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ECG made easy
- 1. How to readECG? Ahmed Elborae, MSc, MD, PhD, MRCP UK (London) Assistant Lecturer of Cardiology, Cairo University
- 2. A 45-year-old malepatient, presenting to ER with chest pain
- 3. ECG “Electrical activity” Echocardiography “Ultrasound imaging” Angiography “Coronarysupply” A single modality rarely gives the whole truth Simple Rapid Cheap Available
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- 5. SA node Right atrium SAnode Right Left
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- 7. AV node-His-Purkinje system AVconduction
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- 11. How to recordour heart electricity?
- 12. ECG machine 4 cablesfor upper and lower limbs 6 cables for the chest
- 13. Right Left 4 Limbelectrodes x Where to place ECG Leads ? Fire > Not seen Desert > Green
- 14. Where to placeECG Leads ? 6 Chest electrodes 4th space 5th space
- 15. V1,V2 V3,V4 V5,V6 Capturing the sameobject from different angles…
- 16. Depolarization Vector ofventricles towards electrode Depolarization Vector of septum away from electrode Positive deflection (R wave) 1st negative deflection (Q wave) 3 Depolarization Vector of the base of heart away from electrode Negative deflection after R (S wave) How it looks from V6?
- 17. Depolarization Vector ofventricles away from electrode Depolarization Vector of septum towards electrode Negative deflection after R (S wave) 1st Positive deflection (R wave) How it looks from V1?
- 18. 12 leads? 6 Limbleads 6chest leads x How these 3 limb electrodes gives 6 leads? Einthoven’s triangle
- 19. 3 Augmented unipolarLimb Leads aVR aVL aVF
- 20. How QRS looksfrom unipolar limb leads?
- 21. 3 Bipolar LimbLeads = record the difference Lead Lead Lead Downward & to the left aVR aVL aVF
- 22. How QRS looksfrom Bipolar limb leads?
- 23. Lead I =LA - RA Lead II = LL - RA Lead III = LL - LA Where is the zero point? (Lead III + Lead I) - Lead II = Zero Lead III + lead I = LL – LA + LA – RA Lead III + Lead I = LL – RA = Lead II
- 24. Localization of limbleads aVR Inferior wall Lateral wall
- 25. 6 Precordial Leads(Camera)
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- 27. 12 leads ECGpaper 6 Limb leads 6chest leads We are commenting on Duration and Voltage of waves
- 28. Duration on theECG paper 40 ms 200 ms One small square here = 40 millisecond on the earth
- 29. Voltage on theECG paper One small square 10 small boxes =Two large boxes 2 large 1 mv Usual Half volt. Double volt. 1 large 1 mv 4 large 1 mv 2 large =1 mv
- 30. How to readECG? Systematic approach
- 31. Systematic approach 1- Rhythm Sinus AF RegularR-R, each P followed by QRS, normal PR interval Irregular R-R, absent P waves, fibrillation waves
- 32. 2- Rate Rule of300 (in regular rhythm only) Each minute contains 300 large squares So, HR = 300 / R-R interval in large boxes So, heart rate here is 300/3 = 100 bpm
- 33. 6 second Rule (Irregularrhythm) No. of complexes in 6 second (30 large squares) x 10 0 1 2 3 4 5 6 7 So, heart rate here =7x10= 70 bpm
- 34. 3-Cardiac axis Lead I= X axis aVF = Y axis
- 35. Lead I aVF Normalaxis Right axis Left axis Extreme axis Cardiac axis
- 36. 4-ECG voltage Normal voltage:QRS amplitude > 5 mm in limb leads ,> 10 mm precordial leads Low voltage: QRS amplitude < 5 mm in all limb leads
- 38. 5-Comment on -Waves( P,QRS,T)voltage& duration -Segments (PR,ST) deviation -Intervals (PR,QT) time
- 39. Normal P- wave •Positive in lead II, biphasic in V1 • Duration less than 3 small squares • Amplitude less than 2.5 small squares Right atrium Left atrium
- 40. ECG pattern ofatrial enlargement Left atrium Right atrium Normal V1 Lead II Lead II
- 41. PR interval (AV conduction) PRsegment P wave < 120 ms 120-200 ms > 200 ms Wolff-Parkinson-White Normal (3-5 ss) 1st degree heart block
- 42. QRS (Morphology, duration,voltage) Poor R wave progression (R in V3 < 3 small squares) might denotes anterior ischemia
- 43. Pathological Q waveof MI Pathological = More than 1x1 small squares Pathological Q = Black hole
- 44. QRS duration < 100ms 100-120 ms > 120 ms Normal Incomplete bundle branch block BBB Ventricular beat
- 45. BBB LBBB:M shaped V6 RBBB:M shaped V1
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- 48. ST Segment Elevation Earliestreliable sign of STEMI
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- 50. Other causes ofST elevation e.g. Brugada syndrome Syncope Sudden death in young
- 51. ST Segment Depression Myocardialischemia or NSTEMI (ST≥ 0.5 mm) Depression are not localizing
- 52. How to diagnoseMI in LBBB?
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- 54. T wave inversion •Ischemia (deep, symmetrical) • Strain with hypertrophy • 2ry to BBB • Hypokalemia • Intracranial hge (Very deep)
- 55. Hyper acute Twave • Ischemia (Early STEMI) • Hyperkalemia • Hypertrophy
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- 57. QTc interval < 440ms > 440 ms Normal Long QT Long QT Bazzet formula
- 58. How to readECG? Rapid focused approach
- 59. Focused approach 1- Ischemia(Q wave, ST segment , T wave),localization 2- Arrhythmia: 4 items to reach diagnosis (Rate, rhythm, P-QRS relation, QRS duration)
- 60. 46 male presentingto ED with chest pain Ischemia (Q wave, ST, segment, T wave), localization
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- 62. 65 male, presentingto ED with chest pain Ischemia (Q wave, ST, segment, T wave), localization
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- 65. De winter ECG(MI equivalent) -- Proximal LAD Depressed J point + hyper acute T wave
- 66. Wellen ECG (MIequivalent) -- Proximal LAD Type 2 > Biphasic T wave Type 1 > deep symmetrical T wave inversion
- 67. (Left main ormulti-vessel occlusion equivalent) Diffuse ST depression+ aVR ST elevation
- 68. Posterior wall MI TallR in v2,V3+ ST depression Mirror image Posterior leads
- 69. 40-year-old , acutedyspnea 1 week post-partum C/S Pulmonary embolism Tachycardia, S1Q3T3, tall R in aVR, RV strain (Inverted T in precordial leads)
- 70. Heart rate Slow Tachycardia Normal P-QRS relation Progressive PR Prolongation MobitzI Multiple P Followed by QRS Fixed PR Mobitz II No relation between P /QRS Complete AV block Multiple P Followed by QRS Atrial flutter 1-QRS duration Narrow Wide 2-Rhythm 2-Rhythm Regular Regular Irregular Irregular 3-P-QRS relation VT SVT+BBB AF+WPW AF+BBB Multiple P Followed by QRS Atrial flutter QRS followed by P Or no P SVT Multiple P Followed by QRS Atrial flutter+ variable block Absent P Atrial fibrillation P-QRS relation Absent P Irregular Atrial fibrillation
- 71. 33-year-old athlete, routineECG Slightly bradycardic, group beating, progressive PR prolongation then dropped beat, narrow QRS x x
- 73. 73-year-old lady, presentingto ER with syncope Bradycardia, multiple P followed by QRS with fixed PR interval, narrow QRS x x x x x x
- 75. 75-year-old gentleman, presentingto ER with delirium Bradycardia, multiple P followed by QRS with variable PR interval (Complete AV dissociation)
- 77. 77 female presentingto ED with palpitations (Rate, rhythm, P-QRS relation, QRS duration) Normal rate, irregular, absent P wave, narrow QRS
- 79. 60 female, presentingto ED with palpitations (Rate, rhythm, P-QRS relation, QRS duration) Normal rate, regular, Multiple P waves followed by QRS, narrow QRS
- 81. 20 female, presentingto ED with palpitations (Rate, rhythm, P-QRS relation, QRS duration) Tachycardia, regular, P wave after QRS, narrow QRS
- 83. 55 male IHD,presenting to ED with palpitations (Rate, rhythm, P-QRS relation, QRS duration) Tachycardia, regular, P wave after QRS, wide QRS
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- 86. 25 male, presentingto ED with dizziness Very fast tachycardia, irregular, no clear P waves, wide QRS (Rate, rhythm, P-QRS relation, QRS duration)
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- 88. Hyperkalemia (Sine wave) 65-year-oldESKD, missed dialysis session, confused Hyperkalemia stretch ECG (PR, QRS, T wave)
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