8/12/2019 medical Ecg

1/49

Teresa Camp-Rogers, MDDepartment of Emergency MedicineVirginia Commonwealth University Medical Center

Richmond, Virginia

The Basic 12 Lead

Electrocardiogram

8/12/2019 medical Ecg

2/49

Objectives

How do they work?

Common mistakes

How to read an EKG Artifacts

Cases

8/12/2019 medical Ecg

3/49

What is an EKG?

Tracing of electrical activity of the heart

8/12/2019 medical Ecg

4/49

History of the EKG

William Einthoven

Early 1900s

String galvanometer

8/12/2019 medical Ecg

5/49

How does an EKG work?

Voltmeter

Saline

Bucket

Saline

Bucket

8/12/2019 medical Ecg

6/49

How does an EKG work?

8/12/2019 medical Ecg

7/49

How does an EKG work?

8/12/2019 medical Ecg

8/49

How does an EKG work?

Einthoven I, II, III

8/12/2019 medical Ecg

9/49

How does an EKG work?

Wilson augmented leads

aVF, aVR, aVL

8/12/2019 medical Ecg

10/49

How does an EKG work?

Pre-cordial leads

V1 V6

Standardized in 1938 by the AHA

8/12/2019 medical Ecg

11/49

Why PQRST?

Uncorrected tracings ABCD

Corrected tracing PQRST

Familiar with Descartes

Middle of alphabet (afterthought)

8/12/2019 medical Ecg

12/49

Indications Chest pain

Syncope Shortness of breath

Nausea/Vomiting

Palpitations

Diaphoresis Stroke symptoms

Before and after cardioversion

Hemodynamic instability

Suspected electrolyte disorder Overdose

Arrhythmia

8/12/2019 medical Ecg

13/49

Common Mistakes

Limb lead placementRIGHT WRONG

8/12/2019 medical Ecg

14/49

Common Mistakes

Pre-cordial lead placement

Angle of Louis

V1 What about breast

tissue?

8/12/2019 medical Ecg

15/49

How to read an EKG

The Paper

The Waveform

The Plan

8/12/2019 medical Ecg

16/49

How to read an EKG

The paper Up and down 1 box = 0.1 mV

Across 1 box = 4 ms

The rate

10 seconds per page

8/12/2019 medical Ecg

17/49

How to read an EKG

The Waveform

8/12/2019 medical Ecg

18/49

How to read an EKG

P wave

8/12/2019 medical Ecg

19/49

How to read an EKG

PR segment

8/12/2019 medical Ecg

20/49

How to read an EKG

QRS complex

8/12/2019 medical Ecg

21/49

How to read an EKG

ST segment

8/12/2019 medical Ecg

22/49

How to read an EKG T wave

8/12/2019 medical Ecg

23/49

How to read an EKG QT/QTc

8/12/2019 medical Ecg

24/49

How to read an EKG R-R

8/12/2019 medical Ecg

25/49

The Plan

Rate

Rhythm

Axis

Interval

Disease

8/12/2019 medical Ecg

26/49

Rate

300 method

300, 150, 100, 75, 60

8/12/2019 medical Ecg

27/49

Rate

10 second method Each EKG is 10 seconds

Count total QRS complexes

Multiply by 6

8/12/2019 medical Ecg

28/49

Rate Normal

60 100

Bradycardia< 60

Tachycardia> 100

8/12/2019 medical Ecg

29/49

Rhythm

Sinus Atrial

Supraventricular

Junctional

Ventricular

Narrow QRS

Wide QRS

8/12/2019 medical Ecg

30/49

Rhythm

Normal Sinus

Sinus Arrhythmia

Sinus Arrest

8/12/2019 medical Ecg

31/49

Rhythm

ATRIAL Atrial Flutter

Atrial Fibrillation

Premature Atrial

Contraction

8/12/2019 medical Ecg

32/49

Rhythm Supraventricular

Catch all term

Supraventricular

Tachycardia

8/12/2019 medical Ecg

33/49

Rhythm

JUNCTIONAL

Junctional Escape

Accelerated Junctional

Premature Junctional

Contraction

8/12/2019 medical Ecg

34/49

Rhythm

VENTRICULAR V Fibrillation

V Tachycardia

Premature Ventricular

Contraction

8/12/2019 medical Ecg

35/49

Axis

General direction of electrical activity

Will not change your management

8/12/2019 medical Ecg

36/49

Interval PR

Block between atria and ventricles

Heart Block First, second, and third degree

QRS Block in the conduction system Bundle Branch Block

LBBB, LAFB, LPFB, RBBB

QT/QTc

8/12/2019 medical Ecg

37/49

8/12/2019 medical Ecg

38/49

QRS Interval

QRS complex = ventricular depolarization

QRS widening = delay in depolarization

8/12/2019 medical Ecg

39/49

QRS Interval Causes of QRS widening

Ventricular rhythm

Damage to the conduction system BBB

MI

Metabolic/Drugs

8/12/2019 medical Ecg

40/49

QRS Interval

8/12/2019 medical Ecg

41/49

QT/QTc Interval

QT

Normal

Prolonged

8/12/2019 medical Ecg

42/49

EKG Artifact

60 Hz interference

Muscle tremor

Wandering baseline

8/12/2019 medical Ecg

43/49

12 leads So far weve just done basic rhythm

recognition with a single lead.

What about the other 11 leads?

8/12/2019 medical Ecg

44/49

12 leads Each lead represents a different view of

the heart

More = better.

8/12/2019 medical Ecg

45/49

12 leads II p waves

Axis

Diseases Myocardial infarction

PE Hyperkalemia

Pericarditis

8/12/2019 medical Ecg

46/49

Practice

8/12/2019 medical Ecg

47/49

Practice

8/12/2019 medical Ecg

48/49

Practice

8/12/2019 medical Ecg

49/49

Practice