ECG workshop ( road to master the ECG )

1. THE SECRET OF ECG
Imtinan Mohammed Barnawi
4 /8 /2017

2. Aim and learning objectives
Aim:
Giving you the interpretation eye glasses and find out the secrete inside the heart.
Learning objectives:
■ To review our heart mechanism of action) action potential(.
■ To find out the secret of the ECG.
■ To draw our maps when we deal with the ECG.
■ To detect and correlate the alerting sign inside one ECG paper.
2

3. Outlines
■ Heart dynamics, action potential
■ Heart pacemaker
■ Electrocardiogram, indication, fixation.
■ Basics steps to read ECG.
■ The most common abnormalities in the ECG.
■ Case scenarios.
3

4. Heart dynamics, action potential
1. Automaticity ( generation of action potential ):
■ All the cardiac cells have ability to initiate the action potential by it self then will
be spread throw out the heart and other cardiac cell throw the gap junction.
■ But there are three main generator of the action potential in the heart as they
have higher frequency so dominant:
1. SA node: higher rate ( 100/ min )
2. AV node: second highest rate ( 40 – 60 / min )
3. Purkinje cells: third highest ( 35 / min )
4

5. 5

6. Heart dynamics, action potential
2. conduction:
6

7. Heart dynamics, action potential
2. conduction:
SA
Atrium
(rt then left)
AV (delay)
Bundle of
his (
rt and left )
Septum
Left
ventricle
then rt
ventricle
7

8. Heart dynamics, action potential
Phase Action comment
0 Na+ in Positive intracellular
Depolarization
QRS
1 Na+ channel
inactive
K+ out
Transient
2 Ca+ in
K+ out
Plateau
ST segment
3 K+ out fast Repolarization
T waves
4 Na – K ATPas
K + in
Resting
8
ventricles

9. Heart dynamics, action potential
Phase Action Comment
0 Ca + in Depolarization
3 K+ out Repolarization
4 Na+ - K+ ATPas Resting
9
SA node

10. ■ Pacemaker of the heart is:
SA node because of ….............
Heart dynamics, action potential
10

11. Puzzles
• Stimulate opening of Ca+ channel.
• Fast rapid influx of Ca+
• Stimulate opening of K+
channel
• Fast rapid efflux of K+
• HyperpolarizationCatecholamine
ACH
11
- ve Chrono
and
dromotropy
+ve Chrono
and
dromotropy

12. ECG = Electrocardiogram
12

13. 13

14. What is that?!
■ This is one of the toll that used to detect the electrical function of the heart.
■ The heart produce electricity and the ECG device connected to the patient in certain
way to detect that electricity.
14

15. When we should use it?!
■ Any clinical scenario we need to approach it, we depend mainly on History
and kind of clinical exam but regarding the investigation will help only to
support the suspected diagnosis.
■ Indications:
1. Chest pain
2. Palpitation
3. SOB
4. Dizziness
5. Syncopal attack.
15

16. How to use it?!
■ Consist of:
1. 6 chest leads
2. 3 limb leads
3. Reading device
16

17. How to use it?!
■ Fixation
17

18. Representation
18

19. How the lead detect the electricity and give waves?!
■ Any electricity directed toward that lead will be detected positive
■ Any electricity detected away from that lead will be negative
19

20. 20
How to approach it ??

21. 21
25 / mm
30 year old ( Fatimah )

22. 1. This is 12 lead ECG for lady 30 year old ( Fatimah )
2. Date 5/8/2017, Friday.
3. Normal speed and calibration
4. Regular rhythm
5. 60 beat / min
6. Normal axis
7. Sinus rhythm
8. Narrow QRS complex
9. Normal P-R interval
10. Normal ST and QT interval
11. NormalT waves
Impression: Normal ECG
22

23. 2325 / mm
25 year old ( Ahmed )

24. 1. This is 12 lead ECG for male 25 year old ( Ahmed )
2. Date Date 5/8/2017, Friday
3. Normal speed and calibration
4. Regular rhythm
5. 300 beat / min
6. Normal axis
7. Non- sinus ( no p– wave )
8. Narrow QRS complex.
9. Normal ST
10. NormalT waves
Impression: SVT ( junctional tachycardia )
24

25. Steps to draw our maps when we deal with the ECG.
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26. 26

27. 1- Personal data, date and day.
27

28. 2- dose this is standard or not?!
■ 12 lead ECG.
■ Speed: 25 mm / min
■ Calibration: 1 MV = 1 cm = 10 mm = 2 large square
28

29. 2- dose this is standard or not?!
29

30. 3- Rhythm
Rhythm
Regular Irregular
Regular – Irregular
Irregular – Irregular
30

31. 3- Rhythm
Irregular
Irregular – irregular
AF
Regular – irregular
Normal
Sinus Arrhythmia (
respiration )
Abnormal
31

32. 32
3- Rhythm
2

33. 33
3- Rhythm
2

34. 34
3- Rhythm

35. 35
3- Rhythm

36. 4- Rate
Rhythm
Regular
Number of
squares
300 / large
Or
1500 / small
Irregular
Number of R in 60 s * 10
36

37. 4- Rate, Regular
37

38. 4- Rate, Irregular
38

39. 4- Rate
39
Rate
Tachycardia
Regular
Irregular
Bradycardia
Regular
irregular

40. 4- Rate
40
Tachy
Regular
- Hyper dynamic
circulation
- Hypovolemic shock
- Atrial flutter
- SVT
Irregular
Atrial
fibrillation

41. 41
35 years old male presented to ER with history of runny nose, cough
documented fever of 39 degree and palpitation.

42. 42
45 male presented to ER with history of 2 hours palpitation he known to
have heart failure on digoxin and he was unsure about the previous dose and
he take another dose.

43. 43
50 years old known case of hypertension long standing 20 years not compliant to
medication presented to ER with history of palpitation, irritability and SOB on
examination the GCS is 12 over 15

44. 4- Rate
44
Brady
Regular
- Physiological
- Hypothyroidism
- Hypothermia
- 1st and 3rd degree heart
block
Irregular
- Irregular regular ( sinus
arrhythmia )
- Irregular regular ( AF )

45. 45
35 years old male known Olympic swimmer came to the hospital for
routine check up.

46. 5- Axis
46

47. 5- Axis ■ How to know positive or negative
47

48. 5- Axis
■ Normal
■ Rt deviation
■ Left deviation
■ Rt extreme axis deviation
■ And DD
48

49. 49

50. 50

51. 5- Axis
51

52. 5- Axis, DD
Rt axis deviation Left axis deviation
Rt extrema axis
deviation
• Rt ventricular
hypertrophy
• Left posterior fascicle
block
• Lung disease acute or
chronic
• Left ventricular
hypertrophy
• Left anterior fascicle
block
• Tricuspid atresia
• Sever RVH
52

53. 6- P wave ( sinus or not, abnormal size )
■ Size ( 1mm tall and 0.04 width, accepted up to 2 )
■ Shape
■ P : QRS
■ Positive or note.
53

54. ■ Sinus
1. Same shape.
2. Each p followed by QRS.
3. Each QRS preceded by P wave.
4. Positive in lead 1,2 and chest lead and Negative in
AVR, lead 3 and some time inV1.
5. Normal rate and rhythm and normal PR interval.
Why AVR have negative reading P, QRS andT ?!
6- P wave ( sinus or not, abnormal size )
54

55. 55
1

56. Tall
• P pulmonal
• Rt atrium
enlargement
Wide
• P mitral
• Left atrium
enlargement
6- P wave ( sinus or not, abnormal size )
56

57. 57

58. 58

59. 7- QRS
■ Duration ( width ) = 3 small square = 0.12 sec = 120 ms
■ Pattern
■ Amplitude
59

60. 7- QRS
Wide
Rate & Rhythm
abnormality
Conduction
abnormality
60

61. 7- QRS
Rate & Rhythm
abnormality
Tacy & normal rhythm
Ventricular tachycardia
Normal rate & abnormal rhythm
Escape or premature
61

62. ■ Example
62

63. 63

64. 64

65. 65

66. conduction:
SA
Atrium ( rt
then left )
AV ( delay )
Bundle of
his ( rt and
left )
Septum
Left
ventricle
then rt
ventricle
66

67. 67

68. 7- QRS, pattern and amplitude
68

69. 7- QRS, pattern and amplitude
69
1

70. 7- QRS
Conduction abnormality
RBBB LBBB
70

71. 71
3

72. 72

73. ■ Increase the amplitude in the same or reverse pattern indicate increase
the muscle mass that mean increase the power and electricity need to
produce appropriate depolarization then appropriate contraction.
7- QRS, pattern and amplitude
73

74. Ventricular hypertrophy
RT Left
7- QRS, pattern and amplitude
74

75. 75

76. Ventricular hypertrophy
RT
Sum of R inV1 and S inV6 =
more than 25
Left
R inV6 = more than 25
S inV1 = more than 35
7- QRS, pattern and amplitude
76

77. 77
4

78. 78
5

79. 8- Q wave
■ Usually either absent or less than 1mm vertical, 0.04 s width
■ If prominent mean old MI and location depend in which lead
the Q wave prominent
79

80. 80

81. 9- PR interval
■ Duration = 3 – 5 small square = 120 – 200 ms
■ Reflect conduction of electricity:
from SA node atrium to AV and ventricle if prong indicate poor conduction
81

82. 9- PR interval
First
• fixed prolong PR
interval
• No drop
Second
• Mopit 1: variable
prolongation then
drop
• Mopit 2: fixed
prolong PR interval
with drop
Third
• Dissociation
• No conduction at all
• Different atrial and
ventricle rate
82

83. 83

84. 84

85. 85

86. 86

87. 10 - ST segment
ST
Normal Elevation
More than 3 small
square= 3 mm
Depression
More than 3 small
square= 3 mm
87

88. 10- ST segment
elevation Depression
STEMI
Pericarditis
Non stable angina
Non- STEMI
88

89. Tricks
■ To confirm that really STEMI : check of site then check the reciprocal
effect
Reciprocal effect
Anterior Inferior
Inferior Lateral
Posterior Lateral
89

90. 90

91. 91

92. 92

93. 93

94. 94

95. 95

96. 96
25 years old lady presented to ER with chest pain for 2 hours duration that persistent
not related to breathing with history of preceded URTI on examination there is normal
S1 and S2 no murmur and positive friction rub.

97. 97
25 years old lady presented to ER with chest pain for 2 hours duration that persistent
not related to breathing with history of preceded URTI on examination there is normal
S1 and S2 no murmur and positive friction rub.

98. 11-T wave
■ Peaked = 5 small square ( limb lead ) = 5 mm ( 1 large )
= 10 small square ( chest lead ) = 10 mm ( 2 large )
■ Flat, small or abnormal
■ Inverted
98

99. peaked flat Inverted
Hyperkalemia
Hypomagnesemia
Early MI
Hypokalemia
Ischemia
Pericarditis
cardiomyopathy
11-T wave, DD
99

100. 100

101. 101

102. 102

103. 103

104. 104

105. Road map for ECG
1. Personal Data, day and date.
2. Standardized or not.
3. Rhythm
4. Rate
5. Axis
6. P wave
7. QRS
8. Q wave
9. PR interval
10. ST segment
11. T waves
105

106. Case scenario 1
Mr. Abdullah, a 55-year-old male businessman, a known case of DM and HTN,
presented to the ER at Al-Noor Specialist Hospital complain of chest pain of 1 day
duration.
He was in his usual state of health until 1 hour prior to presentation when he had a
sudden onset of central retrosternal, dull aching chest pain.This pain was associated
with mild shortness of breath increased by activity and decreased by rest.
The pain progressive in nature with recurrent attacks for the last 8 months.
106

107. 10725 mm / s
6

108. 108
1. This is 12 lead ECG for 55 year old businessman (Abdullah )
2. Date 5/8/2017, Friday.
3. Standard speed and calibration
4. Regular rhythm
5. 80 beat / min
6. Normal axis
7. Sinus rhythm
8. Narrow QRS complex
9. Q wave significant in ( 2, 3 and avf )
10. Normal P-R interval
11. ST elevation (V2,V3 andV4 )
12. T inversion ( AVF ).
Impression: Acute Antro - septal MI with old inferior MI

109. 10925 mm / s
6

110. Case 2
110
7
25 mm / s

111. 111
1. This is 12 lead ECG for 60 year man
2. Date 5/8/2017, Friday.
3. Standard speed and calibration
4. Regular rhythm
5. 75 beat / min
6. Normal axis
7. Sinus rhythm
8. Narrow QRS complex
9. Q waves ( 2, 3 and AVF )
10. Normal P-R interval
11. ST isoelectric
12. T inversion ( 2, 3 and AVF ).
Impression: Inferior MI ( more than 48 h )

112. Case 2
112
7
25 mm / s

113. Case 3
11325 mm / s
8

114. 114
1. This is 12 lead ECG for 20 year lady
2. Date 5/8/2017, Friday.
3. Standard speed and calibration
4. Regular – irregular rhythm
5. 70 beat / min
6. Normal axis
7. Sinus rhythm
8. Narrow QRS complex
9. Normal P-R interval
10. ST isoelectric
11. T normal
Impression: sinus arrhythmia ( musculoskeletal pain )

115. Case 3
11525 mm / s

116. 11625 mm / s
9
Case 4

117. 117
1. This is 12 lead ECG for 30 year man
2. Date 5/8/2017, Friday.
3. Standard speed and calibration
4. Regular rhythm
5. 50 beat / min
6. Normal axis
7. Sinus rhythm but bifid P waves
8. QRS;V1 S= 28 mm and inV6 R = 24
9. Normal P-R interval
10. ST isoelectric
11. T inverted ( 1, avl,V5 and 6 )
Impression: left ventricular hypertrophy with left atrial
enlargement

118. 11825 mm / s
9
Case 4

119. Case 5
119
40 year old lady known to have DM for 10 years represent with long
standing palpitation.

120. 120
1. This is 12 lead ECG for 40 year lady
2. Date 5/8/2017, Friday.
3. Standard speed and calibration
4. Irregular – irregular rhythm
5. 90 beat / min
6. Normal axis
7. Absent P waves
8. QRS normal
9. ST isoelectric
10. T inverted
Impression: chronic AF

121. Case 5
121

122. Secret winner
122

123. 123
D

124. 124
B

125. 125

126. This will never be like magic
for you but you will read it
and fined the secret inside
like magic
126

127. 127