ecg workshop presentation

THE SECRET OF ECG

Imtinan Mohammed Barnawi11/17/16

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

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Outlines

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

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Heart dynamics, action potential1. 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 )

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Heart dynamics, action potential2. conduction:

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Heart dynamics, action potential2. conduction:

SAAtrium (rt then

left)AV

(delay)

Bundle of his ( rt

and left )

Septum

Left ventricle then

rt ventricl

e

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Heart dynamics, action potentialPhase Action comment

0 Na+ in Positive intracellular

Depolarization QRS

1 Na+ channel inactiveK+ out

Transient

2 Ca+ in K+ out

PlateauST segment

3 K+ out fast Repolarization T waves

4 Na – K ATPasK + in

Resting ventricles

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Heart dynamics, action potentialPhas

e Action Comment

0 Ca + in Depolarization

3 K+ out Repolarization

4 Na+ - K+ ATPas

Resting

SA node

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■Pacemaker of the heart is: SA node because of ….............

Heart dynamics, action potential

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Puzzles

• Stimulate opening of Ca+ channel.

• Fast rapid influx of Ca+

• Stimulate opening of K+ channel

• Fast rapid efflux of K+

• Hyperpolarization Catecholami

ne

ACH

- ve Chrono

and dromotro

py

+ve Chrono

and dromotrop

y

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ECG = Electrocardiogram

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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.

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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 pain2. Palpitation3. SOB4. Dizziness5. Syncopal attack.

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How to use it?!

■ Consist of:1. 6 chest leads 2. 3 limb leads 3. Reading device

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How to use it?!■Fixation

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Representation

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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

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1. This is 12 lead ECG for lady 30 year old ( Fatimah )2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular rhythm5. 60 beat / min6. Normal axis

7. Sinus rhythm 8. Narrow QRS complex 9. Normal P-R interval

10.Normal ST and QT interval 11.Normal T waves

Impression: Normal ECG

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1. This is 12 lead ECG for male 25 year old ( Ahmed )2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular rhythm5. 300 beat / min6. Normal axis

7. Non- sinus ( no p– wave ) 8. Narrow QRS complex 9. Normal P-R interval

10.Normal ST 11.Normal T waves

Impression: SVT ( junctional tachycardia )

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

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1- Personal data, date and day.

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2- dose this is standard or not?!

■ 12 lead ECG.■ Speed: 25 mm / min ■ Calibration: 1 MV = 1 cm = = 10 mm = 2 large square

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2- dose this is standard or not?!

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3- Rhythm Rhythm

Regular Irregular

Regular – irregular

Irregular – irregular

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3- Rhythm Irregular

Irregular – irregular

AF

Regular – irregular

NormalSinus

Arrhythmia ( respiration )

Abnormal

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3- Rhythm 2

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3- Rhythm

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4- Rate Rhythm

Regular

Number of squares

300 / largeOr

1500 / small

Irregular

Number of R in 6 s * 10

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4- Rate, Regular

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4- Rate, Irregular

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5- Axis

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5- Axis ■ How to know positive or negative

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5- Axis ■ Normal■ Rt deviation ■ Left deviation ■ And DD

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5- Axis

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5- Axis, DD

Rt axis deviation Left axis deviation

• Rt ventricular hypertrophy • Left posterior fascicle block

• Lung disease acute or chronic

• Left ventricular hypertrophy • Left anterior fascicle block

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6- P wave ( sinus or not, abnormal size ) ■Size ( 1mm tall and 0.04 width )

■Shape■P : QRS ■Positive or note.

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■ Sinus 1. Same shape 2. Each p followed by QRS3. Positive in lead 1,2 and chest lead4. Negative in AVR, lead 3 and some time in V1

Why AVR have negative reading P, QRS and T ?!

6- P wave ( sinus or not, abnormal size )

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Tall • P pulmonal • Rt atrium enlargement

Wide • P mitral • Left atrium enlargement

6- P wave ( sinus or not, abnormal size )

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7- QRS■Duration ( width ) = 3 small square = 0.12 sec =

120 ms■Pattern ■Amplitude

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7- QRS

Wide

Rate & Rhythm abnormality

Conduction abnormality

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7- QRSRate & Rhythm

abnormality

Tacy & normal rhythm

Ventricular tachycardia

Normal rate & abnormal rhythm

Escape or premature

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■ Example

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conduction:

SAAtrium

( rt then left )

AV ( delay )

Bundle of his ( rt

and left )Septum

Left ventricle then rt

ventricle

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7- QRSConduction

abnormality

RBBB LBBB

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7- QRS, pattern and amplitude

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3

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7- QRS, pattern and amplitude 1

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■ 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

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Ventricular hypertrophy

RT Left

7- QRS, pattern and amplitude

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Ventricular hypertrophy

RT

Sum of R in V1 and S in V6 = more than 25

Left R in V6 = more than

25S in V1 = more than

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7- QRS, pattern and amplitude

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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

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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

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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

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10 - ST segment ST

Normal Elevation

More than 3 small square=

3 mm

Depression

More than 3 small square=

3 mm

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10- ST segment

elevation Depression

STEMI Non stable angina Non- STEMI

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Tricks ■ To confirm that really STEMI : check of site then check the

reciprocal effect

Reciprocal effect Anterior STEMI Inferior

Inferior Lateral Posterior Lateral

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11- T wave■Peaked = 5 small square = 5 mm ■Flat, small or abnormal ■Inverted

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peaked flat Inverted

HyperkalemiaHypomagnesemia

Early MI Hypokalemia

Ischemia Pericarditis

cardiomyopathy

11- T wave, DD

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Road map for ECG

1. Personal Data, day and date.2. Standardized or not.3. Rhythm 4. Rate5. Axis 6. P wave7. QRS8. Q wave9. PR interval 10.ST segment 11.T waves

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Case scenario Mr. Abdullah, a 55-year-old male businessman, a known case of diabetes mellitus and hypertension, 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.

9125 mm / s

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1. This is 12 lead ECG for 55 year old businessman (Abdullah )2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular rhythm5. 80 beat / min6. 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 and V4 ) 12.T inversion ( AVF ).

Impression: Acute Antro - septal MI with old inferior MI

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Case 1: team 1

725 mm / s

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1. This is 12 lead ECG for 55 year man2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular rhythm5. 75 beat / min6. 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 )

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Case 2: team 2

25 mm / s

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1. This is 12 lead ECG for 20 year lady2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular – irregular rhythm

5. 70 beat / min6. 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 )

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Case 3: team 1

25 mm / s99

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1. This is 12 lead ECG for 30 year man2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Regular rhythm5. 50 beat / min6. Normal axis

7. Sinus rhythm but bifid P waves 8. QRS; V1 S= 25 mm and in V6 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

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Case 4: team 240 year old lady represent with long standing palpitation.

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1. This is 12 lead ECG for 40 year lady2. Date 16 – 11 – 2016, Wednesday.

3. Normal speed and calibration 4. Irregular – irregular rhythm

5. 90 beat / min6. Normal axis

7. Absent P waves 8. QRS normal

9. ST isoelectric 10.T inverted

Impression: chronic AF

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Secret winner

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D

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B

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How much did we meat the learning objectives?!

Learning objectives Scale of achieveme

nt

To review our heart mechanism of action, action potential.

To fine 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.

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

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