ecg part introduction
Post on 07-May-2015
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ECG diagnosis
The Normal Conduction System
Lead Position
• A typical ECG report shows the cardiac cycle from 12 different vantage points (I, II, III, aVR, aVL, aVF, V1-V6), like viewing the event electrically from 12 different locations (like a 3D perspective).BUT only 10 electrodes are used.
• Lead I represents activity that is going from the right arm to the left arm
• Lead II represents activity that is going from the right arm to the left leg
• Lead III represents activity that is going from the left arm to the left leg
• aVL is placed on the left arm (or shoulder)• aVF is placed on the left leg (or hip)• aVR is placed on the right arm (or shoulder)• V1- 4th intercostal space to the right of sternum• V2- 4th intercostal space to the left of sternum• V3- halfway between V2 and V4• V4- 5th intercostal space in the left mid-clavicular line• V5- 5th intercostal space in the left anterior axillary line• V6- 5th intercostal space in the left mid axillary line
NSR
• NORMAL
• NORMAL
• NSR , Juvenile T-wave inversion.
• NORMAL
WPW Syndrome
AF, Inferior Q waves
RBBB
28 years with palpitations
• SVT
4 years later
• DEVELOPPED AF
50 years old syrian with mild CAD
• VT,THIS PT HAD SEVERE DCM,waiting for AICD
• Paced Rhythm
Waveforms and Intervals
Aims
• 10 ECG rules
• Heart Rate
• ECG signs of M.I.
• Evolution of changes in M.I.
• Classical Appearences
QRS waveform nomenclature
R r qR qRs Qrs QS
Qr Rs rS qs rSr’ rSR’
The 10 rules for a normal ECG
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
.2
Rule 1
PRinterval
Mil
liv
olt
s
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
P
R
T
Q
S
PR interval should be 120 to 200 milliseconds or 3 to 5 little squares
Rule 2
Mil
liv
olt
s
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
QRS
P
R
T
Q
S
The width of the QRS complex should not exceed 110 ms, less than 3 little squares
Rule 3
I II III aVR aVL aVF
The QRS complex should be dominantly upright in leads I and II
Rule 4
I II III aVR aVL aVF
QRS and T waves tend to have the same general direction in the limb leads
Rule 5
P
Q
T
S
All waves are negative in lead aVR
Rule 6
V1
V2
V3
V4
V5
V6
The R wave in the precordial leads must grow from V1 to at least V4
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Rule 7
The ST segment should start isoelectric except in V1 and V2 where it may be elevated
Rule 8
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The P waves should be upright in I, II, and V2 to V6
Rule 9
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
There should be no Q wave or only a small q less than 0.04 seconds in width in I, II, V2 to V6
Rule 10
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The T wave must be upright in I, II, V2 to V6
What is the heart rate?
•(300 / 6) = 50 bpm
•www.uptodate.com
What is the heart rate?
•(300 / ~ 4) = ~ 75 bpm
•www.uptodate.com
What is the heart rate?
•(300 / 1.5) = 200 bpm
10 Second Rule
As most EKGs record 10 seconds of rhythm per page, one can simply count the number of beats present on the EKG and multiply by 6 to get the number of beats per 60 seconds.
This method works well for irregular rhythms.
What is the heart rate?
•33 x 6 = 198 bpm
•The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Characteristic changes in AMI
• ST segment elevation over area of damage• ST depression in leads opposite infarction• Pathological Q waves• Reduced R waves• Inverted T waves
ST elevation
R
P
Q
ST
• Occurs in the early stages
• Occurs in the leads facing the infarction
• Slight ST elevation may be normal in V1 or V2
Deep Q wave
R
P
Q
T
ST
• Only diagnostic change of myocardial infarction
• At least 0.04 seconds in duration
• Depth of more than 25% of ensuing R wave
T wave changes
R
P
Q
T
ST
• Late change
• Occurs as ST elevation is returning to normal
• Apparent in many leads
Bundle branch block
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Anterior wall MI Left bundle branch block
Sequence of changes in evolving AMI
1 minute after onset 1 hour or so after onset A few hours after onset
A day or so after onset Later changes A few months after AMI
Q
R
P
QT
STR
P
Q
ST
P
Q
T
ST
R
P
S
T
P
QT
ST
R
P
Q
T
Anterior infarction
Anterior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left anterior descending artery (LAD)
Inferior infarction
Inferior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Right coronary Artery( RCA) OR Circumflex (LCX)
Lateral infarction
Lateral infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left circumflexcoronary Artery OR DAIAGONAL branch of LAD
Location of infarct combinations
aVR V1 V4I
II
III
LATERAL OR HIGH
LATERAL
INFERIOR
SEPTAL
ANT
ANT
LAT
aVL
aVF
V2
V3
V5
V6
Diagnostic criteria for AMI
• Q wave duration of more than 0.04 seconds
• Q wave depth of more than 25% of ensuing r wave
• ST elevation in leads facing infarct (or depression in opposite leads)
• Deep T wave inversion overlying and adjacent to infarct
• Cardiac arrhythmias
Left axis deviation - negative QRS in lead AVF
Right axis deviation - negative QRS in lead I
Severe Right axis deviation negative QRS in BOTH lead I and AVF
Quick & Easy AXIS DETERMINATION
AVF
AVF
AVF
AVF
AVF
AVF
I
I
I
I
I
I
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)
Determining the Axis
Predominantly Positive
Predominantly Negative
Equiphasic
The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.
Quadrant Approach: Example 1
Negative in I, positive in aVF RAD
The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.edu/kw/ecg/
Quadrant Approach: Example 2
Positive in I, negative in aVF Predominantly positive in II
Normal Axis (non-pathologic LAD)
The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.edu/kw/ecg/
Thank U Very Much
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