basics of ecg.ppt dr.k.subramanyam
TRANSCRIPT
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Basics of Basics of ElectrocardiographyElectrocardiography
Dr.K.SubramanyamDr.K.Subramanyam
23-3-200923-3-2009
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OutlineOutline
1.1. Review of the conduction systemReview of the conduction system
2.2. ECG leads and recording ECG leads and recording
3.3. ECG waveforms and intervalsECG waveforms and intervals
4.4. Normal ECG and its variantsNormal ECG and its variants
5.5. Interpretation and reporting of an ECGInterpretation and reporting of an ECG
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What is an ECG?What is an ECG?
An ECG is the recording (gram) An ECG is the recording (gram)
of the electrical activity(electro) of the electrical activity(electro) generated by the cells of the generated by the cells of the heart(cardio) heart(cardio)
that reaches the body that reaches the body surface.surface.
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Recording ECGRecording ECG
William Einthoven
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Useful in diagnosis of…Useful in diagnosis of…
Cardiac ArrhythmiasCardiac Arrhythmias
Myocardial ischemia and infarctionMyocardial ischemia and infarction
PericarditisPericarditis
Chamber hypertrophyChamber hypertrophy
Electrolyte disturbancesElectrolyte disturbances
Drug effects and toxicityDrug effects and toxicity
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Recording an ECGRecording an ECG
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BasicsBasics
ECG graphs:ECG graphs:
– 1 mm squares1 mm squares
– 5 mm squares 5 mm squares
Paper Speed:Paper Speed:
– 25 mm/sec standard25 mm/sec standard
Voltage Calibration: Voltage Calibration:
– 10 mm/mV standard10 mm/mV standard
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ECG Paper: DimensionsECG Paper: Dimensions5 mm
1 mm
0.1 mV
0.04 sec
0.2 sec
Speed = rate
Voltage ~Mass
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ECG LeadsECG Leads
Leads are electrodes which measure the Leads are electrodes which measure the difference in electrical potential between either:difference in electrical potential between either:
1. Two different points on the body (bipolar 1. Two different points on the body (bipolar leads)leads)
2. One point on the body and a virtual reference 2. One point on the body and a virtual reference point with zero electrical potential, located in point with zero electrical potential, located in the center of the heart (unipolar leads)the center of the heart (unipolar leads)
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+-
RA
RA
LL+
+
--LA
LL
LA
LEAD II
LEAD I
LEAD III
Remember, the RLis always the ground
• By changing the arrangement of which arms or legs are positive or negative, three unipolar leads (I, II & III ) can be derived giving three "pictures" of the heart's electrical activity from 3 angles.
The Concept of a “Lead”
Leads I, II, and III
I
II III
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ECG LeadsECG Leads
The standard ECG has 12 leads:The standard ECG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads
The axis of a particular lead represents the viewpoint from The axis of a particular lead represents the viewpoint from which it looks at the heart.which it looks at the heart.
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ECG LEADSECG LEADS
Gold Berger :aV frontal leadsGold Berger :aV frontal leads
Wilson & co-workwers :chest leadsWilson & co-workwers :chest leads
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Standard Limb LeadsStandard Limb Leads
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Precordial LeadsPrecordial Leads
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Precordial LeadsPrecordial Leads
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Summary of LeadsSummary of Leads
Limb LeadsLimb Leads Precordial LeadsPrecordial Leads
BipolarBipolar I, II, IIII, II, III(standard limb leads)(standard limb leads)
--
UnipolarUnipolar aVR, aVL, aVF aVR, aVL, aVF (augmented limb leads)(augmented limb leads)
VV11-V-V66
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Limb Leads (Einthoven leads)Limb Leads (Einthoven leads)
Einthoven triangle
Einthoven Rule
I+II+III==0
I+(-II)+III=0
I+III=II
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Arrangement of Leads on the EKGArrangement of Leads on the EKG
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Anatomic GroupsAnatomic Groups(Septum)(Septum)
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Anatomic GroupsAnatomic Groups(Anterior Wall)(Anterior Wall)
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Anatomic GroupsAnatomic Groups(Lateral Wall)(Lateral Wall)
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Anatomic GroupsAnatomic Groups(Inferior Wall)(Inferior Wall)
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Anatomic GroupsAnatomic Groups(Summary)(Summary)
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Localising the arterial territoryLocalising the arterial territory
InferiorII, III, aVF
LateralI, AVL, V5-V6
Anterior / SeptalV1-V4
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Standard sites unavailableStandard sites unavailable
Patient pathologyPatient pathology
Amputation or burns or bandagesAmputation or burns or bandages should be placed as closely as possible to should be placed as closely as possible to the standard sitesthe standard sites
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Specific cardiac abnormalitiesSpecific cardiac abnormalities
Situs inversus dextrocardiaSitus inversus dextrocardia right & left right & left arm electrodes should be reversedarm electrodes should be reversed
pre-cordial leads should be recorded from pre-cordial leads should be recorded from V1R(V2) to V6V1R(V2) to V6
RVH & RV infarction:V3R & V4RRVH & RV infarction:V3R & V4R
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Continuous monitoringContinuous monitoring
Bed side: Bed side:
Holter monitoring:Holter monitoring:
TMT: Mason Likar systemTMT: Mason Likar system
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Other practical pointsOther practical points
Electrodes should be selected for Electrodes should be selected for maximum adhesiveness and minimum maximum adhesiveness and minimum discomfort,electrical noise,and skin-discomfort,electrical noise,and skin-electrode impedanceelectrode impedance
Effective contact between electrode and Effective contact between electrode and skin is essential.skin is essential.
ECG :calibrationECG :calibration
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ECG :paper speedECG :paper speed
Electrical artifacts:external or internalElectrical artifacts:external or internal
external can be minimized by straightening external can be minimized by straightening the lead wiresthe lead wires
internal can be due to muscle internal can be due to muscle tremors,shivering ,hiccoughs .tremors,shivering ,hiccoughs .
Supine positionSupine position
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Interpretation of an ECGInterpretation of an ECG
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Steps involvedSteps involved
Heart RateHeart Rate
RhythmRhythm
AxisAxis
Wave morphologyWave morphology
Intervals and segments analysisIntervals and segments analysis
Chamber enlargementChamber enlargement
Specific changesSpecific changes
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Wave formsWave forms
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Determining the Heart RateDetermining the Heart Rate
Rule of 300Rule of 300
10 Second Rule10 Second Rule
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Rule of 300Rule of 300
Take the number of “big boxes” between Take the number of “big boxes” between neighboring QRS complexes, and divide this neighboring QRS complexes, and divide this into 300. The result will be approximately into 300. The result will be approximately equal to the rateequal to the rate
Although fast, this method only works for Although fast, this method only works for regular rhythms.regular rhythms.
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The Rule of 300The Rule of 300
It may be easiest to memorize the following table:It may be easiest to memorize the following table:
# of big # of big boxesboxes
RateRate
11 300300
22 150150
33 100100
44 7575
55 6060
66 5050
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10 Second Rule10 Second Rule
As most ECGs record 10 seconds of rhythm per As most ECGs record 10 seconds of rhythm per page, one can simply count the number of beats page, one can simply count the number of beats present on the ECG and multiply by 6 to get the present on the ECG and multiply by 6 to get the number of beats per 60 seconds.number of beats per 60 seconds.
This method works well for irregular rhythms.This method works well for irregular rhythms.
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QRS axisQRS axis
Dr.K.SubramanyamDr.K.Subramanyam
9-4-20099-4-2009
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Genesis of QRSGenesis of QRS
Initially there is a small vector from left to Initially there is a small vector from left to right through the IVS ,followed by a larger right through the IVS ,followed by a larger vector from right to left through the free vector from right to left through the free wall of the LVwall of the LV
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Effect of left oriented leadEffect of left oriented lead
Small septal vector ,directed away from Small septal vector ,directed away from the positive pole resulting in a small q the positive pole resulting in a small q wavewave
Larger vector of the free wall ,directed Larger vector of the free wall ,directed towards the positive pole resulting in a tall towards the positive pole resulting in a tall R waveR wave
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Effect of right oriented leadEffect of right oriented lead
Small septal vector which is directed Small septal vector which is directed towards the positive pole,hence a small r towards the positive pole,hence a small r wavewave
Large vector of free LV wall which is Large vector of free LV wall which is directed away from the lead and hence a directed away from the lead and hence a large s wavelarge s wave
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Transition zoneTransition zone
Transition from rS to qR pattern which is Transition from rS to qR pattern which is usually seen in V3 /V4usually seen in V3 /V4
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Rotation of the heartRotation of the heart
Around AP axis;here the axis runs through Around AP axis;here the axis runs through the IVS from the ant to post surface of the the IVS from the ant to post surface of the heartheartHorizontal position;main body of the LV is Horizontal position;main body of the LV is oriented upwards and to the left:towards oriented upwards and to the left:towards leads I and avL(left axis)leads I and avL(left axis)Vertical position;main body of the LV is Vertical position;main body of the LV is oriented to leads II and avF(right and oriented to leads II and avF(right and inferior)inferior)
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Around oblique axis;the axis runs through Around oblique axis;the axis runs through the IVS from apex to basethe IVS from apex to base
Anatomical rotation Anatomical rotation clock-wise and clock-wise and counter clock wise rotationcounter clock wise rotation
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Counter clock-wise Counter clock-wise more anterior more anterior position of LVposition of LV
Results in transition zone shifting to leftResults in transition zone shifting to left
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Clock wise rotation;here th RV assumes a Clock wise rotation;here th RV assumes a more anterior position so that the IVS lay more anterior position so that the IVS lay parallel to the chest wallparallel to the chest wall
There is a shift of the transition zone to the There is a shift of the transition zone to the rightright
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The QRS AxisThe QRS Axis
The QRS axis represents the net overall The QRS axis represents the net overall direction of the heart’s electrical activity.direction of the heart’s electrical activity.
Abnormalities of axis can hint at:Abnormalities of axis can hint at:
Ventricular enlargementVentricular enlargement
Conduction blocks (i.e. hemiblocks)Conduction blocks (i.e. hemiblocks)
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The QRS AxisThe 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)
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Determining the AxisDetermining the Axis
The Quadrant ApproachThe Quadrant Approach
The Equiphasic ApproachThe Equiphasic Approach
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Determining the AxisDetermining the Axis
Predominantly Positive
Predominantly Negative
Equiphasic
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The Quadrant ApproachThe Quadrant Approach1. Examine the QRS complex in leads I and aVF to determine 1. Examine the QRS complex in leads I and aVF to determine
if they are predominantly positive or predominantly if they are predominantly positive or predominantly negative. The combination should place the axis into one negative. The combination should place the axis into one of the 4 quadrants below.of the 4 quadrants below.
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Example 1Example 1
Negative in I, positive in aVF RAD
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Example 2Example 2
Positive in I, negative in aVF Predominantly positive in II
Normal Axis (non-pathologic LAD)
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-90°-60°
-30°
0°
aVL
I
30°
60°
aVR
II
90°
120°III
150°
180°
-150°
-120°
aVF
Marked RAD
LAD
RAD
Normal Axis
-30° to +100°
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Example 1Example 1
Equiphasic in aVF Predominantly positive in I QRS axis ≈ 0°
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Example 2Example 2
Equiphasic in II Predominantly negative in aVL QRS axis ≈ +150°
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Using leads I, II, IIIUsing leads I, II, III
LEAD 1LEAD 1 LEAD 2LEAD 2 LEAD 3LEAD 3
NormalNormal UPRIGHTUPRIGHT UPRIGHTUPRIGHT UPRIGHTUPRIGHT
PhysiologicPhysiological Left Axisal Left Axis UPRIGHTUPRIGHT UPRIGHT / UPRIGHT /
BIPHASICBIPHASIC NEGATIVENEGATIVE
Pathological Pathological Left AxisLeft Axis UPRIGHTUPRIGHT NEGATIVENEGATIVE NEGATIVENEGATIVE
Right AxisRight Axis NEGATIVENEGATIVEUPRIGHTUPRIGHT
BIPHASICBIPHASIC
NEGATIVENEGATIVEUPRIGHTUPRIGHT
Extreme Extreme Right AxisRight Axis NEGATIVENEGATIVE NEGATIVENEGATIVE NEGATIVENEGATIVE
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Common causes of LADCommon causes of LAD
May be normal in the elderly and very May be normal in the elderly and very obeseobeseDue to high diaphragm during pregnancy, Due to high diaphragm during pregnancy, ascites, or ABD tumorsascites, or ABD tumorsInferior wall MIInferior wall MILeft Anterior HemiblockLeft Anterior HemiblockLeft Bundle Branch BlockLeft Bundle Branch BlockWPW SyndromeWPW SyndromeCongenital LesionsCongenital LesionsRV Pacer or RV ectopic rhythmsRV Pacer or RV ectopic rhythmsEmphysemaEmphysema
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Common causes of RADCommon causes of RAD
Normal variantNormal variant
Right Ventricular HypertrophyRight Ventricular Hypertrophy
Anterior MIAnterior MI
Right Bundle Branch BlockRight Bundle Branch Block
Left Posterior HemiblockLeft Posterior Hemiblock
Left Ventricular ectopic rhythms or Left Ventricular ectopic rhythms or pacingpacing
WPW Syndrome WPW Syndrome
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The Normal ECGThe Normal ECG
Dr.K.SubramanyamDr.K.Subramanyam
30-3-200930-3-2009
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Normal Sinus RhythmNormal Sinus Rhythm
Originates in the sinus nodeOriginates in the sinus nodeRate between 60 and 100 beats per minRate between 60 and 100 beats per minP wave axis of +45 to +65 degrees, ie. P wave axis of +45 to +65 degrees, ie. Tallest p waves in Lead IITallest p waves in Lead IIMonomorphic P wavesMonomorphic P wavesNormal PR interval of 120 to 200 msecNormal PR interval of 120 to 200 msecNormal relationship between P and QRSNormal relationship between P and QRSSome sinus arrhythmia is normalSome sinus arrhythmia is normal
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Sinus ArrhythmiaSinus Arrhythmia
ECG Characteristics: Presence of sinus P waves
Variation of the PP interval which cannot be attributed to either SA nodal block or PACs
When the variations in PP interval occur in phase with respiration, this is considered to be a normal variant. When they are unrelated to respiration, they may be caused by the same etiologies leading to sinus bradycardia.
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Normal P waveNormal P wave
Atrial depolarisationAtrial depolarisation
Duration 80 to 100 msecDuration 80 to 100 msec
Maximum amplitude 2.5 mmMaximum amplitude 2.5 mm
Axis +45 to +65Axis +45 to +65
Biphasic in lead V1Biphasic in lead V1
Terminal deflection should not exceed 1 Terminal deflection should not exceed 1 mm in depth and 0.03 sec in duration mm in depth and 0.03 sec in duration
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Normal P waveNormal P wave
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P’ waveP’ wave
Results in negative wave form in leads Results in negative wave form in leads II,III and avFII,III and avF
Axis;-80 to -90Axis;-80 to -90
Retrograde activation of atria due to Retrograde activation of atria due to impulse arising from or passing through impulse arising from or passing through AV nodeAV node
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Dome & dart p waveDome & dart p wave
Low left atrial rhythmLow left atrial rhythm
Initial dome-like deflexion and a terminal Initial dome-like deflexion and a terminal sharp & spike like deflexionsharp & spike like deflexion
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Normal QRS complexNormal QRS complex
Completely negative in lead aVR , maximum Completely negative in lead aVR , maximum positivity in lead IIpositivity in lead IIrS in right oriented leads and qR in left oriented rS in right oriented leads and qR in left oriented leads (septal vector)leads (septal vector)Transition zone commonly in V3-V4Transition zone commonly in V3-V4RV5 > RV6 normallyRV5 > RV6 normallyNormal duration 50-110 msec, not more than Normal duration 50-110 msec, not more than 120 msec120 msecPhysiological q wave not > 0.03 secPhysiological q wave not > 0.03 sec
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ECG showing qR pattern in lead ECG showing qR pattern in lead III ,disappears on deep inspiration III ,disappears on deep inspiration q q wave not significantwave not significant
Mech:shift in the QRS axisMech:shift in the QRS axis
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QRS-T angleQRS-T angle
The normal t wave axis is similar to the The normal t wave axis is similar to the QRS axisQRS axis
Normally the QRS-T angle does not Normally the QRS-T angle does not exceed 60 degexceed 60 deg
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Amplitude of QRSAmplitude of QRS
Depends on the following factorsDepends on the following factors
1.electrical force generated by the 1.electrical force generated by the ventricular myocardiumventricular myocardium
2.distance of the sensing electrode from 2.distance of the sensing electrode from the ventriclesthe ventricles
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3.Body build;a thin individual has larger 3.Body build;a thin individual has larger complexes when compared to obese complexes when compared to obese individualsindividuals
4.direction of the frontal QRS axis4.direction of the frontal QRS axis
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Normal T waveNormal T wave
Same direction as the preceding QRS Same direction as the preceding QRS complexcomplex
Blunt apex with asymmetric limbsBlunt apex with asymmetric limbs
Height < 5mm in limb leads and <10 mm Height < 5mm in limb leads and <10 mm in precordial leadsin precordial leads
Smooth contoursSmooth contours
May be tall in athletesMay be tall in athletes
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ST segmentST segment
Merges smoothly with the proximal limb of Merges smoothly with the proximal limb of the T wavethe T wave
No true horizontalityNo true horizontality
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Normal u waveNormal u wave
Best seen in midprecordial leadsBest seen in midprecordial leads
Height < 10% of preceding T waveHeight < 10% of preceding T wave
Isoelectric in lead aVL (useful to measure Isoelectric in lead aVL (useful to measure QTc)QTc)
Rarely exceeds 1 mm in amplitudeRarely exceeds 1 mm in amplitude
May be tall in athletes (2mm)May be tall in athletes (2mm)
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QT intervalQT interval
Normally corrected for heart rateNormally corrected for heart rate
Bazett’s formulaBazett’s formula
Normal 350 to 430 msecNormal 350 to 430 msec
With a normal heart rate (60 to 100), the With a normal heart rate (60 to 100), the QT interval should not exceed half of the QT interval should not exceed half of the R-R interval roughlyR-R interval roughly
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Measurement of QT intervalMeasurement of QT interval
The beginning of the QRS complex is best The beginning of the QRS complex is best determined in a lead with an initial q wave determined in a lead with an initial q wave
leads I,II, avL ,V5 or V6leads I,II, avL ,V5 or V6
QT interval shortens with tachycardia and QT interval shortens with tachycardia and lengthens with bradycardia lengthens with bradycardia
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Prolonged QTcProlonged QTc
During sleepDuring sleepHypocalcemiaHypocalcemiaAc myocarditisAc myocarditisAMIAMIDrugs like quinidine,procainamide,tricyclic Drugs like quinidine,procainamide,tricyclic antidepressantsantidepressantsHypothermiaHypothermiaHOCMHOCM
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Advanced AV block or high degree AV Advanced AV block or high degree AV blockblock
Jervell-Lange –Neilson syndromeJervell-Lange –Neilson syndrome
Romano-ward syndromeRomano-ward syndrome
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Shortened QT Shortened QT
Digitalis effectDigitalis effect
HypercalcemiaHypercalcemia
HyperthermiaHyperthermia
Vagal stimulationVagal stimulation
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Normal standardizationNormal standardization
1 mV=10 mm1 mV=10 mm
Will result in perfect right angles at each Will result in perfect right angles at each cornercorner
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overdampingoverdamping
When the pressure of the stylus is too firm When the pressure of the stylus is too firm on the paper so that it’s movements are on the paper so that it’s movements are retardedretardedThe ecg deflexions are inscribed more The ecg deflexions are inscribed more slowly so that they become fractionally slowly so that they become fractionally widerwiderResults in diminished amplitude of Results in diminished amplitude of deflexionsdeflexions a small s wave may a small s wave may disappeardisappear
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Underdamping or overshootUnderdamping or overshoot
When the writing stylus is not pressed When the writing stylus is not pressed firmly enough against the paperfirmly enough against the paper
Results in overshoot of the upswing and Results in overshoot of the upswing and downswing of the writing stylus,resulting in downswing of the writing stylus,resulting in sharp spikes at the cornerssharp spikes at the corners
Effects:deflexions are inscribed more Effects:deflexions are inscribed more rapidly rapidly resulting in fractionally narrower resulting in fractionally narrower complexescomplexes
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The ecg deflexions may be increased in The ecg deflexions may be increased in amplitude .amplitude .
An s wave becomes exaggerated An s wave becomes exaggerated
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Normal Variants in the ECGNormal Variants in the ECG
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Sinus arrhythmiaSinus arrhythmia
Persistent juvenile patternPersistent juvenile pattern
Early repolarisation syndromeEarly repolarisation syndrome
Non specific T wave changesNon specific T wave changes
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Persistent juvenile patternPersistent juvenile pattern
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Features of ERPSFeatures of ERPS
Vagotonia / athletes’ heartVagotonia / athletes’ heartProminent J pointProminent J pointConcave upwards, minimally elevated ST segmentsConcave upwards, minimally elevated ST segmentsTall symmetrical T wavesTall symmetrical T wavesProminent q waves in left leadsProminent q waves in left leadsTall R waves in left oriented leadsTall R waves in left oriented leadsProminent u wavesProminent u wavesRapid precordial transitionRapid precordial transitionSinus bradycardiaSinus bradycardia
EEarly arly RRecognition ecognition PPrevents revents SStreptokinase infusion !treptokinase infusion !
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Reporting an ECGReporting an ECG
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1. Patient Details1. Patient Details
“ “ Whose ECG is it ?!”Whose ECG is it ?!”
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2. Standardisation and lead 2. Standardisation and lead placementplacement
““Is it properly taken ?”Is it properly taken ?”
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3. Analysis of Rate, Rhythm and 3. Analysis of Rate, Rhythm and AxisAxis
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4. Segment and wave form 4. Segment and wave form analysis analysis
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5. Chamber enlargements5. Chamber enlargements
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Final ImpressionFinal Impression
“ “ Does the ECG correlate with Does the ECG correlate with the clinical scenario ?” the clinical scenario ?”
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Thank you !Thank you !