Abnormal ECG

1. Importance of ECG in ICU care

2. Chest (Precordial) Leads
Wilson’s Central terminus
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK549803/

3. The Precordial (Chest) Leads

5. The Precordial (Chest) Leads
V2
V1 V3
V4
V5
V6
-
-
+ +
+
+

14. Why is the T-wave
concordant (Same
direction) as the
QRS complex?

17. Effect of lead placement on recording

18. Sinus Rhythm

19. Clinical applications of ECG
Diagnosis of acute coronary insufficiency (angina, infarction)
Diagnosis of conduction defects of the heart and detection of arrhythmia
Detection of electrolyte imbalances
Assist in detection of atrial and ventricular hypertrophy
Assist in clinical management of all patients in ICU
Preoperative risk assessment of surgical interventions
Monitor the treatment of arrhythmia
Screening for high risk employment and sports activity

20. Case 1
18 year old male referred by his Psychiatrist for an ECG

21. Case 2
28 year old with rash, Febrile illness and Light-headedness

22. Case 3
24 year old male with chief complaint of palpitations

23. Case 4
20 year old Male had Syncopal Episode while playing football

24. Case 5
22 year old woman had Chest pain and SOB

25. Case 6
20 year old woman with anorexia and vomiting

26. ECG Features
I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave

27. ECG Placement
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

28. Case 1
18 year old male referred by his Psychiatrist for an ECG

29. ECG Findings
o QRS in Lead I
• Negative (RAD)
o P wave in Lead I
🢝 Negative
o R Waves Precordial
🢝 Normal progression
o Reversed Arm Leads
◾ Left Arm-Right Arm
Lead I
Precordial Leads
Case 1
18 year old male referred by his Psychiatrist for an ECG (Cont..)

30. Dextrocardia

31. ECG Features
I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave

32. Interval Measurement
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

33. How to Estimate HR:
1) 30 Large Boxes = 6 seconds
 HR = # QRS or P wave x 10
4x10
40/min
16x10
160/min
Rate
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

34. 2) RR Interval (# Big Boxes)
• HR = 300 150 100 75 60 50 43 37 33 30
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10
#7
43/min
#2
150/min
Rate
How to Estimate HR:
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

35. ▣ Normal
60-100/min
▣ Bradycardia
◾ <60/min
▣ Tachycardia
◾ >100/min
▣ Seattle Criteria: Abnormal ECG findings in
Athletes
 Profound bradycardia <3 0min
 Sinus pauses > 3 seconds
ECG finding Definition
Profound sinus
bradycardia
< 30 BPM
Sinus pauses ≥ 3 sec
Rate
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

36. ECG Features
I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave

37. ▣ Normal
◾ Sinus
Rhythm

38. ▣ Sinus
◾Sinus Arrhythmia
◾Sick Sinus Node
▣ Atrial
◾Atrial Fibrillation
◾Atrial Flutter
◾Multifocal Atrial Tachycardia
◾Paroxysmal Atrial tachycardia
Rhythm
▣ AV Node
◾Junctional
◾AV Block
▣ Supraventricular
◾Supraventricular Tachycardia
▣ Ventricular
◾VF/VT
▣ Pacemaker
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

39. Case 2
28yo W with Rash, FLI and Lightheadedness

40. ▣ ECG Findings:
◾ 3rd degree AV Block
◾ Complete AV dissociation
Case 2
28yo W with Rash, FLI and Lightheadedness (Cont..)

41. ▣ Lyme
◾ Cardiac involvement in early disseminated stage
◾ Average 21 days from EM
◾ Conduction system disease:
 AV node block
🢝 1st, 2nd, 3rd AV block
 Unresponsive to Atropine
 Usually benign and self-limiting
 May require temporary pacemaker
Rhythm: Lyme Carditis
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

42. ▣ Atrial Fibrillation
▣ Atrial Flutter
▣ Junctional
▣ SVT
Rhythm

43. ▣ First Degree AV Block
▣ Second Degree AV
Block Type 1
▣ Second Degree AV
Block Type 2
▣ Third Degree AV Block
Rhythm

44. ▣ Ventricular Fibrillation
▣ Ventricular Tachycardia
▣ Torsade de Pointes
Rhythm

45. ▣ Normal Variant findings in Asymptomatic Athletes
◾ Sinus arrhythmia
◾ Ectopic atrial rhythm
◾ Junctional escape rhythm
◾ 1° AV block (PR interval > 200 ms)
◾ Mobitz Type I (Wenckebach) 2° AV block
ECG Finding
Sinus arrhythmia
Ectopic atrial rhythm
Junctional escape rhythm
1° AV block (PR interval > 200 ms)
Mobitz Type I (Wenckebach) 2° AV block
Rhythm: Seattle Criteria
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

46. Abnormal ECG findings in Athletes
ECG finding Definition
2° AV block
Mobitz type II
h
Intermittently non-conducted P
waves
No PR prolongation and PR
shortening
3° AV block Complete heart block
Atrial
tachyarrhythmias
SVT, AF, Atrial Flutter
PVCs ≥ 2 PVCs per 10 second tracing
Ventricular
arrhythmias
Couplets, triplets, and non-
sustained ventricular tachycardia
Rhythm: Seattle Criteria
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

47. ECG Features
I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave

48. Electrical Axis

49. Normal (-30 - +100)
◾ Lead I
◾ Lead AVF
R+
R+
Electrical Axis

50. ▣ LAD (>-30)
◾ Lead I
◾ Lead AVF
R+
neg (rS, QS)
▣ RAD (>+100)
neg (rS)
R+
Electrical Axis
◾ Lead I
◾ Lead AVF

51. Abnormal ECG findings in Athletes
 LAD -30° to -90°
 RAD > 120° with RVH pattern (R-V1 + S-V5 > 10.5 mm )
ECG finding Definition
LAD -30° to -90°
RAD with RVH pattern > 120°
R-V1 + S-V5 > 10.5 mm
Electrical Axis: Seattle Criteria
Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549803/

52. ECG Features
I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave

53. ▣ Atrial Contraction
▣ Normal
◾ <2-3 mm amplitude
◾ <0.11 second width
◾ Gently rounded
◾ Upright in I, II, AVF, V4-6
◾ Inverted in AVR
◾ Diphasic or inverted in III
◾ Variable in AVL, V1-2
P Wave

54. ▣ Atrial enlargement/dilatation
P Wave
◾ Increased Amplitude (>2-3mm)
◾ Increased Width (>0.12 second)
▣ Ectopic atria or AV junctional
◾ Inversion
▣ Absence
◾ AV junctional
◾ SA block

55. ▣ P-mitrale/LAE
◾ Diphasic
 2nd half negative V1 (>1mm)
 Wide (>0.04s)
◾ Notched
 Wide, notched I, II (>0.12s)
 Tall I>III
▣ Seattle Criteria:
 LAE
Abnormal ECG finding
LAE
P Wave

56. ▣ P-pulmonale/RAE
◾ Peaking
 Pointed II, III, AVF
 Tall III>I
P Wave

57. I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave
ECG Features

58. ▣ Beginning P wave to beginning QRS
▣ Atria through AV junction
▣ Normal
◾ 0.12-0.20 second
PR Interval

59. ▣ Prolonged
- Normal variant
- AV block
- Hyperthyroidism
- Lyme disease
▣ Shortened
◾ Normal variant
◾ AV junctional
◾ WPW
◾ LGL syndrome
◾ Fabry, collagen storage
◾ Pheochromocytoma
◾ Hypertension
PR Interval

60. Case 3
24yo M c/o Palpitations

61. ▣ ECG Findings:
◾ Short PR< 0.12 seconds
◾ Delta wave
Case 3
24yo M c/o Palpitations (Cont..)

62. ▣ WPW
◾ General
 0.2% Population
 Accessory AV pathway (Kent bundle)
 Tachyarrhythmia
◾ Clinical features
 Asymptomatic
 Palpitations
◾ ECG Features
 PR< 0.12 seconds
 QRS> 0.10 seconds
 Delta wave
PR Interval: WPW

63. ▣ WPW
◾ General
 0.2% Population
 Accessory AV pathway (Kent bundle)
 Tachyarrhythmia
◾ Clinical features
 Asymptomatic
 Palpitations
◾ ECG Features
 PR< 0.12 seconds
 QRS> 0.10 seconds
 Delta wave
PR Interval: WPW

64. Abnormal ECG findings in Athletes
◾ Ventricular pre-excitation
 PR interval < 0.12 s
 Delta wave
 Wide QRS (> 0.12 s)
ECG finding Definition
Ventricular pre-excitation PR interval < 0.120 s
Delta wave
Wide QRS (> 0.120 s)
PR Interval: Seattle Criteria

65. I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave
ECG Features

66. ▣ End P wave to beginning QRS
▣ Normal
◾ Isoelectric
▣ Displaced
◾ Atrial infarction
◾ Acute pericarditis
PR Segment

67. I. Rate
II. Rhythm
III. Axis
IV. P wave
V. PR interval
VI. PR segment
VII. QRS complex
VIII.ST segment
IX. T wave
X. QT duration
XI. U wave
ECG Features

68. ▣ Ventricular depolarization
▣ Normal
◾ Duration
 Limb: 0.05 - 0.10 s
 Chest: 0.06 - 0.12 s
◾ Amplitude
 Limb: >5 mm
 Chest: >10 mm
 <20-30mm
◾ Q wave
 Normal but Small (<0.03 second)
 V5-V6, II, III, AVF
ECG Features

69. • Wide
◾ Bundle Branch Block
◾ Drugs
• Low Voltage
◾ Normal variant
◾ Obesity
◾ Emphysema
◾ Pericardial effusion
◾ Pleural effusion
◾ Hypothyroidism (myxedema)
• High Voltage (LVH)
◾ Hypertension
◾ Hypertrophic cardiomyopathy
QRS Complex

70. ▣ SV1 + RV5 or RV6
 >30yo
 20-30yo
 16-20yo
◾ >35mm
◾ >40mm
◾ >60mm
▣ Precordial R + S >45mm
OR
▣ R Lead I >14mm
OR
▣ R aVL >12mm
QRS Complex: LVH Criteria

71. >10.5 mm
▣R V1 + S V5
▣RAD
QRS Complex: RVH Criteria

72. Case 4
21yo M with Chest Pain

73. ▣ ECG Findings:
◾ LVH
◾ ST segment elevation
◾ T wave inversion
Case 4
21yo M with Chest Pain (Cont..)

74. ▣ 2-5/1000
▣ Gene mutations
◾ MYH7 or MYBPC3 genes
▣ Clinical presentation
◾ Dyspnea
◾ Chest pain
◾ Syncope
◾ Sudden death
▣ ECG
◾ LVH 80-90%
◾ ST segment elevation
◾ T wave inversion
◾ Q waves septal
◾ Arrhythmias e.g. AF
QRS Complex: HOCM

75. Case 5
43yo Laotion M with Atypical Chest Pain,
Normal Coronary Angiography

76. ▣ ECG Findings:
◾ Right precordial (V1-3)
 ST elevation
 T wave inversion
Case 5
43yo Laotion M with Atypical Chest Pain,
Normal Coronary Angiography (Cont..)

77. ▣ Brugada Syndrome
◾ 5/10,000
◾ Autosomal dominant
 Na channel mutations
◾ Clinical presentation
 Male predominance
 Endemic in Southeast Asia
 Sudden unexpected nocturnal death syndrome
ST Segment: Brugada
El Sayed M, Goyal A, Callahan AL. Brugada Syndrome. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519568/

78. ▣ Brugada Syndrome
◾ Right precordial ST
elevation (V1-3)
+
◾ One or more
 Documented VT/VF
 Unexplained syncope
 Nocturnal agonal
breathing
 Inducible VF
 Family history of sudden cardiac
death <45yo or coved ECG
ST Segment: Brugada
El Sayed M, Goyal A, Callahan AL. Brugada Syndrome. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519568/

79. Case 6
16yo Female with Anorexia and Vomiting

80. ▣ ECG Findings
◾ Prolonged QT interval
◾ Flat T wave
◾ Prominent U wave
▣ Hypokalemia
Case 6
16yo Female with Anorexia and Vomiting (Cont..)

81. Thank You