advanced ecg interpretation - shaconferences · advanced ecg interpretation for nurses adel a....
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Advanced ECG Interpretationfor Nurses
Adel A. Hasanein, RN, BSN Academic Coordinator
NED‐KFMC
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OutlineOutline
• ECG leads• Ischemic Changes• The ECG in ST Elevation MI• Bundle Branch Blocks and Chambers
Enlargement
Adel Hasanein
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ECG leads
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Arrangement of Leads on the ECGArrangement of Leads on the ECG
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Normal 12 leads ECGNormal 12 leads ECG
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ECG AbnormalitiesECG Abnormalities
Associated with ischemia
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Ischaemic ChangesIschaemic Changes
• S‐T segment elevationS T segment elevation• S‐T segment depression• Hyper‐acute T‐waves• T‐wave inversion• Pathological Q‐waves• Left bundle branch blockLeft bundle branch block
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ST SegmentST Segment• The ST segment represents period between ventricular
depolarization and repolarisation. • The ventricles are unable to receive any further
stimulationstimulation• The ST segment normally lies on the isoelectric line.
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ST Segment ElevationST Segment ElevationThe ST segment lies above the
isoelectric line:isoelectric line:Represents myocardial injury• It is the hallmark of
M di l I f tiMyocardial Infarction• The injured myocardium is
slow to repolarise and remains more positively charged thanmore positively charged than the surrounding areas
• Other causes to be ruled out include pericarditis andinclude pericarditis and ventricular aneurysm
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Myocardial InfarctionMyocardial Infarction
• A medical emergency!!!A medical emergency!!!• ST segment curves upwards in the leads looking at the threatened myocardiumlooking at the threatened myocardium.
• Presents within a few hours of the infarct.• Reciprocal ST depression may be present
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Adel Hasanein
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Adel Hasanein
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ST Segment DepressionST Segment Depression
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Horizontal ST DepressionHorizontal ST Depression
Myocardial Ischemia:Myocardial Ischemia:• Stable & Unstable Angina
S l i ll i d• Non ST elevation MI ‐ usually quite deep, can be associated with deep T wave inversion.
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ST Segment DepressionST Segment Depression
Downsloping ST segment depression:‐Downsloping ST segment depression:• Can be caused by Digoxin.
Upward sloping ST segment depression:‐• Normal during exercise.
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Adel Hasanein
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T wavesT waves
• Hyperacute T waves ypoccur with ST segment elevation in acute MI
• T wave inversion occurs during ischemia and shortly after MI
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Hyperacute T wavesHyperacute T waves
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Adel Hasanein
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T wave inversion in an evolving MIT wave inversion in an evolving MI
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Q Waves
h l i lNon Pathological Q wavesQ waves of less than 2mm are normal
Pathological Q wavesat o og ca Q a esQ waves of more than 2mm indicate full thickness myocardial damage from an infarctLate sign of MI (evolved)
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Pathological Q wavesPathological Q waves
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Adel Hasanein
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????
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The ECG in ST Elevation MIThe ECG in ST Elevation MI
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Adel Hasanein
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Bundle Branch Blocksand Chamber Enlargement
Some EKGs in this presentation have been borrowed from:
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
2006
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Left Bundle Branch BlockLeft Bundle Branch Block
• QRS duration ≥• QRS duration ≥ 120ms
• Broad R waveBroad R wave in I and V6
• Prominent QSProminent QS wave in V1
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Right Bundle Branch BlockRight Bundle Branch Block
• QRS duration ≥• QRS duration ≥ 110ms
• rSR’ pattern orrSR pattern or notched R wave in V11
• Wide S wave in I and V66
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Left Atrial EnlargementLeft Atrial Enlargement
Criteria
P wave duration in II ≥120ms
or
Negative component of biphasic P wave in V ≥ 1biphasic P wave in V1 ≥ 1
“small box” in area
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Right Atrial EnlargementRight Atrial Enlargement
Criteria
P wave height in II ≥ 2.4mm
or
Positive component ofPositive component of biphasic P wave in V1 ≥ 1
“small box” in area
Adel Hasanein
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Left Ventricular Hypertrophyyp p yMany sets of criteria for diagnosing LVH have been proposed:
Sensitivity Specificity
The sum of the S wave in V1 and the R wave in either V5 or V6 > 35 mm
43% 95%mm
Sum of the largest precordial R wave and the largest precordial S 45% 93%wave and the largest precordial S wave > 45 mm
45% 93%
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Adel Hasanein
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Left Ventricular HypertrophyLeft Ventricular Hypertrophy
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Right Ventricular HypertrophyRight Ventricular HypertrophyAlthough there is no widely accepted criteria for detecting the presence of RVH any combination of the following EKG features is suggestive of
• Right axis deviation
of RVH, any combination of the following EKG features is suggestive of its presence:
• Right axis deviation• Right atrial enlargementD l i ST d i i V V ( k RV t i• Downsloping ST depressions in V1‐V3 (a.k.a. RV strain pattern)
• Tall R wave in V• Tall R wave in V1
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Right Ventricular HypertrophyRight Ventricular Hypertrophy
Adel Hasanein
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Adel Hasanein
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