infarction, ventricular hypertrophy or metabolic abnormalities,but are often non specific.
  32. 32. ECG INTERPRETATIONWhat is the rate ? …………………………………What is the rhythm ? …………………………………Is there a “P” wave ? ………………………………..Describe the “P” wave …………………………………Is there QRS complex …………………………………Describe the QRS complex ………………………………..What is the PR interval? ………………………………….Is there a “T” wave? …………………………………..Describe the “T” wave ……………………………………Describe the ST segment …………………………………..What is the name of the RHYTHM ………………………………

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