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ECG made simple

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  • helpful website that may help others. This website has practice exams for various nursing classes as well as videos, presentations, notes, nclex help, and many other tools that already are helping me. Hope they help
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  1. 1. Echocardiography <ul><li>Indications for 2 d echocardiogram </li></ul><ul><ul><li>Patients suspected of having </li></ul></ul><ul><ul><ul><li>Valvular heart disease, CAD, tumors, thrombus, pericardial effusion </li></ul></ul></ul><ul><ul><li>To define cardiac chamber size </li></ul></ul><ul><ul><li>Evaluate LV function </li></ul></ul><ul><ul><li>Visualize vegetations of endocarditis </li></ul></ul>
  2. 2. Echocardiography <ul><li>Indications for doppler studies </li></ul><ul><ul><li>Organic heart murmurs </li></ul></ul><ul><ul><li>Qualification of valvular disease </li></ul></ul><ul><ul><li>Quantification of intracardiac shunt </li></ul></ul><ul><ul><li>Doppler – relates to the frequency of sounds in proportion to the velocity of movement. </li></ul></ul><ul><ul><li>Ejection fraction- LV systolic function </li></ul></ul>
  3. 3. Exercise stress testing <ul><li>Indications </li></ul><ul><ul><li>For diagnosis of CAD </li></ul></ul><ul><ul><li>Prognostic assessment and functional capacity evaluation </li></ul></ul><ul><ul><li>Prognostic assessment and txt evaluation </li></ul></ul><ul><ul><li>Evaluation of therapy for arrhythmias </li></ul></ul>
  4. 4. Exercise stress testing <ul><li>Contraindication for stress testing </li></ul><ul><ul><li>Cannot exercise due to physical disability </li></ul></ul><ul><ul><li>Acute non-cardiac illness </li></ul></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><li>Angina at rest </li></ul></ul><ul><ul><li>Pts suspected to have left main CAD </li></ul></ul>
  5. 5. Exercise stress testing <ul><li>Contraindications for stress testing </li></ul><ul><ul><li>Uncompensated CHF FC II and IV </li></ul></ul><ul><ul><li>BP > 170/100 prior to exercise </li></ul></ul><ul><ul><li>Severe aortic or mitral stenosis </li></ul></ul><ul><ul><li>Untreated life threatening arrhythmias </li></ul></ul><ul><ul><li>Advance AV block </li></ul></ul>
  6. 6. High risk exercise parameters <ul><li>Positive stress test less than 6 mets </li></ul><ul><li>Failure to increase BP > 120 systole or a decrease > 10 systole </li></ul><ul><li>ST segment depression of > 2 mm, downsloping ST segment depression </li></ul><ul><li>Exercise induced ST segment elevation </li></ul><ul><li>Reproducible sustained or symptomatic ventricular tachycardia </li></ul>
  7. 7. 24 hour Holter ECG monitoring <ul><li>Indications </li></ul><ul><ul><li>To document a suspected rhythm disturbance </li></ul></ul><ul><ul><li>Correlate rhythm disturbance with symptoms </li></ul></ul><ul><ul><li>Determine the mechanism of rhythm disturbance </li></ul></ul><ul><ul><li>Determine the efficacy of anti-arrhythmic txt </li></ul></ul><ul><ul><li>Determine pacemaker malfunction </li></ul></ul><ul><ul><li>Monitor variant angina </li></ul></ul>
  8. 8. Important findings in 24 hr holter <ul><li>Episodes of > 2 –3 second pauses with symptom correlation </li></ul><ul><li>Episodes of SVT or VT esp with symptom correlation </li></ul><ul><li>Ischemic ST and T wave changes </li></ul>
  9. 9. Thallium Myocardial scan <ul><li>Indications for stress thallium </li></ul><ul><ul><li>Prognostic stratification after acute MI and unstable angina </li></ul></ul><ul><ul><li>Identification of extent and severity of ischemia </li></ul></ul><ul><ul><li>Determination of myocardial viability </li></ul></ul><ul><ul><li>Identifying lesions causing ischemia if not otherwise known by ecg </li></ul></ul>
  10. 10. Thallium myocardial scan <ul><li>Indications: </li></ul><ul><ul><li>Risk stratification for selected patients before non-cardiac surgery </li></ul></ul><ul><ul><li>Assessment of ischemia in patients after PTCA or CABG </li></ul></ul>
  11. 11. High risk parameter in Stress Thallium <ul><li>Multiple perfusion defects </li></ul><ul><li>Large reversible or fixed perfusion defects </li></ul><ul><li>Increased heart to lung ratio </li></ul><ul><li>LV dilatation with exercise </li></ul>
  12. 12. Electrophysiologic Study(EPS) <ul><li>Indications: </li></ul><ul><ul><li>Record intracardiac electrical activity to study heart block </li></ul></ul><ul><ul><li>Provoke electrical activity to study ectopy or tachyarrhythmias </li></ul></ul><ul><ul><li>Evaluate medical or surgical therapy </li></ul></ul><ul><ul><li>Determine indication and type of permanent pacemaker </li></ul></ul>
  13. 13. Cardiac Catheterization and coronary arteriography <ul><li>Indications for angiography with known or suspected CAD </li></ul><ul><ul><li>CAD stable or suspected CAD </li></ul></ul><ul><ul><ul><li>High risk – treadmill or stress thallium </li></ul></ul></ul><ul><ul><ul><li>Signs of LV dysfunction(EF <40%) </li></ul></ul></ul><ul><ul><li>Unstable angina </li></ul></ul><ul><ul><ul><li>Unresponsive to medical treatment </li></ul></ul></ul><ul><ul><ul><li>Signs of significant LV dysfunction </li></ul></ul></ul><ul><ul><ul><li>High risk parameters – hypotension,rest pain </li></ul></ul></ul>
  14. 14. Coronary angiography <ul><li>Indications: </li></ul><ul><ul><li>Acute MI </li></ul></ul><ul><ul><ul><li>Recurrent chest pains despite medical treatment </li></ul></ul></ul><ul><ul><ul><li>Signs of LV dysfunction </li></ul></ul></ul><ul><ul><ul><li>Life threatening ventricular arrhythmias due to ischemia </li></ul></ul></ul><ul><ul><ul><li>Positive stress test </li></ul></ul></ul>
  15. 15. Coronary angiography <ul><li>Indications </li></ul><ul><ul><li>Aortic disease – ascending aneurysm or dissection </li></ul></ul><ul><ul><li>Contemplated open heart surgery in middle age group </li></ul></ul><ul><ul><li>High risk cardiac pt to undergo major non-cardiac surgery </li></ul></ul><ul><ul><li>Suspected congenital coronary anomalies </li></ul></ul><ul><ul><li>Sudden cardiac death; Post PTCA CABG angina </li></ul></ul>
  16. 16. Normal Hemodynamic values <ul><li>Maximum normal chamber pressures </li></ul><ul><li>Aorta: 140/90 PA: 30/12 </li></ul><ul><li>LV: 140/12 RV: 30/8 </li></ul><ul><li>LA: mean 12 RA: mean 8 </li></ul><ul><li>A wave 16 A wave 10 </li></ul><ul><li>V wave 20 V wave 10 </li></ul>
  17. 17. Normal hemodynamic values <ul><li>SVR : 700-1600 dynes/sec/cm </li></ul><ul><li>PVR : 20 –130 dynes/sec/cm </li></ul><ul><li>Cardiac output: 4 – 6 liters/min </li></ul><ul><li>Cardiac index : 2.6 – 3.5 L/min/m </li></ul><ul><li>Valve areas: Aortic : 2.6 – 3.5 cm2 </li></ul><ul><li>mitral : 4 – 6 cm </li></ul><ul><li>pulmonic: 7 cm </li></ul><ul><li>tricuspid : 10 cm </li></ul>
  18. 18. Electrocardiogram <ul><li>Indications: </li></ul><ul><ul><li>Determine cardiac rate </li></ul></ul><ul><ul><li>Define cardiac rhythm </li></ul></ul><ul><ul><li>Diagnose old or new myocardial infarction </li></ul></ul><ul><ul><li>Identify intracardiac conduction disturbances </li></ul></ul><ul><ul><li>Aid in diagnosis of CAD, pericarditis, myocarditis, electrolytes abnormalities, and pacemaker malfunction </li></ul></ul>
  19. 19. Position of ECG chest leads <ul><li>V1 - 4 th ICS right sternal border </li></ul><ul><li>V2 – 4 th ICS at left sternal border </li></ul><ul><li>V3 – halfway between V2 and V4 </li></ul><ul><li>V4 – 5 th ICS LMCL </li></ul><ul><li>V5 – 5 th ICS LAAL </li></ul><ul><li>V6 – 5 th ICS LMAL </li></ul><ul><li>V3R – halfway between V1 & V4R </li></ul><ul><li>V4R – 5 th ICS at the right MCL </li></ul>
  20. 20. Components of ECG interpretation <ul><li>Rate </li></ul><ul><li>Rhythm </li></ul><ul><li>Axis </li></ul><ul><li>Hypertrophy </li></ul><ul><li>Ischemia and infarction </li></ul><ul><li>Miscellaneous findings </li></ul>
  21. 21. Axis interpretation <ul><li>Lead I Lead AVF </li></ul><ul><li>Normal axis + + </li></ul><ul><li>Left axis d + - </li></ul><ul><li>Right axis - + </li></ul><ul><li>Indeterminate - - </li></ul><ul><li>LAD – normal variant, LVH, Inferior wall MI, CLBBB,WPW syndrome </li></ul><ul><li>RAD – normal variant, RVH,Lateral wall MI, PTE,left posterior fascicular block, WPW </li></ul>
  22. 22. Left ventricular hypertrophy <ul><li>S in V1 + R wave in V5 or V6> 35 mm </li></ul><ul><ul><ul><li>Sens = 43% spec. =97% </li></ul></ul></ul><ul><li>R in AVL > 11 mm </li></ul><ul><ul><ul><li>Sens =11% spec = 100% </li></ul></ul></ul><ul><li>Romhilt and Estes criteria(best criteria) </li></ul><ul><ul><li>Total possible LVH = 3 points </li></ul></ul><ul><ul><li>Probable LVH = 4 points </li></ul></ul><ul><ul><li>Definite LVH => 5 points </li></ul></ul>
  23. 23. Romhilt and Estes Criteria <ul><li>a. Amplititude 3 pts </li></ul><ul><li>S in V1 and V2 > 30 mm </li></ul><ul><li>R in V5 or V6 > 30 mm </li></ul><ul><li>b. ST T changes typical of LV strain 3 pts </li></ul><ul><li>c. LAE 3 pts </li></ul><ul><li>d. LAD 2 pts </li></ul><ul><li>e. QRS duration > 0.09 sec 1 pt </li></ul><ul><li>f. Intrinsicoid deflection V5 and V6 > .05 </li></ul>
  24. 24. RVH ECG criteria <ul><li>RAD </li></ul><ul><li>Lead V1 R wave > S wave </li></ul><ul><li>Deep S wave in leads V5 and V6 </li></ul><ul><li>ST depression and T wave inversion V1-V3 </li></ul>
  25. 25. Atrial enlargement ECG criteria <ul><li>Left atrial enlargement </li></ul><ul><ul><li>VI biphasic >1mm wide and > 1 mm deep </li></ul></ul><ul><ul><li>In any lead: P wider than .12 s (> 3 small sq) </li></ul></ul><ul><ul><li>> 1 mm notched in the middle </li></ul></ul><ul><li>Right atrial enlargement </li></ul><ul><ul><li>V1 : tall peak P tent like >2mm wide and tall </li></ul></ul><ul><ul><li>In any lead: P wave > 2.5 mm tall </li></ul></ul>
  26. 26. Ischemia and infarction <ul><li>Leads involved Area </li></ul><ul><ul><li>II, III, AVF Inferior wall </li></ul></ul><ul><ul><li>I & AVL high lateral </li></ul></ul><ul><ul><li>V1, V2 septal wall </li></ul></ul><ul><ul><li>V3, V4 anterior wall </li></ul></ul><ul><ul><li>V5, V6 lateral wall </li></ul></ul><ul><ul><li>V1-V3 anteroseptal </li></ul></ul><ul><ul><li>V3-V6,I,AVL anterolateral </li></ul></ul>
  27. 27. Ischemia and Infarction <ul><li>leads involved Areas </li></ul><ul><ul><li>V5,V6,II,III,AVF inferolateral wall </li></ul></ul><ul><ul><li>almost all leads diffuse,global,massive </li></ul></ul><ul><ul><li>mirror image of V1,V2 posterior LV </li></ul></ul><ul><ul><li>V3R & V4R RV wall </li></ul></ul><ul><ul><li>Sudden inc in R forces in leads V1 and V2 suggests posterior wall MI </li></ul></ul>
  28. 28. Ischemia and infarction <ul><li>Ischemia </li></ul><ul><ul><li>At least 1 mm ST segment depression </li></ul></ul><ul><ul><li>Symetrically or deeply inverted T waves </li></ul></ul><ul><li>Infarction </li></ul><ul><ul><li>ST elevation > 2 mm in 2 or more chest or limb leads </li></ul></ul><ul><ul><li>Q waves > 0.04 sec </li></ul></ul>