ecg workshop presentation
TRANSCRIPT
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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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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