ECG skills enhancement

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ECG skills enhancement

  1. 1. JILL IRENE Z. CAPISTRANO MD, FPCP, DPCCPostgraduate EducationBS Physical Therapy, Silliman University, 1996BS Zoology, MSU-Iligan Institute of Technology 1999Doctor of Medicine, Mindanao State University-College of MedicinePost-graduate InternshipUniversity of the Philippines, Philippine General Hospital 2003-2004Internal Medicine ResidencyUniversity of the Philippines, Philippine General Hospital 2004-2007Fellowship in CardiologyUniversity of the Philippines, Philippine General Hospital 2008-2011AffiliationsFellow, Philippine College of PhysciansFellow, Philippine Heart AssociationDiplomate, Philippine College of Cardiology
  2. 2. Dr. Jill Irene Z. Capistrano, FPCP,DPCC INTERNAL MEDICINE-CARDIOLOGY
  3. 3. R PR ST segment segment TP J point Q PR ST Sinterval interval QRS interval QT interval
  4. 4. Normal IntervalsHeart rate 60 - 100 beats/min bradycardia < 60 tachycardia > 100PR interval 0.12 – 0.20 secQRS < 0.12 secQRS axis - 30º to + 110ºQTc < 0.45 sec
  5. 5. Normal P wave morphology
  6. 6. Normal QRS Complex Morphology
  7. 7. Normal T wave morphology
  8. 8. Guide in Reading ECG• Standardization & technique• Rhythm• Rate: atrial & ventricular• P wave morphology & duration• P-R interval• QRS complex morphology & duration• ST segment• T-wave• U wave• Q-T interval
  9. 9. Determination of Rhythm
  10. 10. RHYTHM (Sinus? Regular? Irregular?)• A.• B.• C.• D.
  11. 11. RHYTHM (Sinus? Regular? Irregular?)• A.• B.• C.• D.
  12. 12. Determination of Rate
  13. 13. v vMeasurement of Rate
  14. 14. Measurement of Rate• Formula 1: 300 # big squares between R-R• Formula 2: 1500 # small squares between R-R
  15. 15. Normal rate? Bradycardia? Tachycardia?• A.• B.• C.
  16. 16. Determination of Axis
  17. 17. aVR aVL I II III aVFStandard Locations of Limb Leads
  18. 18. Determination of Axis Lead I Lead aVF
  19. 19. Determine the axis of the ff:• A.• B.• C.
  20. 20. Chamber Enlargement
  21. 21. Standard Locations of Chest Leads
  22. 22. Atrial Enlargement
  23. 23. Atrial Enlargement II V1BV1
  24. 24. Ventricular Enlargement
  25. 25. RIGHT VENTRICULAR HYPERTROPHYSokolow-Lyon Criteria: R in V1 + S in V5-V6 > 11 mm R in V1 > 7mm R : S in V1 > 1 RAD > +90 degrees Additional Criteria: QR in V1 S1 Q3 pattern S1 S2 S3 pattern p pulmonale
  26. 26. A 55F hypertensive sought consult at the ER for a blood pressure of150/100. You requested for ancillary procedures, including an ECG.
  27. 27. 13 X 2 S in V1 + R in V5 or V6 > 35mm VENTRICULAR LEFT 20 X 2 HYPERTROPHYSinus rhythm, normal axis, left ventricular hypertrophy
  28. 28. A 24 year-old male with Atrial Septal Defect was admitted for shortness of breath.
  29. 29. SINUS TACHYCARDIAInterval between QRS complex < 3majordivisions1500/# small squares = 1500/12 = 125beats/min
  30. 30. QRS downward in lead I and upright in lead aVF RIGHT AXIS DEVIATIONP waves tall and pointed in II andaVF RIGHT ATRIAL ENLARGEMENT
  31. 31. QRS upright in V1 Prominent S waves across precordial leads RIGHT VENTRICULAR HYPERTROPHYSinus tachycardia, right axis deviation, right atrial abnormality, right ventricularhypertrophy
  32. 32. LAE, RAE, RVH LAE RVHP pulmonale
  33. 33. Bundle Branch Block
  34. 34. A 24 year old female admitted for heart murmur.
  35. 35. Intrinsicoid deflection time QRS complex >120 msec Delayed intrinsicoid deflection time in V1 RIGHT BUNDLE BRANCH BLOCKNormal sinus rhythm, right bundle branch block
  36. 36. RSR’ in V1 Wide S waves in I, V6 RIGHT BUNDLE BRANCH BLOCKNormal sinus rhythm, right bundle branch block
  37. 37. A 50/M smoker diabetic admitted for pain.
  38. 38. Pseudoinfarct pattern in V1 Monophasic R / notched R in V6 LEFT BUNDLE BRANCH BLOCKSinus rhythm, left bundle branch block
  39. 39. Myocardial ischemia and infarction
  40. 40. Myocardial InjuryCriteria: 1. Elevation of the origin of ST segment at its junction (J point) with the QRS of: a. >1.0 mm (0.10 mV) in >2 limb leads lasting at least 80 msecs or b. >2.0 mm (0.20 mV) in >2 precordial leads
  41. 41. Myocardial InjuryCriteria: 2. Depression of the origin of ST segment at the J point >1.0 mm (0.20 mV) in at least 2 leads *ST segment deviation typically either horizontal or slope toward the direction of T waves
  42. 42. Myocardial InfarctionCriteria:1. Development of new Q waves on areas overlying the infarct which is: a. >0.04. secs duration b. >25% of the height of associated R wave
  43. 43. Onset and first several hours Normal ECG First and second day First dayAfter 2days Several days or months
  44. 44. Occlusion of left descendingcoronary artery
  45. 45. Occlusion of left circumflexcoronary artery
  46. 46. Occlusion of right coronaryartery
  47. 47. Exercise ECGs
  48. 48. Thank You!

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