8 morphology of qrs

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8 morphology of qrs

  1. 1. 12-Lead Electrocardiography a comprehensive course Adam Thompson, EMT-P, A.S.
  2. 2. QRS ComplexThe morphology of the QRS complex willassist us in identifying BBBs, V-tach, LVH, RVH, and infarction.
  3. 3. QRS Complex • Height & Morphology will vary, depending on the lead. • Normal Width – > 0.10 seconds – < 0.12 seconds
  4. 4. Bundle Branches
  5. 5. Bundle Branch Blocks• Right Bundle Branch Block (RBBB) – The single right fascicle is blocked.• Left Bundle Branch Block (LBBB) – Both left fascicles are blocked.• Non-Specific Intraventricular conduction delay (IVCD) – BBB that doesn’t meet RBBB or LBBB criteria.
  6. 6. Bundle Branch Blocks• May mimic an MI• The side that is blocked conducts last and takes longer.
  7. 7. Bundle Branch Blocks Mean vector• Normal conduction 4 Cardiac vector without a block. 1 3 3 2 2
  8. 8. Right Bundle Branch Block + + A B A + BMean vector moves towards positive electrode = positive QRSMean vector moves away from positive electrode = negative QRSMean vector is perpendicular to positive electrode = equiphasic QRS
  9. 9. Bundle Branch Blocks • With a RBBB, the right fascicle is blocked, so the left ventricle is1 conducted first and 2 then the impulse 3 returns to the right.
  10. 10. Bundle Branch Blocks • With a LBBB, the right ventricle is conducted first, and the impulse1 travels back to the 2 left. 3
  11. 11. Bundle Branch BlocksV1
  12. 12. Bundle Branch Blocks V1 J-PointsThe J-point is the exact point where the QRS ends
  13. 13. Bundle Branch BlocksV1
  14. 14. Bundle Branch BlocksV1
  15. 15. Bundle Branch BlocksV1
  16. 16. Bundle Branch BlocksV1 = RBBBV1 = LBBB
  17. 17. Bundle Branch BlocksV1 LBBB RBBB
  18. 18. Right Bundle Branch Block • RBBB morphologiesV1
  19. 19. Right Bundle Branch Block
  20. 20. Left Bundle Branch Block V1
  21. 21. Left Bundle Branch Block
  22. 22. Intraventricular Conduction Delay• A Non-specific IVCD is less common than a RBBB or LBBB• They are wide, atrial rhythms that usually look like a left or right BBB in V1, but do not match the criteria in I & V6.
  23. 23. Ventricular Enlargement• Left Ventricular Hypertrophy (LVH) – The left ventricle is enlarged – Probably due to left-sided heart failure• Right Ventricular Hypertrophy (RVH) – The right ventricle is enlarged – Probably due to right sided heart failure – May be due to pulmonary disease
  24. 24. Ventricular Enlargement• Left Ventricular Hypertrophy (LVH) – May cause left axis deviation – May cause a left ventricular strain pattern • Often mimics an anterior MI• Right Ventricular Hypertrophy (RVH) – May cause right axis deviation – May cause a right ventrcular strain pattern • May mimic a inferior or posterior wall MI
  25. 25. LVHNormal LVH RV LV Hypertrophy
  26. 26. LVHLVH Criteria – Large QRS complexes • Deepest S-wave in V1 or V2 • Tallest R-wave in V5 or V6 – Add them together » If the result is > 25mm = LVH
  27. 27. LVH V5 or V6V1 or V2 S + R
  28. 28. LVHLets take a look at an example
  29. 29. LVHLets take a look at an example
  30. 30. LVHLets take a look at an example
  31. 31. LVHLets take a look at an example 14mm
  32. 32. LVHLets take a look at an example 14mm
  33. 33. LVH14 + 15 = 29mm 14mm 15mm
  34. 34. LVH• Since our total was 29mm, and a total of > 25mm meets LVH criteria, we can assume that this ECG is that of a patient with LVH.*LVH may look a lot like a narrow LBBB.
  35. 35. LVH • A wave that is too tall or deep may be cut off by the monitor • This is a indicator of hypertrophy
  36. 36. LVH • A wave that is too tall or deep may be cut off by the monitor • This is a indicator of hypertrophy
  37. 37. LVHAdditional LVH Criteria Any precordial > 45mm lead aVL > 11mm Lead I > 12mm aVF > 20mm
  38. 38. Ventricular Leads
  39. 39. RVH• Right Ventricular Hypertrophy – Criteria = R:S ration > 1 in V1/V2 • This means that the R-wave is bigger than the S- wave in V1 or V2. • The QRS complex should be narrow • P-Pulmonale may be present. • Right axis deviation is common.
  40. 40. RVHV1 or V2 R = 9mm V1/V2: R > S = RVH •QRS < 120ms (0.12 sec) S = 6mm
  41. 41. RVH
  42. 42. RVHLet’s take a look…
  43. 43. RVHLet’s take a look…
  44. 44. Pathologies Frontal Plane Axis Precordial Axis ERAD Right Axis Pathological Early Transition Late Transition Deviation Left Axis Counterclockwise Clockwise -90 to 180 90 to 180 Deviation Rotation Rotation -30 to -90• Ventricular • May be normal • Pregnancy • Posterior wall • SometimesRhythm • LPFB • LAFB infarction Normal,• Paced • Pulmonary • WPW • RVH especially inRhythm disease • RBBB women • Pulmonary• Dextrocardia • RVH disease • WPW • Anterior MI• Electrolyte • RBBB • LBBB • LVHderangement • WPW • Hyperkalemia • LAFB • Dextrocardia • Q-waves, MI • LBBB •Venrticular • Lung Disease Rhythm
  45. 45. QRS ComplexLow Voltage – Chronic Cor Pulmonale • Progressive lung disease, leading to right-sided heart failure. – Pericardial Effusion • Fluid in the pericardial sac. – Excessive Obesity
  46. 46. END• UP NEXT, THE T-WAVE

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