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Basics of ECG http://emergencymedic.blogspot.com Dr Subroto Mandal, MD, DM, DC Associate Professor, Cardiology
HISTORY ,[object Object],[object Object],[object Object],[object Object],[object Object]
CONTD… ,[object Object],[object Object],[object Object],[object Object]
 
MODERN ECG INSTRUMENT
What is an EKG? ,[object Object],[object Object],[object Object]
With EKGs we can identify Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances (i.e. hyperkalemia, hypokalemia) Drug toxicity (i.e. digoxin and drugs which prolong the QT interval)
Depolarization ,[object Object],[object Object]
Pacemakers of the Heart ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object]
Impulse Conduction & the ECG ,[object Object],[object Object],[object Object],[object Object],[object Object]
The “PQRST” ,[object Object],[object Object],[object Object]
The PR Interval ,[object Object],[object Object],[object Object],[object Object],[object Object]
NORMAL  ECG
The ECG Paper ,[object Object],[object Object],[object Object],[object Object],[object Object]
EKG Leads which measure the difference in electrical potential between two points 1. Bipolar Leads: Two different points on the body  2. Unipolar Leads:  One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart
EKG Leads The standard EKG has 12 leads: 3 Standard Limb Leads 3 Augmented Limb Leads 6 Precordial Leads
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
All Limb Leads
Precordial Leads
Precordial Leads
Right Sided & Posterior Chest Leads
Arrangement of Leads on the EKG
Anatomic Groups (Septum)
Anatomic Groups (Anterior Wall)
Anatomic Groups (Lateral Wall)
Anatomic Groups (Inferior Wall)
Anatomic Groups (Summary)
  ECG  RULES ,[object Object]
RULE 1 ,[object Object]
  RULE 2 ,[object Object]
RULE 3 ,[object Object]
RULE 4 ,[object Object]
RULE 5 ,[object Object]
RULE 6 The R wave must grow from V1 to at least V4 The S wave  must grow from V1 to at least V3  and disappear in V6
RULE 7 ,[object Object],[object Object]
RULE 8 ,[object Object]
RULE 9 ,[object Object]
RULE 10 ,[object Object]
P wave ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Right Atrial Enlargement ,[object Object]
[object Object],Left Atrial Enlargement
P Pulmonale P Mitrale
Short PR Interval ,[object Object],[object Object]
Long PR Interval ,[object Object]
QRS Complexes ,[object Object],[object Object],[object Object],[object Object]
QRS in LVH & RVH
Conditions with Tall R in V1
Right Atrial and Ventricular Hypertrophy
Left Ventricular Hypertrophy ,[object Object],[object Object],[object Object]
 
ST Segment ,[object Object],[object Object],[object Object]
Variable Shapes Of ST Segment Elevations in AMI Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified Approach. 7th ed: Mosby Elsevier; 2006.
T wave ,[object Object],[object Object],[object Object],[object Object],[object Object]
T wave
QT interval ,[object Object],[object Object],[object Object],[object Object],[object Object]
QT Interval
U wave ,[object Object],[object Object],[object Object],[object Object]
Determining the Heart Rate Rule of 300/1500 10 Second Rule
Rule of 300 Count  the number of “big boxes” between two QRS complexes, and divide this into 300.  (smaller boxes with 1500)  for regular rhythms.
What is the heart rate? (300 / 6) = 50 bpm
What is the heart rate? (300 / ~ 4) = ~ 75 bpm
What is the heart rate? (300 / 1.5) = 200 bpm
The Rule of 300 It may be easiest to memorize the following table: 50 6 60 5 75 4 100 3 150 2 300 1 Rate No of big boxes
10 Second Rule EKGs record 10 seconds of rhythm per page, Count the number of beats present on the EKG Multiply by 6  For irregular rhythms.
What is the heart rate? 33 x 6 = 198 bpm
Calculation of Heart Rate
Question ,[object Object]
The QRS Axis The QRS axis represents overall direction of the heart’s electrical activity. Abnormalities hint at: Ventricular enlargement Conduction blocks (i.e. hemiblocks)
The QRS Axis Normal QRS axis from -30 °  to +90 ° . -30 °  to -90 °  is referred to as a left axis deviation (LAD) +90 °  to +180 °  is referred to as a right axis deviation (RAD)
Determining the Axis The Quadrant Approach The Equiphasic Approach
Determining the Axis Predominantly Positive Predominantly Negative Equiphasic
The Quadrant Approach ,[object Object],[object Object],[object Object]
The Quadrant Approach ,[object Object],[object Object],[object Object]
Quadrant Approach: Example 1 Negative in I, positive in aVF    RAD
Quadrant Approach: Example 2 Positive in I, negative in aVF     Predominantly positive in II     Normal Axis (non-pathologic LAD)
The Equiphasic Approach 1. Most equiphasic QRS complex.  2. Identified Lead lies 90° away from the lead  3. QRS in this second lead is positive  or Negative
QRS Axis = -30 degrees
                                                                     QRS Axis = +90 degrees-KH
 
Equiphasic Approach Equiphasic in aVF    Predominantly positive in I    QRS axis  ≈ 0°
Thank You
BRADYARRYTHMIA Dr Subroto Mandal, MD, DM, DC Associate Professor, Cardiology
Classification ,[object Object],[object Object],[object Object],[object Object]
Impulse Conduction & the ECG ,[object Object],[object Object],[object Object],[object Object]
Sinus Bradycardia
Junctional Rhythm
SA Block ,[object Object],[object Object],[object Object],[object Object],[object Object]
AV Block ,[object Object],[object Object],[object Object]
First Degree AV Block ,[object Object],[object Object],[object Object],[object Object]
Second Degree AV Block ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Mobitz type 1 (Wenckebach Phenomenon)
Mobitz type 1 (Wenckebach Phenomenon)
[object Object],[object Object],[object Object],[object Object],[object Object]
Third Degree Heart Block ,[object Object],[object Object],[object Object]
Third Degree Heart Block 3rd degree AV block with a left ventricular escape rhythm,  'B' the right ventricular pacemaker rhythm is shown.
The nonconducted PAC's set up a long pause which is terminated by ventricular escapes;  Wider QRS morphology of the escape beats indicating their ventricular origin.  AV Dissociation
AV Dissociation Due to Accelerated ventricular rhythm
Thank You
Putting it all Together ,[object Object]
Interpretation ,[object Object]
Putting it all Together ,[object Object]
Inferior Wall MI ,[object Object]
Putting it all Together ,[object Object]
Anterolateral MI ,[object Object]
Rhythm #6 70 bpm ,[object Object],[object Object],regular flutter waves 0.06 s ,[object Object],[object Object],none ,[object Object],Interpretation? Atrial Flutter
Rhythm #7 74   148 bpm ,[object Object],[object Object],Regular    regular Normal    none 0.08 s ,[object Object],[object Object],0.16 s    none ,[object Object],Interpretation? Paroxysmal Supraventricular Tachycardia (PSVT)
PSVT ,[object Object],[object Object]
Ventricular Arrhythmias ,[object Object],[object Object]
Rhythm #8 160 bpm ,[object Object],[object Object],regular none wide (> 0.12 sec) ,[object Object],[object Object],none ,[object Object],Interpretation? Ventricular Tachycardia
Ventricular Tachycardia ,[object Object],[object Object]
Rhythm #9 none ,[object Object],[object Object],irregularly irreg. none wide, if recognizable  ,[object Object],[object Object],none ,[object Object],Interpretation? Ventricular Fibrillation
Ventricular Fibrillation ,[object Object],[object Object]
Arrhythmia Formation ,[object Object],[object Object],[object Object],[object Object],[object Object]
SA Node Problems ,[object Object],[object Object],[object Object],[object Object],[object Object],Sinus Tachycardia may be an appropriate response to stress.
Atrial Cell Problems ,[object Object],[object Object],[object Object],[object Object],[object Object]
AV Junctional Problems ,[object Object],[object Object],[object Object],[object Object],[object Object]
Rhythm #1 30 bpm ,[object Object],[object Object],regular normal 0.10 s ,[object Object],[object Object],0.12 s ,[object Object],Interpretation? Sinus Bradycardia
Rhythm #2 130 bpm ,[object Object],[object Object],regular normal 0.08 s ,[object Object],[object Object],0.16 s ,[object Object],Interpretation? Sinus Tachycardia
Rhythm #3 70 bpm ,[object Object],[object Object],occasionally irreg. 2/7 different contour 0.08 s ,[object Object],[object Object],0.14 s (except 2/7) ,[object Object],Interpretation? NSR with Premature Atrial Contractions
Premature Atrial Contractions ,[object Object],[object Object]
Rhythm #4 60 bpm ,[object Object],[object Object],occasionally irreg. none for 7 th  QRS 0.08 s (7th wide) ,[object Object],[object Object],0.14 s ,[object Object],Interpretation? Sinus Rhythm with 1 PVC
Ventricular Conduction Normal Signal moves rapidly through the ventricles Abnormal Signal moves slowly through the ventricles
AV Nodal Blocks ,[object Object],[object Object],[object Object],[object Object]
Rhythm #10 60 bpm ,[object Object],[object Object],regular normal 0.08 s ,[object Object],[object Object],0.36 s ,[object Object],Interpretation? 1st Degree AV Block
1st Degree AV Block ,[object Object]
Rhythm #11 50 bpm ,[object Object],[object Object],regularly irregular nl, but 4th no QRS 0.08 s ,[object Object],[object Object],lengthens ,[object Object],Interpretation? 2nd Degree AV Block, Type I
Rhythm #12 40 bpm ,[object Object],[object Object],regular nl, 2 of 3 no QRS 0.08 s ,[object Object],[object Object],0.14 s ,[object Object],Interpretation? 2nd Degree AV Block, Type II
2nd Degree AV Block, Type II ,[object Object],[object Object]
Rhythm #13 40 bpm ,[object Object],[object Object],regular no relation to QRS wide (> 0.12 s) ,[object Object],[object Object],none ,[object Object],Interpretation? 3rd Degree AV Block
3rd Degree AV Block ,[object Object],[object Object]
Supraventricular Arrhythmias ,[object Object],[object Object],[object Object]
Rhythm #5 100 bpm ,[object Object],[object Object],irregularly irregular none 0.06 s ,[object Object],[object Object],none ,[object Object],Interpretation? Atrial Fibrillation
Atrial Fibrillation ,[object Object],[object Object],[object Object],[object Object]
Rhythm #6 70 bpm ,[object Object],[object Object],regular flutter waves 0.06 s ,[object Object],[object Object],none ,[object Object],Interpretation? Atrial Flutter
Rhythm #7 74   148 bpm ,[object Object],[object Object],Regular    regular Normal    none 0.08 s ,[object Object],[object Object],0.16 s    none ,[object Object],Interpretation? Paroxysmal Supraventricular Tachycardia (PSVT)
PSVT ,[object Object],[object Object]
Ventricular Arrhythmias ,[object Object],[object Object]
Rhythm #8 160 bpm ,[object Object],[object Object],regular none wide (> 0.12 sec) ,[object Object],[object Object],none ,[object Object],Interpretation? Ventricular Tachycardia
Ventricular Tachycardia ,[object Object],[object Object]
Rhythm #9 none ,[object Object],[object Object],irregularly irreg. none wide, if recognizable  ,[object Object],[object Object],none ,[object Object],Interpretation? Ventricular Fibrillation
Ventricular Fibrillation ,[object Object],[object Object]
Diagnosing a MI ,[object Object],Rhythm Strip 12-Lead ECG
Views of the Heart ,[object Object],Anterior portion of the heart Lateral portion of the heart Inferior portion of the heart
ST Elevation ,[object Object]
ST Elevation (cont) ,[object Object]
Anterior View of the Heart ,[object Object]
Anterior Myocardial Infarction ,[object Object]
Putting it all Together ,[object Object]
Interpretation ,[object Object]
Other MI Locations ,[object Object]
Other MI Locations ,[object Object],Anterior portion of the heart Lateral portion of the heart Inferior portion of the heart
Other MI Locations ,[object Object],Limb Leads Augmented Leads Precordial Leads
Other MI Locations ,[object Object],Limb Leads Augmented Leads Precordial Leads
Anterior MI ,[object Object],Limb Leads Augmented Leads Precordial Leads
Lateral MI ,[object Object],Limb Leads Augmented Leads Precordial Leads Leads I, aVL, and V 5 - V 6
Inferior MI ,[object Object],Limb Leads Augmented Leads Precordial Leads Leads II, III and aVF
Putting it all Together ,[object Object]
Inferior Wall MI ,[object Object]
Putting it all Together ,[object Object]
Anterolateral MI ,[object Object]
RIGHT ATRIAL ENLARGEMENT
[object Object],[object Object],The P waves are tall, especially in leads II, III and avF. Ouch! They would hurt to sit on!!
[object Object],[object Object],[object Object],[object Object],Remember 1 small box in height = 1 mm A cause of RAE is RVH from pulmonary hypertension. > 2 ½ boxes (in height) > 1 ½ boxes (in height)
[object Object],[object Object],The P waves in lead II are notched and in lead V1 they have a deep and wide negative component. Notched  Negative deflection
[object Object],[object Object],[object Object],[object Object],Normal LAE A common cause of LAE is LVH from hypertension.
Left Ventricular Hypertrophy
Left Ventricular Hypertrophy ,[object Object],Normal Left Ventricular Hypertrophy Answer: The QRS complexes are very tall (increased voltage)
Left Ventricular Hypertrophy ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],There is right axis deviation (negative in I, positive in II) and there are tall R waves in V1, V2.
[object Object],[object Object],[object Object],[object Object],A common cause of RVH is left heart failure.
[object Object],[object Object],[object Object],[object Object],Normal RVH
[object Object],[object Object],There is left axis deviation (positive in I, negative in II) and there are tall R waves in V5, V6 and deep S waves in V1, V2. The deep S waves seen in the leads over the right ventricle are created because the heart is depolarizing left, superior and posterior (away from leads V1, V2).
[object Object],[object Object],[object Object],[object Object],A common cause of LVH is hypertension. * There are several other criteria for the diagnosis of LVH. S = 13 mm R = 25 mm
Bundle Branch Blocks
Normal Impulse Conduction Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers
Bundle Branch Blocks ,[object Object],Therefore, a conduction block of the Bundle Branches would be reflected as a change in the QRS complex. Right BBB
Bundle Branch Blocks ,[object Object],[object Object],[object Object]
 
Right Bundle Branch Blocks ,[object Object],V 1 For  RBBB  the wide QRS complex assumes a unique, virtually diagnostic shape in those leads overlying the right ventricle (V 1  and V 2 ).  “ Rabbit Ears”
RBBB
 
Left Bundle Branch Blocks ,[object Object],Normal For  LBBB  the wide QRS complex assumes a characteristic change in shape in those leads  opposite  the left ventricle (right ventricular leads - V 1  and V 2 ).  Broad, deep S waves
 
 
 
 
 
HYPERKALEMIA
HYPERKALEMIA
 
SEVERE HYPERKALEMIA
HYPOKALEMIA
HYPOKALEMIA
HYPOKALEMIA
HYPERCALCEMIA
HYPOCALCEMIA
 
ACUTE PERICARDITIS
ACUTE PERICARDITIS
CARDIAC TAMPONADE
PERICARDIAL EFFUSION-Electrical alterans
HYPOTHERMIA-OSBORNE WAVE
HYPOTHERMIA-  Giant Osborne waves

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ECG Basics

Editor's Notes

  1. Atrial depolarisation Electrically both atria act almost as one. They have relatively little muscle and generate a single, small P wave. P wave amplitude rarely exceeds two and a half small squares (0.25 mV). The duration of the P wave should not exceed three small squares (0.12 s). The wave of depolarisation is directed inferiorly and towards the left, and thus the P wave tends to be upright in leads I and II and inverted in lead aVR. Sinus P waves are usually most prominently seen in leads II and V1. A negative P wave in lead I may be due to incorrect recording of the electrocardiogram (that is, with transposition of the left and right arm electrodes), dextrocardia, or abnormal atrial rhythms. Normal P waves may have a slight notch, particularly in the precordial (chest) leads. Bifid P waves result from slight asynchrony between right and left atrial depolarisation. A pronounced notch with a peak­to­peak interval of > 1 mm (0.04 s) is usually pathological, and is seen in association with a left atrial abnormality—for example, in mitral stenosis.
  2. The R wave in lead V6 is smaller than the R wave in V5, since the V6 electrode is further from the left ventricle. The depth of the S wave, generally, should not exceed 30 mm in a normal individual (although > 30 mm are occasionally recorded in normal young male adults) In another website it is also shown that small q wave seen in leads III and aVF Normal q-waves reflect normal septal activation (beginning on the LV septum); they are narrow (<0.04s duration) and small (<25% the amplitude of the R wave). They are often seen in leads I and aVL when the QRS axis is to the left of +60o, and in leads II, III, aVF when the QRS axis is to the right of +60o. Septal q waves should not be confused with the pathologic Q waves of myocardial infarction (http://medstat.med.utah.edu/kw/ecg/ecg_outline/Lesson3/index.html)
  3. Sokolow + Lyon (Am Heart J, 1949;37:161) S V1+ R V5 or V6 > 35 mm Cornell criteria (Circulation, 1987;3: 565-72) SV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in women Framingham criteria (Circulation,1990; 81:815-820) R avl > 11mm, R V4-6 > 25mm S V1-3 > 25 mm S V1 or V2 + R V5 or V6 > 35 mm R I + S III > 25 mm Romhilt + Estes (Am Heart J, 1986:75:752-58) Point score system
  4. ST segment depression is always an abnormal finding, although often nonspecific (http://medstat.med.utah.edu/kw/ecg/ecg_outline/Lesson3/index.html)
  5. As a general rule, T wave amplitude corresponds with the amplitude of the preceding R wave, though the tallest T waves are seen in leads V3 and V4. Tall T waves may be seen in acute myocardial ischaemia and are a feature of hyperkalaemia.
  6. Poor Man's Guide to upper limits of QT: For HR = 70 bpm, QT<0.40 sec; for every 10 bpm increase above 70 subtract 0.02 sec, and for every 10 bpm decrease below 70 add 0.02 sec. For example: QT < 0.38 @ 80 bpm QT < 0.42 @ 60 bpm