INTRODUCTION LEADS TERMINOLOGIES PLACEMENT INDIVIDUAL WAVES AND AXIS BUNDLE BLOCKS ARRYTHMIA’S CASES

1. Topic :- ECG AND ITS BASICS update (2020)
Dr Rahul JainDr Sharda Jain
for Gynaecologist & Surgery Specialist

2. Over 400 ppts are available on
slideshare.net ***for use of public/Doctors
www.slideshare.net / Lifecarecentre

3. CONTENTS-
• INTRODUCTION
• LEADS
• TERMINOLOGIES
• PLACEMENT
• INDIVIDUAL WAVES AND AXIS
• BUNDLE BLOCKS
• ARRYTHMIA’S
• CASES

5. ELECTROCARDIOGRAPHY
• An ECG records the heart's rhythm and activity on a moving
strip of paper or a line on a screen.
• ECG basically records electrical activity of heart.

6. LEADS-
• AUGMENTED LEADS- aVr , aVl , aVf
• LIMB LEADS- LEADS 1,2,3
• CHEST LEADS-V1,V2,V3.V4,V5.V6

9. Terminologies-
• Standard Speed of ECG recording=25mm/sec
• 1mm width=1/25=.04 sec
• 1mm height=0.1 mV

10. HEART RATE-
• 1.BOX counting methods-
heart rate=300/no. of large boxes b/w 2 qrs complexes
=1500/no. of small boxes b/w 2 qrs complexes
• 2.QRS counting methods-for irregular heart beat
count no. of QRS complexes in 10 sec and multiply by 6
• 3.RR interval method-
heart rate=60/RR(in sec)

11. Placement of leads-
SIGNIFICANCE LEADS
INFERIOR
WALL
LEAD 2,3,aVF
LATERAL WALL LEAD
1,aVL,V5,V6
SEPTAL LEADS V1,V2
ANTERIOR
LEADS
V3,V4

12. Diff b/w segment and Interval?
• SEGMENT=ISOELECTRIC SEGMENT
• INTERVAL=SEGMENT+WAVE

14. P WAVE
• LEAD 2- Height < 2.5mm(normal)
width <2.5mm(normal)
• LEAD V1-Biphasic p wave

15. RIGHT ATRIAL
ENLARGEMENT
LEFT ATRIAL
ENLARGEMENT
LEAD 2 HT>2.5MM WIDTH>2.5MM
LEAD V1 POSITIVE DEFLECTION
AREA(HEIGHT(mm) *
WIDTH(sec))
NEGATIVE DEFLECTION
AREA(DEPTH(mm)*
WIDTH(sec))
>0.16mmsec >0.04mmsec=morris
index positive

17. PR INTERVAL-
• Start of P WAVE TO start of QRS WAVE
• NORMAL WIDTH- 3 TO 5 mm= 0.12-0-20 seconds
• Represents AV NODE CONDUCTION
• CLINICAL SIGNIFICANCE-
• 1.AV NODE BLOCK
• 2.LGL SYNDROME(JAMES PATHWAY-ATRIA TO BOH)
• 3.WPW SYNDROME(BUNDLE OF KENT-ATRIA TO VENT)
• 4.MOBITZ TYPE 1(2 DEG AV BLOCK)

18. QRS COMPLEX-
• RIGHT VENTRICLE-LOOK AT V1
• LEFT VENTRICLE-LOOK AT V5,V6
• NORMAL WIDTH-2-3mm(0.08-0.12sec)

19. TALL QRS LOW QRS
LVH ANASARCA
THIN ADULTS HYPOTHROIDISM
ATHLETES LARGE PERICARDIAL EFFUSION
EMPHYSEMA
DIFFUSE MYOCARDIAL DISEASE
OBESITY

20. MORPHOLOGY OF QRS-
• FIRST POSITIVE WAVE-R WAVE
• NEG BEFORE R-Q WAVE
• NEG AFTER R-S WAVE
• rsR’ pattern in RBBB IN V1
• M pattern in LBBB IN V6
• MARROW
• WILLIAM

21. ST SEGMENT-
• Isoelectric segment with smooth margin into T Waves.
• CLINICAL SIGNIFICANCE-
• Hockey stick sign in digoxin
• Saddle back st in brugada syndrome
• ST Segment Elevation in STEMI

22. T WAVE-
• Represent Ventricular Repolarisation
• Abnormalities-
• 1)TALL T-(height>50% of R)-hyperkalemia,MI
• 2)SMALL OR INV T WAVES-ischemia,LVH(conc)

23. QT/QTc INTERVAL-
• Corrected QT interval=
• QT INTERVAL/√RR INTERVAL
• QT interval inversely related with
heart rate,so correction for 60 bpm
is essential.
• Prolonged QT interval suggests electrolyte imbalance

24. FINDING AXIS-
• NORMAL AXIS= -30 deg to +110 deg(0 to 90)
negative
negative positive
positive

25. -LEAD aVF
-LEAD 1 +LEAD 1
+LEAD aVF

26. CAUSES OF LAD-
• LEFT ANTERIOR FASCICULAR BLOCK
• INFERIOR WALL MI
• LEFT VENTRICULAR HYPERTROPHY

27. CAUSES OF RAD-
• LEFT POSTERIOR FASICULAR BLOCKS
• RIGHT VENTRICULAR HYPERTROPHY
• LATERAL WALL MYOCARDIAL INFARCTION

28. RVH CRITERIA
1. V1-predominant R wave
2. V1- R wave height>7mm
3. S1Q3 pattern(RV STRAIN)-deep S in lead 1
Q wave in lead 3

30. LVH CRITERIA-
1. V5/V6-R wave>25mm
2. S wave of V1+ R wave of V5 or V6>35mm
3. T wave inversion(strain)-concentric hypertrophy

32. QUESTIONS-(FIND RATE AND
AXIS)

34. Fasicles and conduction
pathways of heart-

35. RT BUNDLE BRANCH BLOCK-
1
2
3
1-represent septal depol towards V1
2-represent left ventricle depol away from V1
3-represent late depol of right ventricle towards V1
(MARROW)

36. LT BUNDLE BRANCH BLOCK-
1
2
3
1-represents septal depol towards v6
2-represents right ventricle depol away from v6
3-represents late depol of left ventricle towards v6
(WILLIAM)

37. LT ANTERIOR FASIC. BLOCK-
• no anterior fasicle depolarisation
• More depolarisation in left posterior fasicle
• Behaves as left axis deviation(+ lead 1,-lead aVf)
• S2S3aVfS Pattern(prominent s wave in lead 2,3,aVf)
• QRS duration remains normal

39. LT POSTERIOR FASIC. BLOCK-
• no posterior fasicle depolarisation
• More depolarisation in left anterior fasicle
• Behaves as right axis deviation(- lead 1,+lead aVf)
• QRS duration normal(2-3mm)

41. QUIZ-

45. NORMAL ECG-

46. CASE AND FINDING?

47. ARRYTHMIA’S-
• TACHYARRYTHMIA’S(HR>100)
1. SUPRAVENTRICULAR TACHYCARDIA-SVT,A FIB, A FLUTTER
2. VENTRICULAR TACHYCARDIA-
3. SINUS TACHYCARDIA
4. POLYMORPHIC VT
• BRADYARRYTHMIA’S(HR<60)
1. SINUS BRADYCARDIA
2. JUNCTIONAL RHYTHM
3. HEART BLOCKS-1ST ,2ND , 3RD DEGREE

48. TACHARRYTHMIA-
• SVT
• HR~300BPM
• NARROW QRS
• RX-CAROTID MASSAGE>IV ADENOSINE 6MG

49. VENTRICULAR TACHYCARDIA
• HR~300BPM
• BROAD QRS
• TREATMENT-RAPID DEFIBRILLATION

50. POLYMORPHIC VT
• DOC-IV MAGNESIUM SULPHATE

51. BRADYARRYTHMIA
• SINUS BRADYCARDIA

53. FINAL CHECKLIST-
1. STANDARDIZATION
2. HEART RATE
3. RHYTHM
4. PR INTERVAL
5. QRS INTERVAL(DURATION)
6. CORRECTED QT INTERVAL(PROLONGED SUGG ELECTROLYTE
DISTURBANCES)

54. CHECKLIST(CONTD)-
• 7.ELECTRICAL AXIS
• 8. P WAVES(WIDTH,HEIGHT AND SHAPE)
• 9. QRS VOLTAGES(TALL OR LOW)
• 10. R WAVE PROGRESSION(INC IN R/S RATIO FROM V1 TO V6)
• 11. ABNORMAL Q WAVES
Prominent q waves in lead 2,3, aVf indicates
inferior wall infarction
• 12.ST SEGMENT
st elevation or depression
• 13. T WAVES-normally + in lead v3 to v6,lead 2
- in lead aVR

55. CHECKLIST(CONTD)-
• 14.PROMINENT U WAVES-
IN LEAD V2 TO V4- SIGN OF HYPOKALEMIA,DRUG
TOXICITIES EX.-AMIODARONE,QUINIDINE,SOTALOL