ecg basics.ppts
DESCRIPTION
ECGTRANSCRIPT
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ECGDr Majid Shojaee
Assisstant Professor of Emergency Medicine
Shahid Beheshti university of medical sciences
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Leads 1,2,3,aVR,aVL,aVF
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Limb leads & colours
?
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Euro & Iran Rt Lt
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Precordial Leads= V1-V6
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Precordial Leads Measure potentials close to the heart, V1-
V6
Unipolar leads
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ECG Chest Leads
Precardial (chest) Lead Position V1 = 4th ICS, right sternal border V2 = 4th ICS, left sternal border V3 = between V2 and V4 V4 = 5th ICS, left Mid clavicular Line V5 = 5th ICS Left anterior axillary line V6 = 5th ICS Left mid axillary line
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Calibration, or standardization refers to the amplitude of the waveforms
on the tracing. It is usually set at a default value of 10 mm/mV
Increasing the calibration to 20 mm/mV is helpful when trying to decipher P wave morphology.
Decreasing the calibration to 5 mm/mV is helpful in cases wherein the amplitude of the QRS complex (usually in the precordial leads) is so large
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Paper speed
usually is set at a default of 25 mm/sec. It may be manipulated for purposes of deciphering a dysrhythmia,
It is important that the clinician examine all ECG tracings for standardization and speed parameters before attempting clinical interpretation.
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ADDITIONAL lEADS
15 lead ECG Posterior leads Right leads Invasive procedural leads
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15 leads: V7-V8-V9V7: post. Axillary linev8: tip of Lt scapulav9: near the border of paraspinal m.
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Posterior leads
V8-V9
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Right side leads; V4R (Rt 5th intercostal space mid-clavicular line) is the most useful lead for detecting STE in RV MI
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Lewis leads RA &LLVertical sternal (Barker) leads RA &LLModified bipolar chest leads (MCL)MCL1: RA & LAMCL6: RA & LL
Alternative leads
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WHY?
Rhythm assessment often requires ECGmonitoring over continuous periods of time,
making the standard 12-lead ECG (requiring 10 electrodes), and
even unipolar precordial V1 monitoring (requiring 5 electrodes), not feasible.
A number of alternative lead systems requiring fewer electrodes have been described.
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& vertical sternal leads produce a larger P wave than other systems
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Einthoven’s triangle
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Lewis, Barker & MCL6 : lead 2MCL1: lead 1
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Einthoven’s triangle
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Lead misplacement
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Normal ECG Signal
P – atrial depolarization
QRS complex – ventricular depolarization
T – ventricular repolarization
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Reading 12-Lead ECGs
The best way to read 12-lead ECGs is : 6-step approach:
1. Calculate RATE2. Determine RHYTHM3. Determine QRS AXIS4. Calculate INTERVALS5. Assess for HYPERTROPHY6. Look for evidence of INFARCTION
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Rate Determination300/RR(large square)
40
Next
QRS
QRS
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Rhythm
Sinus? Each P followed by QRS, R-R
constant
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Dr Majid Shojaee 42
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Rate Rhythm Axis Intervals Hypertrophy Infarct
We can quickly determine whether the QRS axis is normal by looking at leads I and II.
If the QRS complex is overall positive (R > Q+S) in leads I and II, the QRS axis is normal.
QRS negative (R < Q+S)
QRS equivocal (R = Q+S)
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Rate Rhythm Axis Intervals Hypertrophy Infarct
Now using what you just learned fill in the following table. For example, if the QRS is positive in lead I and negative in lead II what is the QRS axis? (normal, left, right or right superior axis deviation)
44
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
QRS Complexes
I
Axis I II
+ + normal
II
Dr Majid Shojaee
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Rate Rhythm Axis Intervals Hypertrophy Infarct
Now using what you just learned fill in the following table. For example, if the QRS is positive in lead I and negative in lead II what is the QRS axis? (normal, left, right or right superior axis deviation)
45
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
QRS Complexes
I
Axis I II
+ +
+ -
normal
left axis deviation
II
Dr Majid Shojaee
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Rate Rhythm Axis Intervals Hypertrophy Infarct
… if the QRS is negative in lead I and positive in lead II what is the QRS axis? (normal, left, right or right superior axis deviation)
46
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
QRS Complexes
I
Axis I II
+ +
+ -
- +
normal
left axis deviation
right axis deviation
II
Dr Majid Shojaee
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0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
Rate Rhythm Axis Intervals Hypertrophy Infarct
… if the QRS is negative in lead I and negative in lead II what is the QRS axis? (normal, left, right or right superior axis deviation)
47
QRS Complexes
I
Axis I II
+ +
+ -
- +
- -
normal
left axis deviation
right axis deviation
right superior axis deviation
0o
30o
-30o
60o
-60o-90o
-120o
90o 120o
150o
180o
-150o
II
Dr Majid Shojaee
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Rate Rhythm Axis Intervals Hypertrophy Infarct
Is the QRS axis normal in this ECG?
No, there is left axis deviation.
The QRS is positive in I and negative in II.
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Axis Determination
49
NORMAL RIGHT LEFT
ALL UPRIGHT
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Intervals
QT= 0.33”-0.42” (<0.47”) QTcQT/√RR
QRS <0.12” PR =0.10”-0.20”
P duration < 0.12 sec P amplitude < 2.5 mm
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Hyperthrophy / Enlargement
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Right Atrial Enlargement
Always examine Lead 2 for RAE Tall Peaked P Waves, Arrow head P waves Amplitude is 4 mm ( 0.4 mV) - abnormal Pulmonary Hypertension, Mitral Stenosis Tricuspid Stenosis, Regurgitation Pulmonary Valvular Stenosis Pulmonary Embolism Atrial Septal Defect with L to R shunt
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Right Atrial Enlargement
53
P wave voltage is 4 boxes or 4 mm
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Left Atrial Enlargement
Always examine V 1 and Lead 1 for LAE Biphasic P Waves, Prolonged P waves P wave 0.16 sec, ↑ Downward
component Systemic Hypertension, MS and or MR Aortic Stenosis and Regurgitation Left ventricular hypertrophy with
dysfunction Atrial Septal Defect with R to L shunt
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Left Atrial Enlargement
55
P wave duration is 4 boxes-0.04 x 4 = 0.16
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Atrial Hypertrophy: Enlarged Atria
RIGHT ATRIAL HYPERTROPHYTall, peaked P wave in leads I and II
LEFT ATRIAL HYPERTROPHYWide, notched P wave in lead IIDiphasic P wave in V1
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Ventricular Hypertrophy
Ventricular Muscle Hypertrophy
QRS voltages in V1 and V6, L1 and aVL
We may have to record to ½ standardization
T wave changes opposite to QRS direction
Associated Axis shifts Associated Atrial hypertrophy
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Marriott's Practical Electrocardiography: Galen S. Wagner
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Normal Variations in ECG May have slight left axis due to rotation of heart
May have high voltage QRS – simulating LVH
Mild slurring of QRS but duration < 0.09
J point depression, early repolarization
T inversions in V2, V3 and V4 – Juvenile T ↓
Similarly in women also T↓
Low voltages in obese women and men
Non cardiac causes of ECG changes may
occur
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S.A.H. ECG changes
60
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?
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Pediatric ECG
This is the ECG of a 6 year old child -Heart rate is 100 – Normal for the age -See )V1 + V5( R >> 35 – Not LVH –
Normal -T↓ in V1, V2, V3 – Normal in child -Base line disturbances in V5, V6 due to
movement by child
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