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Ecg part introduction

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ECG basic
Introduction to ECG
Important Examples of ECG
Axis

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Ecg part introduction

  1. 1. ECG diagnosis
  2. 2. The Normal Conduction System
  3. 3. Lead Position • 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. • Lead I represents activity that is going from the right arm to the left arm Lead II represents activity that is going from the right arm to the left leg Lead III represents activity that is going from the left arm to the left leg • • • • • • • • • • • aVL is placed on the left arm (or shoulder) aVF is placed on the left leg (or hip) aVR is placed on the right arm (or shoulder) V1- 4th intercostal space to the right of sternum V2- 4th intercostal space to the left of sternum V3- halfway between V2 and V4 V4- 5th intercostal space in the left mid-clavicular line V5- 5th intercostal space in the left anterior axillary line V6- 5th intercostal space in the left mid axillary line
  4. 4. NSR
  5. 5. • NORMAL
  6. 6. • NORMAL
  7. 7. • NSR , Juvenile T-wave inversion.
  8. 8. • NORMAL
  9. 9. WPW Syndrome
  10. 10. AF, Inferior Q waves
  11. 11. RBBB
  12. 12. 28 years with palpitations
  13. 13. • SVT
  14. 14. 4 years later
  15. 15. • DEVELOPPED AF
  16. 16. 50 years old syrian with mild CAD
  17. 17. • VT,THIS PT HAD SEVERE DCM,waiting for AICD
  18. 18. • Paced Rhythm
  19. 19. Waveforms and Intervals
  20. 20. Aims • • • • • 10 ECG rules Heart Rate ECG signs of M.I. Evolution of changes in M.I. Classical Appearences
  21. 21. QRS waveform nomenclature R r qR qRs Qrs QS Qr Rs rS qs rSr’ rSR’
  22. 22. The 10 rules for a normal ECG I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 .2
  23. 23. Rule 1 1.0 Millivolts 0.5 R PR interval PR interval should be 120 to 200 milliseconds or 3 to 5 little squares T P Q 0 S -0.5 0 200 400 Milliseconds 600
  24. 24. Rule 2 1.0 R The width of the QRS complex should not exceed 110 ms, less than 3 little squares Millivolts 0.5 T P Q 0 S -0.5 QRS 0 200 400 Milliseconds 600
  25. 25. Rule 3 I II III aVR aVL aVF The QRS complex should be dominantly upright in leads I and II
  26. 26. Rule 4 I II III aVR aVL aVF QRS and T waves tend to have the same general direction in the limb leads
  27. 27. Rule 5 All waves are negative in lead aVR P T Q S
  28. 28. Rule 6 V1 V2 V3 V4 V5 V6 The R wave in the precordial leads must grow from V1 to at least V4
  29. 29. Rule 7 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 The ST segment should start isoelectric except in V1 and V2 where it may be elevated
  30. 30. Rule 8 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 The P waves should be upright in I, II, and V2 to V6
  31. 31. Rule 9 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 There should be no Q wave or only a small q less than 0.04 seconds in width in I, II, V2 to V6
  32. 32. Rule 10 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 The T wave must be upright in I, II, V2 to V6
  33. 33. What is the heart rate? •www.uptodate.com •(300 / 6) = 50 bpm
  34. 34. What is the heart rate? •www.uptodate.com •(300 / ~ 4) = ~ 75 bpm
  35. 35. What is the heart rate? •(300 / 1.5) = 200 bpm
  36. 36. 10 Second Rule 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. This method works well for irregular rhythms.
  37. 37. What is the heart rate? •The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/ •33 x 6 = 198 bpm
  38. 38. Characteristic changes in AMI • • • • • ST segment elevation over area of damage ST depression in leads opposite infarction Pathological Q waves Reduced R waves Inverted T waves
  39. 39. ST elevation • Occurs in the early stages R ST P Q • Occurs in the leads facing the infarction • Slight ST elevation may be normal in V1 or V2
  40. 40. Deep Q wave • Only diagnostic change of myocardial infarction R ST • At least 0.04 seconds in duration P T Q • Depth of more than 25% of ensuing R wave
  41. 41. T wave changes • Late change R • Occurs as ST elevation is returning to normal ST P • Apparent in many leads T Q
  42. 42. Bundle branch block Anterior wall MI I II III aVR aVL aVF Left bundle branch block V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
  43. 43. Sequence of changes in evolving AMI R R T R ST ST P P Q S P T Q 1 minute after onset Q 1 hour or so after onset A few hours after onset R ST P ST P T Q A day or so after onset T P T Q Later changes Q A few months after AMI
  44. 44. Anterior infarction Anterior infarction I II III Left anterior descending artery (LAD) aVR aVL aVF V1 V2 V3 V4 V5 V6
  45. 45. Inferior infarction Inferior infarction I II III Right coronary Artery( RCA) OR Circumflex (LCX) aVR aVL aVF V1 V2 V3 V4 V5 V6
  46. 46. Lateral infarction Lateral infarction I II III Left circumflex coronary Artery OR DAIAGONAL branch of LAD aVR aVL aVF V1 V2 V3 V4 V5 V6
  47. 47. Location of infarct combinations I aVR LATERAL OR HIGH II aVL LATERAL V1 V4 SEPTAL ANT V2 V5 ANT V3 III INFERIOR aVF V6 LAT
  48. 48. Diagnostic criteria for AMI • • • • • Q wave duration of more than 0.04 seconds Q wave depth of more than 25% of ensuing r wave ST elevation in leads facing infarct (or depression in opposite leads) Deep T wave inversion overlying and adjacent to infarct Cardiac arrhythmias
  49. 49. Quick & Easy AXIS DETERMINATION  Left axis deviation - negative QRS in lead AVF I I AVF AVF  Right axis deviation - negative QRS in lead I I I AVF AVF  Severe Right axis deviation negative QRS in BOTH lead I and AVF I I AVF AVF
  50. 50. The QRS Axis By near-consensus, the normal QRS axis is defined as ranging 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)
  51. 51. Determining the Axis Predominantly Positive Predominantly Negative Equiphasic
  52. 52. The Quadrant Approach 1. Examine the QRS complex in leads I and aVF to determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.
  53. 53. Quadrant Approach: Example 1 The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.ed u/kw/ecg/ Negative in I, positive in aVF  RAD
  54. 54. Quadrant Approach: Example 2 The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.ed u/kw/ecg/ Positive in I, negative in aVF  Predominantly positive in II Normal Axis (non-pathologic LAD) 
  55. 55. Thank U Very Much

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