ecg practical approach
DESCRIPTION
ECG PRACTICAL APPROACH. Dr. Hossam Hassan Consultant Emergency Medicine. Objectives. To emphasize simplicities Practical approach Interpretation & clinical scenario are inseparable Systematic approach. Conduction System. Nomenclature. Magic numbers of Dr. Hossam. 3. 5. Rate - PowerPoint PPT PresentationTRANSCRIPT
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ECG PRACTICAL ECG PRACTICAL APPROACHAPPROACHDr. Hossam HassanDr. Hossam Hassan
Consultant Emergency MedicineConsultant Emergency Medicine
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Objectives Objectives
• To emphasize simplicities
• Practical approach
• Interpretation & clinical scenario are inseparable
• Systematic approach
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Conduction SystemConduction System
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Nomenclature Nomenclature
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Magic numbers of Dr. HossamMagic numbers of Dr. Hossam
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Systematic approachSystematic approach
• Rate• Rhythm• axis
• P-wave• PR interval• QRS complex• ST segment• T-wave
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Rate Rate
• The interval between 2 successive R-wave
• How many big squares?
• Divide 300 / # big squares
• Normal 60 – 100/min
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Rhythm Rhythm
Sinus Rhythm
Every P=wave is followed by QRS complex
P-wave is upright in lead II
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NSRNSR
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Types of Sinus RhythmTypes of Sinus Rhythm
• NSR
• Sinus Tachycardia
• Sinus Bradycardia
• Sinus arrhythmia
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Sinus tachycardiaSinus tachycardia
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Axis Axis
• Normal axis
• Right axis deviation
• Left axis deviation
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RADRAD
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LADLAD
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P-waveP-wave
• Atrial depolarization
• Atrial contraction is a result
• Normally a dome-like structure
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Abnormalities of P-waveAbnormalities of P-wave
• Peaked p-pulmonle– Pulmonary HTN– PE– Pulmonary valve stenosis
• M-shaped M-mitrale– Mitral valve stenosis– Left atrial hypertrophy
• Inverted 2nd atrial / junctional ectopy
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P-pulmonaleP-pulmonale
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PR intervalPR interval
• Definition
From the start of P to beginning of QRS
• Represent the delay in transmission in AV node
• Normally 0.12 – 0.20 msec
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Abnormalities of PR intervalAbnormalities of PR interval
• Prolonged >
1st degree HB
• Short <
Pre-excitation syndromes– WPW Syndrome– LGL Syndrome
Junctional rhythm
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QRS ComplexQRS Complex
• Amplitute
• Duration
• Shape
• Q-wave
• R-wave
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QRS AMPLITUTEQRS AMPLITUTE
• LVH By voltage criteria – S-wave in V 1 or V 2 + R-wave in V5 or V6
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LVH & STRAIN PATTERNLVH & STRAIN PATTERN
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Causes of LVHCauses of LVH
• HTN
• Aortic stenosis
• HOCM
• Aortic regurgitation
• Mitral regurgitation
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QRS DURATIONQRS DURATION
• Ventricular depolarization
• Ventricular contraction is a result
• Normally < 0.12 msec
< small squares
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Causes of wide QRSCauses of wide QRS
• Ventricular tachycardia
• BBB– Left BBB– Right BBB
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L BBBL BBB
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R BBBR BBB
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Shape Shape
• Upstroke & downstroke of R-wave
• Delta wave
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Q-waveQ-wave
• 1st negative deflection after the P-wave
• Normally 1mm wide & 2 mm deep
• Lead III , V5 & V6
Pathological Q-wave
Wider & deeper
>1/4 of the ensuing R-wave
Old MI
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+ve R-wave in V1+ve R-wave in V1
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Causes +ve R-wave in V ICauses +ve R-wave in V I
• RVH
• R BBB
• Posterior MI
• Type A WPW
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ST-SegmentST-Segment
• From the end of S-wave to the beginning of T-wave
• Normally iso-electric
• Abnormalities– Elevated– depressed
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Elevated ST segmentElevated ST segment
• Acute MI
• Pericarditis
• Early repolarization pattern in the young
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Infarct localizationInfarct localization
• Inferior– Lead II , III , aVF
• Septal – V I , V II
• Anterior– V3 , V4
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• Lateral– Lead I , AVL,V5 , V6• Posterior MI
- Prominent R wave in V1,V2 with depressed ST segment
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Acute inf MIAcute inf MI
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Anteroseptal MIAnteroseptal MI
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Anterior MIAnterior MI
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Lateral MILateral MI
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Depressed ST SegmentDepressed ST Segment
• Unstable angina
• Left ventricular strain pattern
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LVH & strain patternLVH & strain pattern
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T-waveT-wave
• Ventricular repolarization• Dome like structure• Abnormalities
– Peaked / tented t-wave• Hyperkalaemia• Subendocadial ischemia
– Inverted • LV Strain pattern• Dynamic t-wave changes of ischemia
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DYNAMIC T-WAVE CHANGESDYNAMIC T-WAVE CHANGES
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Hay….. Hay….. wake up we wake up we
are doneare done