Ecg Part 1

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  • Ecg Part 1

    1. 1. ECG diagnosis
    2. 2. Lead Position <ul><li>A typical ECG report shows the cardiac cycle from 12 different vantage points (I, II, III, aVR, aVL, aVF, V1-V6), like viewing the event electrically from 12 different locations (like a 3D perspective).BUT only 10 electrodes are used. </li></ul><ul><li>Lead I represents activity that is going from the right arm to the left arm </li></ul><ul><li>Lead II represents activity that is going from the right arm to the left leg </li></ul><ul><li>Lead III represents activity that is going from the left arm to the left leg </li></ul><ul><li>aVL is placed on the left arm (or shoulder) </li></ul><ul><li>aVF is placed on the left leg (or hip) </li></ul><ul><li>aVR is placed on the right arm (or shoulder) </li></ul><ul><li>V1- 4th intercostal space to the right of sternum </li></ul><ul><li>V2- 4th intercostal space to the left of sternum </li></ul><ul><li>V3- halfway between V2 and V4 </li></ul><ul><li>V4- 5th intercostal space in the left mid-clavicular line </li></ul><ul><li>V5- 5th intercostal space in the left anterior axillary line </li></ul><ul><li>V6- 5th intercostal space in the left mid axillary line </li></ul>
    3. 3. NSR
    4. 4. Aims <ul><li>10 ECG rules </li></ul><ul><li>Heart Rate </li></ul><ul><li>ECG signs of M.I. </li></ul><ul><li>Evolution of changes in M.I. </li></ul><ul><li>Classical Appearences </li></ul>
    5. 5. QRS waveform nomenclature R r qR qRs Qrs QS Qr Rs rS qs rSr’ rSR’
    6. 6. The 10 rules for a normal ECG .2 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    7. 7. Rule 1 Millivolts Milliseconds 0 200 400 600 -0.5 0 0.5 1.0 P R T Q S PR interval should be 120 to 200 milliseconds or 3 to 5 little squares PR interval
    8. 8. Rule 2 Millivolts Milliseconds 0 200 400 600 -0.5 0 0.5 1.0 QRS The width of the QRS complex should not exceed 110 ms, less than 3 little squares P R T Q S
    9. 9. Rule 3 The QRS complex should be dominantly upright in leads I and II I II III aVR aVL aVF
    10. 10. Rule 4 QRS and T waves tend to have the same general direction in the limb leads I II III aVR aVL aVF
    11. 11. Rule 5 All waves are negative in lead aVR P Q T S
    12. 12. Rule 6 V 1 V 2 V 3 V 4 V 5 V 6 The R wave in the precordial leads must grow from V1 to at least V4
    13. 13. Rule 7 The ST segment should start isoelectric except in V1 and V2 where it may be elevated I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    14. 14. Rule 8 The P waves should be upright in I, II, and V2 to V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    15. 15. Rule 9 There should be no Q wave or only a small q less than 0.04 seconds in width in I, II, V2 to V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    16. 16. Rule 10 The T wave must be upright in I, II, V2 to V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    17. 17. What is the heart rate? <ul><li>(300 / 6) = 50 bpm </li></ul><ul><li>www.uptodate.com </li></ul>
    18. 18. What is the heart rate? <ul><li>(300 / ~ 4) = ~ 75 bpm </li></ul><ul><li>www.uptodate.com </li></ul>
    19. 19. What is the heart rate? <ul><li>(300 / 1.5) = 200 bpm </li></ul>
    20. 20. 10 Second Rule <ul><li>As most EKGs record 10 seconds of rhythm per page, one can simply count the number of beats present on the EKG and multiply by 6 to get the number of beats per 60 seconds. </li></ul><ul><li>This method works well for irregular rhythms. </li></ul>
    21. 21. What is the heart rate? <ul><li>33 x 6 = 198 bpm </li></ul><ul><li>The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/ </li></ul>
    22. 22. Characteristic changes in AMI <ul><li>ST segment elevation over area of damage </li></ul><ul><li>ST depression in leads opposite infarction </li></ul><ul><li>Pathological Q waves </li></ul><ul><li>Reduced R waves </li></ul><ul><li>Inverted T waves </li></ul>
    23. 23. ST elevation <ul><li>Occurs in the early stages </li></ul><ul><li>Occurs in the leads facing the infarction </li></ul><ul><li>Slight ST elevation may be normal in V 1 or V 2 </li></ul>R P Q ST
    24. 24. Deep Q wave <ul><li>Only diagnostic change of myocardial infarction </li></ul><ul><li>At least 0.04 seconds in duration </li></ul><ul><li>Depth of more than 25% of ensuing R wave </li></ul>R P Q T ST
    25. 25. T wave changes <ul><li>Late change </li></ul><ul><li>Occurs as ST elevation is returning to normal </li></ul><ul><li>Apparent in many leads </li></ul>R P Q T ST
    26. 26. Bundle branch block I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Anterior wall MI Left bundle branch block
    27. 27. Sequence of changes in evolving AMI 1 minute after onset 1 hour or so after onset A few hours after onset A day or so after onset Later changes A few months after AMI Q R P Q T ST R P Q ST P Q T ST R P S T P Q T ST R P Q T
    28. 28. Anterior infarction Anterior infarction Left anterior descending artery (LAD) I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    29. 29. Inferior infarction Inferior infarction Right coronary Artery( RCA) OR Circumflex (LCX) I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    30. 30. Lateral infarction Lateral infarction Left circumflex coronary Artery OR DAIAGONAL branch of LAD I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
    31. 31. Location of infarct combinations aVR V1 V4 I II III LATERAL OR HIGH LATERAL INFERIOR SEPTAL ANT ANT LAT aVL aVF V2 V3 V5 V6
    32. 32. Diagnostic criteria for AMI <ul><li>Q wave duration of more than 0.04 seconds </li></ul><ul><li>Q wave depth of more than 25% of ensuing r wave </li></ul><ul><li>ST elevation in leads facing infarct (or depression in opposite leads) </li></ul><ul><li>Deep T wave inversion overlying and adjacent to infarct </li></ul><ul><li>Cardiac arrhythmias </li></ul>
    33. 33. Hay….. wake up we are done

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