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Systematic ECG analysis
This document provides an overview of systematically analyzing an ECG. It discusses the normal components of an ECG including rate, rhythm, axis, P wave, PR interval, QRS complex, QT interval, ST segment, T wave, and other waves. It then examines each component in more detail, providing examples of normal and abnormal findings. Key aspects that could indicate conditions like myocardial infarction, arrhythmias, conduction abnormalities, and structural heart disease are emphasized. The document concludes with sample ECG rhythm and segment interpretation questions.
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Systematic ECG analysis
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- 2. REFERENCES ECG • previous CME talks •Life In The Fast Lane • Dr Smiths ECG blog • Google Image Search • Time on the Floor
- 3. COMPONENTS ECG • Rate • Rhythm •Axis • P • PR • QRS • QT • ST • T • Delta • Epsilon • Osborne • U
- 4. THE NORMAL ECG •Rhythm: <10% variation in R-R intervals • Rate: 60 - 100bpm • Axis -30 - -90 • P Waves • 0.2-0.3mV • 0.06 – 0.12s • Upright in I, II, aVF, V2- V6 • Inverted in aVR • Varies in III, aVLSinus origin • PR Interval • 0.12 – 0.2s • Q Waves • Small in I, II, aVL, V5, V6 • QRS Complex • <0.12s • ST Segment • Isoelectric • T Waves • <2/3 height of preceding R wave • 0.5mm in I, II, III • <10mm in V1 – V6 • Same direction as preceding R wave • U Waves • <25% of T wave • Same direction as T wave • QTc • <440ms in males • <460ms in females
- 5. THE NORMAL ECG Getused to knowing what normal looks like.
- 6. RATE • Small square:0.04sec • Big square: 0.2sec • If it looks fast • 1500/small squares • If it looks slow/normal • 300/big squares • If irregular, count complexes on rhythm strip x 6 for average
- 7. RHYTHM • Regular • Irregular •Regularly Irregular • Irregularly Irregular • P-wave: • Are they present? • Are they regular? • Is there a P for every QRS? • Do the P-waves look similar? • PR Interval • Long? >0.12s • Short? <0.06s • Are the PR intervals Consistent? • QRS • Long? >0.12s • Similar in appearance to each other? • Atrial, AVNRT, Accessory Pathways, Junctional rhythms, Ventricular rhythmas
- 8. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Normal Sinus Rhythm
- 9. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? 1st degree Heart Block
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- 11. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Atrial Fibrillation
- 12. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Atrial Flutter 4:1 block
- 13. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Atrial Flutter
- 14. TO ILLUMINATE THEP WAVES RHYTHM
- 15. CLASSIC LEAD PLACEMENTTHEN WITH LEWIS LEADS RHYTHM
- 16. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? SVT - AVNRT
- 17. SUPRA VENTRICULAR TACHYCARDIAS RHYTHM •A tachydysrhythmia originating above the Bundle of His • Sinus tachy, Atrial flutter, Atrial Fibrillation • Atrio-Ventricular Re-Entry Tachycardia (AVRT) • AV Nodal Re-Entry Tachycardia (AVNRT) • Automatic Junctional Tachycardia
- 18. AVNRT VS AVRT RHYTHM •Left - AVNRT • Right - AVRT (accessory pathway)
- 19. AVNRT • Slow andfast pathway within the AV Node • If a PAC arrives whilst a pathway is refractory, it can allow the other pathway to set up a re-entry pathway within the AV node
- 20. ACCESSORY PATHWAYS AVRT • Orthodromic• Antidromic
- 21. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? AVRT - Orthodromic
- 22. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? AVRT - Antidromic
- 23. VT VS SVTWITH ABERRANT CONDUCTION RHYTHM • VT is more likely when • absence of typical RBBB/LBBB morphology • Very broad complexes (>160ms) • AV dissociation • Fusion beats - when sinus and ventricular beat fuse to cause hybrid complex • Entirely positive or entirely negative complexes throughout V1-6 • Brugada’s - Distance from onset of QRS to nadir of S-wave is >100ms • Josephson’s Sign - notching near nadir of S-wave • RSR complexes w/ Left Rabbit Ear being taller. In contrast Right Rabbit Ear is taller in RBBB
- 24. VT VS SVTWITH ABERRANT CONDUCTION RHYTHM • Fusion then capture • Positive concordance
- 25. VT VS SVTWITH ABERRANT CONDUCTION RHYTHM • Brugada • Josephson’s • RSR in V1
- 26. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Ventricular Fibrillation
- 27. RHYTHM Regular? P waves?PR interval? - long, short, consistent?P for every QRS? QRS? Polymorphic VT
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- 39. WHAT IS ALICHTENBERG FIGURE? RHYTHM QUIZ 11.
- 40. ATRIAL FLUTTER 3:1BLOCK RHYTHM QUIZ 1.
- 41. AVRT - ORTHODROMICWPW RHYTHM QUIZ 2.
- 42. MOBITZ 1 -WENCKEBACH RHYTHM QUIZ 3.
- 43. VT THEN BIGEMINY RHYTHMQUIZ 4.
- 44. TORSADES DE POINTES RHYTHMQUIZ 5.
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- 47. AIVR OR JUNCTIONALRHYTHM WITH LBBB RHYTHM QUIZ 8.
- 48. COMPLETE HEART BLOCK RHYTHMQUIZ 9.
- 49. SHORT PR -WPW RHYTHM QUIZ 10.
- 50. WHAT IS ALICHTENBERG FIGURE? RHYTHM QUIZ 11. They are branching electric discharges that sometimes appear on the surface or in the interior of insulating materials.
- 51.
- 52. AXIS • Normal Axis= -30 - +90 • Left Axis = <-30 • Right Axis = >+90 • Extreme Right Axis = -90 - 180
- 53. AXIS • QRS PositiveDeflection = axis toward that lead • QRS Negative Deflection = axis away from the lead • QRS Isoelectric = Axis perpendicular to that lead
- 54. DIFFERENTIALS AXIS • RAD • RVH •RV Strain • Lateral STEMI • COPD • HyperK+ • Na+ Blockade • WPW • Normal Paeds ECG • LAD • LVH • LBBB • Inf. MI • Ventricular pacing • WPW • Extreme Axis • HyperK+ • Ventricular arrhythmias • Severe RVH
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- 62. WHAT IS COMMOTIOCORDIS? AXIS QUIZ 7.
- 63. LEFT AXIS DEVIATION AXISQUIZ 1.
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- 65. LEFT AXIS DEVIATION- LVH AXIS QUIZ 3.
- 66. LEFT AXIS DEVIATION AXISQUIZ 4.
- 67. RIGHT AXIS DEVIATION- RVH AXIS QUIZ 5.
- 68. RIGHT AXIS DEVIATION AXISQUIZ 6.
- 69. WHAT IS COMMOTIOCORDIS? AXIS QUIZ 7. Commotio cordis (Latin, "agitation of the heart") is an often lethal disruption of heart rhythm that occurs as a result of a blow to the area directly over the heart (the precordial region), at a critical time during the cycle of a heart beat causing cardiac arrest. It is a form of ventricular fibrillation (V-Fib), not mechanical damage to the heart muscle or surrounding organs, and not the result of heart disease. The fatality rate is about 65% even with prompt CPR and defibrillation, and more than 80% without.
- 70. THE P WAVE •P Wave • Width <120ms • Amplitude • <2.5mm limb leads • <1.5mm Precordial • V1 biphasic • aVF inverted
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- 72. THE PR INTERVAL •PR Interval • 120-200ms • Long - any heart block • Short - WPW, pre-excitation • Elevation/Depression - Pericarditis
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- 74. NEGATIVE DEFLECTION BEFORETHE R WAVE THE Q WAVE • They are pathological if: • >40ms wide • >2mm deep • >0.25% QRS • Present in leads V1-V3 • >2mm in leads III/avR can be a normal variant
- 75. NEGATIVE DEFLECTION BEFORETHE R WAVE THE Q WAVE • They are pathological if: • >40ms wide • >2mm deep • >0.25% QRS • Present in leads V1-V3 • >2mm in leads III/avR can be a normal variant
- 76. FIRST POSITIVE DEFLECTIONAFTER THE P-WAVE THE R WAVE • Causes of a dominant R wave in V1 • Normal in paediatric and young adults • RVH • RBBB • Posterior STEMI • WPW • Dextrocardia • HOCM • Dystrophy • Myotonic • Duchennes RVH
- 77. FIRST POSITIVE DEFLECTIONAFTER THE P-WAVE THE R WAVE • Dominant R wave in aVR • Poisoning - Na-Channel Blockers • Dextrocardia • Incorrect lead placement • Commonly in VT TCA poisoning
- 78. FIRST POSITIVE DEFLECTIONAFTER THE P-WAVE THE R WAVE • Poor R Wave Progression - R wave <4mm in V3 • Prior anteroseptal MI • LVH • Inaccurate lead placement • Can be normal variant
- 79. THE QRS • LBBB- depolarisation activated from RV via right bundle then to LV via left bundle • RBBB - Right ventricular depolarisation is delayed and so depolarisation spreads from left to right BUNDLE BRANCH BLOCK
- 80. LEFT VENTRICULAR HYPERTROPHY THEQRS • Muscle wall thickens • Increased S wave in Right sided leads • Increased R wave in Left sided leads • Prolonged depolarisation • Repolarisation abnormalities in lateral leads • Causes • HTN • AR/AS • MR • HOCM
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- 82. RIGHT VENTRICULAR HYPERTROPHY THEQRS • Right Axis • Dominant R in V1 >7mm • Dominant S in V6 >7mm • RV Strain - ST depression in V1-4 and inferiorly • Causes • PE • Chronic Lung Dx • Pulm. HTN • Mitral Stenosis • Congenital Heart Dx
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- 91. THE HEART OFA BLUE WHALE IS ABOUT AS BIG AS A…? QRS QUIZ 7. A. Volkswagen Beetle B. Piano C. Average Person D. Bus
- 92. ANTERIOR Q WAVES QRSQUIZ 1.
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- 95. POOR R WAVEPROGRESSION - LAD OCCLUSION QRS QUIZ 4.
- 96. PATHOLOGICAL Q WAVES- AMI 1/52 PRIOR QRS QUIZ 5.
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- 98. THE HEART OFA BLUE WHALE IS ABOUT AS BIG AS A…? QRS QUIZ 7. A. Volkswagen Beetle B. Piano C. Average Person D. Bus
- 99. REPRESENTS INTERVAL BETWEENVENTRICULAR DEPOLARISATION AND REPOLARIZATION THE ST SEGMENT
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- 102. MODIFIED SGARBOSSA ST SEGMENT STdepression >0.3 height of R wave
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- 104. DONDE ESTA LASTEMI? ST QUIZ 1.
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- 111. AN OCTOPUS HASHOW MANY HEARTS? ST QUIZ 8.
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- 119. AN OCTOPUS HASHOW MANY HEARTS? ST QUIZ 8. 3!!! Two brachial hearts on either side of the body that oxygenate blood by pumping it through the gills One systemic heart pumps blood from gills to the rest of the body
- 120. START OF THEQ TO THE END OF T YOU QT • Represents Ventricular de- and repolarization • Inversely proportional to heart rate • 440ms for males, 460 for females • QT >500ms increases risk of TDP
- 121. VENTRICULAR REPOLARIZATION T WAVES •Can be inverted in V1 and aVR • Flat, Biphasic, Inverted, Peaked, Tented • Look for dynamic change • Don’t miss Wellen’s Syndrome • Hyperacute - early STEMI, prinzmetal Angina • Inverted T - can be normal, MI, BBB, Hypertrophy, PE, HOCM • Biphasic - Ischaemia, Hypokalaemia
- 122. WELLENS’ SYNDROME T WAVES •Inverted or Biphasic T-waves in V2-3 (in patients presenting with ischaemic chest pain) highly specific for critical stenosis of LAD Type A Type B
- 123. DE WINTERS -LAD OCCLUSION T WAVES • Peaked anterior T waves with ascending limb of T wave commencing below isoelectric line - tall, prominent, symmetric • Upsloping ST depression in precordial leads
- 124. DELTA WAVE OTHER WAVES •WPW - pre excitation
- 125. U WAVE OTHER WAVES •Thought to be delayed depolarisation of Purkinje Fibers • Prominent U waves: Bradycardia, Hypo-Ca/Mg, Hypothermia, LVH, HOCM, Digoxin, Class Ia, III antiarrhythmics • Inverted U waves: CAD, HTN, Valvular HD, Congenital HD, Hyperthyroid
- 126. OSBORNE WAVE OTHER WAVES •Positive deflection at J point • Hypothermia, Normal Variant, Hypercalcaemia Hypothermia Temp 32
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- 128. CENTRAL CHEST PAIN QUIZTIME 1.
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- 130. CENTRAL CHEST PAINAND SHORTNESS OF BREATH QUIZ TIME 3.
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- 135. WHAT IS ASHARKS SIXTH SENSE? BONUS POINTS: NAME THE ORGAN THAT DETECTS THIS QUIZ TIME 8.
- 136. DE WINTERS TWAVES - LAD OCCLUSION QUIZ TIME 1.
- 137. HYPERKALAEMIA K+ 9.0- PEAKED T, WIDE QRS, SINE WAVE APPEARANCE QUIZ TIME 2.
- 138. MASSIVE PE -EXTREME RAD, S1Q3T3, RBBB, TWI V1-4 QUIZ TIME 3.
- 139. HYPOTHERMIA TEMP 26- OSBORN WAVES QUIZ TIME 4.
- 140. LBBB - CONCORDANTST DEPRESSION V3 - STEMI QUIZ TIME 5.
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- 142. WIDE QRS, TACHYCARDIA,POSITIVE R WAVE IN AVR - TCA OVERDOSE QUIZ TIME 7.
- 143. WHAT IS ASHARKS SIXTH SENSE? BONUS POINTS: NAME THE ORGAN THAT DETECTS THIS QUIZ TIME 8. They can sense electricity! Ampullae of Lorenzini
- 144.
Editor's Notes
- #4 Aim to practice some pattern recognition Keep it simple stupid Practice parts at a time Know what normal is
- #8 systematic approach for working out rhythm
- #9 Normal Sinus Rhythm
- #10 1st degree heart block
- #12 Atrial Fibrillation
- #13 Atrial Flutter
- #14 atrial flutter - more subtle on purpose to illustrate a point
- #17 AVNRT
- #22 AVRT - Orthodromic
- #23 AVRT - Antidromic
- #26 Nadir = lowest point
- #30 Flutter 3:1
- #31 AVRT - Orthodromic
- #32 Wenckebach
- #33 VT then Bigeminy
- #34 Torsades
- #35 AF
- #36 VF
- #37 AIVR
- #38 complete heart block
- #39 WPW - Short PR
- #53 17 ways to skin a cat - this is one of them
- #57 LAD
- #58 Normal Axis
- #59 LAD
- #60 LAD
- #61 RAD
- #62 RAD
- #72 V1 can have biphasic T
- #82 S wave in right leads R wave in left leads
- #84 Dominant R in V1 Dominant S in V6 ST Depression V1-V4 RAD
- #86 anterior Q waves
- #87 RBBB
- #88 LVH
- #89 Poor R wave progression
- #90 Pathological Q waves
- #91 LBBB
- #105 Lateral STEMI
- #106 Inferior STEMI
- #107 Pericarditis
- #108 Posterior STEMI
- #109 Anterior STEMI
- #110 Inferior STEMI
- #111 Anterolateral
- #129 De-Winter’s T Waves
- #130 Hyperkalaemia
- #131 PE
- #132 Osborn
- #133 LBBB w/ STEMI
- #134 Pericarditis
- #135 TCA