cardiac rhythm and anaesthesia: basics of ecg abnormal rhythms relevant to anaesthetic practice...
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Cardiac Rhythm and Anaesthesia: Basics of ECGAbnormal rhythms relevant to anaesthetic practiceAntidysrhythmic agentsManagement of perioperative arrhythmiasAbnormal rhythms relevant to anaesthetic practiceManagement of perioperative arrhythmiasAntiarrhythmic agents
Dr. B. Uma
University College of Medical Science & GTB Hospital, Delhi
Basics of ECG
Objectives
1. What is an ECG
2. ECG indications
3. Review of the conduction system
4. ECG recording
ECG paper
ECG leads
5. ECG interpretation
What is an ECG?
The electrocardiogram (ECG) is a graphic recording of the electrical potentials generated by the heart. The signals are detected by means of metal electrodes attached to the extremities and chest wall and are then amplified and recorded by the electrocardiograph
Introduced by William Einthoven in 1901
ECG Indications
Monitoring
Diagnosis
ECG Indications…
Preoperative period
Risk Assessment• Assess the baseline cardiac status• Information regarding MI, conduction or rhythm
abnormalities• Reveals findings related to life threatening
metabolic disturbances or susceptibility to sudden cardiac death
ECG Indications…
Intraoperative period
Monitoring to detect changes in rate and rhythm or myocardial ischaemia
Monitoring of proper function of pacemakers or implantable cardiac defibrillators in patients undergoing surgery with these devices in place
ECG Indications…
Postoperative period
Monitoring
• Important in high risk patients when new ischemic or rhythm changes are suspected
ECG Paper
The Normal Conduction System
P wave caused by atrial
depolarization
Right atrial activation reflected by
ascending limb of P wave
Duration=0.02-0.04s
Left atrial activation reflected by
descending limb of P wave
Duration=0.05-0.06s
Hence, total duration=0.08- 0.10s
(maximum duration=0.11s)
Maximum normal amplitude=2.5mm
QRS complex is caused by the ventricular depolarization
QRS duration 0.05 - 0.11 sec
QRS amplitude
S amplitude in V1 + R amplitude in V6 < 3.5 millivolt (mV)
R in V5 or V6 < 2 mV
The ST segment and T wave reflect ventricular repolarization
ST segment duration=0.08-0.12s
T wave duration=0.16 s
T wave should be at least ⅛th but less than ⅔rd of the amplitude of the corresponding R wave
ECG Leads
Leads are electrodes which measure the difference in electrical potential between either:
1. Two different points on the body (bipolar leads)
2. One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart (unipolar leads)
ECG Leads
The standard ECG has 12 leads: 6 Frontal plane leads
6 Horizontal plane leads
Frontal plane leads - oriented in frontal or coronal plane of the body and consist of standard leads I, II, III and augmented limb leads AVR, AVL, AVF.
Horizontal plane leads - oriented in transverse or horizontal plane of the body and are formed by precordial leads V1-V6.
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
All Limb Leads
Precordial leads
Summary of Leads
Limb Leads Precordial Leads
Bipolar I, II, III(standard limb leads)
-
Unipolar aVR, aVL, aVF (augmented limb leads)
V1-V6
Anatomic Groups(Summary)
3 Electrode ECG monitoring
Electrodes placed on the torso to reduce artifacts from limb movement
RA/LA electrodes placed in right and left infraclavicular fossae
LL leg electrode below the left rib cage
Most common mode in OR and ICU
Good enough to detect HR and VF
Inadequate for detecting complex arrhythmias and ST segment monitoring
5- Electrode ECG monitoring
Modified Chest leadsModified chest leads (MCL) are useful in detecting bundle branch blocks and premature beats.
Lead MCL1 simulates chest lead V1 and views the ventricular septum.
Lead MCL6 simulates chest lead V6 and views the lateral wall of the left ventricle
CS 5 (RA electrode placed under the right clavicle and LA electrode placed in the V5 position) for detection of anterior myocardial wall ischaemia
CB5 (RA electrode over the center of the right scapula and LA electrode in the V5 position) for detection of ischaemia and supraventricular arrhythmias
Ten-Electrode, Twelve-Lead ECG Monitoring
The Right-Sided 12-Lead ECG
The limb leads are placed as usual but the chest leads are a mirror image of the standard 12-lead chest placement
Clinical significance: Patients with an acute inferior MI should have right-sided ECGs to assess for possible right ventricular infarction
Invasive Electrocardiographic Monitoring
Esophageal electrocardiogram: Much closer to atria. Hence better option when p waves recording is uncertain
Detection of posterior wall ischaemia
Esophageal electrodes incorporated into esophageal stethoscopes and welded to conventional electrocardiographic wires
:Intracardiac electrocardiogram:Multipurpose pulmonary artery catheter with 3atrial and 2ventricular electrodes for intracavitary ECG
Relatively insensitive to electrocautery
Endotracheal electrocardiogram:Endotracheal tube with 2 electrodes embedded
Diagnosis of atrial arrhythmias in pediatrics
Intracoronary electrocardiogram:Coronary guide wire during angioplasty is used
Greater detection of acute ischaemia
ECG Interpretation
Rate
Rhythm
QRS axis
P Wave
PR Interval
QRS Complex
QT Interval
ST Segment
Documentation: name of the patient and the date and time it was recorded.
Calibration signal: The amplifier gain is normally adjusted so that a 1 millivolt signal through the ECG amplifier results in a vertical deflection of 10 mm (two large ECG squares). All voltage measurements on the ECG depend entirely on the accuracy of this calibration signal.
Determining the Heart RateRule of 1500
Heart rate=1500/no. of small boxes between adjacent RR intervals
Rule of 300Heart rate=300/no. of big boxes between adjacent QRS complexes
6/3 second ruleNo. of RR intervals in 3sec multiplied by 20
or
No. of RR intervals in 6sec multiplied by 10
What is the heart rate?
1500/30 = 50 bpm
www.uptodate.com
What is the heart rate?
Count number of large boxes between first and second R waves=7.5. 300/7.5 large boxes = rate 40
What is the heart rate?
Count 30 large boxes, starting from the first R wave. There are 8 R-R intervals within 30 boxes. Multiply 8 x 10 = Rate 80
Rhythm
Normal: Each QRS preceded by a P wave with a regular PR and RR interval and a rate between 60 and 100 bpm
Irregular– Regularly Irregular – Irregularly Irregular
The QRS Axis
The QRS axis represents the net overall direction of the heart’s electrical activity
Direction of the axis determined on the basis of the hexaxial reference system
The QRS Axis
By near-consensus, the normal QRS axis is defined as ranging from -30° to +90°.
-30° to -90° is referred to as a left axis deviation (LAD)
+90° to +180° is referred to as a right axis deviation(RAD)
Movement of the electrical impulse towards the positive electrode will result in a positive deflection on the ECG.
Movement of the electrical impulse towards the negative electrode will result in a negative deflection on the ECG.
Movement of an electrical impulse perpendicular to a line between the positive and negative electrodes results in a biphasic deflection on the ECG.
Determining the Axis
Predominantly Positive
Predominantly Negative
Equiphasic
The Equiphasic Approach
1. Determine which limb lead contains the most equiphasic QRS complex. The fact that the QRS complex in this lead is equally positive and negative indicates that the net electrical vector (i.e. overall QRS axis) is perpendicular to the axis of this particular lead.
2. Examine the QRS complex in whichever lead lies 90° away from the lead identified in step 1. If the QRS complex in this second lead is predominantly positive, than the axis of this lead is approximately the same as the net QRS axis. If the QRS complex is predominantly negative, than the net QRS axis lies 180° from the axis of this lead.
Equiphasic Approach: Example 1
Equiphasic in aVF Predominantly positive in I QRS axis ≈ 0°
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Equiphasic Approach: Example 2
Equiphasic in II Predominantly negative in aVL QRS axis ≈ +150°
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Two lead approach
Look for net QRS deflection in leads I and aVF
If both +ve – Normal axis
If I +ve & aVF predominantly –ve – Left axis deviation
If I –ve & aVF +ve – Right axis deviation
Calculation of Axis – Third Approach
Calculate the net QRS deflection in lead I and aVF
E.g. in lead I, Q wave measures 3 small squares & R wave measures 6 small squares - net deflection is +3
Similarly, net deflection in aVF is -5
Cardiac vector is thus sum of individual vectors from leads I and aVF
P Wave
Best evaluated in standard lead II and lead V1
In standard lead II P wave is pyramidal with a rounded apex
In lead V1 biphasic P wave with an initial positive and a terminal negative deflection
Axis within 40°to 60°
P Wave – Clinical Significance
P Pulmonale
-Tall peaked P wave
-Amplitude in lead II >2.5 mm
-Duration WNL
-Expression of right atrial enlargement
P Mitrale
-Double peaked, notched or
camel humped P wave
-Negative deflection in V1> 1mm
-Duration of notch > 0.04s
-Expression of left atrial enlargement
PR Interval
PR interval - between beginning of P wave and beginning of QRS complex
Duration = 0.12 to 0.20 sec
Reflects time taken for conduction of impulse from SA node to the ventricles through the AV node
Long PR interval: first degree heart block, hyperkalemia
Short PR interval: WPW syndrome
QRS Complex - Interpretation
QRS interval
QRS voltages
Precordial R-wave progression
Abnormal Q waves
The QRS Complex
QRS Complex – Clinical Significance
LVH
RVH
Ventricular ectopics
RBBB
LBBB
Hemiblocks
RVH
LVH
Q waves
Pathologic Q waves are a sign of previous myocardial infarction.
The precise criteria for pathologic Q waves:• Q-wave 0.04 s in duration • Deeper than one fourth of the
following R wave in voltage• Q wave is deep usually greater
than 4mm in depth
ST Segment
Represents greater part of ventricular repolarization
Merges smoothly and imperceptibly with the proximal limb of T wave
Leaves the baseline immediately after its origin; hence not isoelectric
Flat, downsloping, depressed: coronary ischaemia, hypokalemia, digitalis toxicity
Elevation: MI
T Wave
Represents the repolarization of the ventricles
Last half represents relative refractory period
Positive deflection in most leads
Negative deflection in AVR
Biphasic in V1
T wave inversion: coronary ischaemia
Tall tented T wave: hyperkalemia
Flat T wave: hypokalemia
Heavily notched: pericarditis
ST-T segment: Significance
ST-T segment is the component of ECG most sensitive to acute myocardial ischaemia
Transmural ischaemia→ ST elevation accompanied by tall positive (hyperacute) T waves
Subendocardial ischaemia→ ST depression
Myocardial infarction→ pathologic Q waves
QT Interval
Interval from the beginning of the QRS complex to the end of T wave
Represents the total duration of ventricular electrical activity
Corrected QT interval (Q-Tc)= QT/√R-R
Normal values= 0.39±0.04 s.
QT Interval –Clinical Significance
Prolonged QTc interval:Acute myocarditis
Acute MI
Torsades de pointes
Romano Ward syndrome
Shortened QTc interval:Digitalis effect
U Wave
Small rounded deflection (< 1 mm) that occurs immediately after T wave and has same polarity as T wave
Best seen in leads V2-V4
?repolarization of papillary muscles or purkinje fibres
Prominent U wave: hypokalemia, drugs e.g. dofetilide, amiodarone, sotalol, quinidine, procainamide, disopyramide
Inverted U wave: Sign of ischaemia
J Point
The J point in the ECG is the point where the QRS complex joins the ST segment.
It represents the approximate end of depolarization and the beginning of repolarization as determined by the surface ECG.
There is an overlap of 10 milliseconds.
Some Practical Points
Skin prepared by-• Hair should be shaved• Skin cleaned with spirit • Abrade skin lightly
Muscle tremor presents as artifact. Electrode should be placed over bony prominence.
Electrodes – pregelled, disposable
Broken electrodes to be discarded
Artifacts
Equipments interfering with ECG:• 60 hz power lines• Electrocautery (mc)• Cardiopulmonary equipment• Defibrillators• Transplanted heart(pseudoartifact)
What is the axis?
Outline
Factors causing perioperative arrhythmias
Mechanisms of arrhythmogenesis
Sinus Rhythms
Atrial Rhythm disturbances
Junctional Rhythms
Ventricular Rhythm disturbances
Conduction blocks
Arrhythmias
Abnormality of cardiac rate, rhythm or conduction
Most frequent perioperative cardiac abnormality
Both during cardiac and non cardiac surgeries
With general and regional anaesthesia
Factors contributing to perioperative arrhythmias
Patient related
Anaesthesia related
Surgery related
Patient related factors
Pre existing cardiac disease – higher incidence, more fatal
CNS stimulation – SAH → ST-T changes
Old age – Post-op AF frequent due to degenerative changes in atrial anatomy
Anaesthesia related factors
Endotracheal intubation
General anaesthetics Halothane (reentry, sensitization to catecholamines), enflurane,
sevoflurane (severe bradycardia), desflurane (QTc prolongation) Drugs blocking reuptake of catecholamines- ketamine
Local anaesthetics Inadvertent intravenous injection of large dose - cardiac arrest High thoracic levels of regional anaesthesia- bradyarrhythmias
Abnormal arterial blood gas and electrolyte levels
Hypercarbia, hypoxia, hypocarbia a/w hypokalemia
Surgery related factors
Autonomic reflexes Peritoneal traction, pressure on vagus - sinus bradycardia, AV
block, asystole Oculocardiac reflex- bradycardia, asystole IJV cannulation
Cardiac surgery Release of aortic cross clamp Placement of venous cannulae Retraction of the heart Suturing over the atrium
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