microsoft powerpoint - ecg workshop
TRANSCRIPT
Simon Simon AbouAbou JaoudJaoudééCardiology DepartmentCardiology Department
HôtelHôtel--DieuDieu
ECG reading: the common and dangerous
ECG reading: the ECG reading: the common and dangerouscommon and dangerous
Review essential technical aspects of ECG recordingReview essential technical aspects of ECG recording
Content and ObjectivesContent and Objectives
Distinguish between Distinguish between ““normalnormal”” and and ““abnormalabnormal”” ECG findingsECG findings
List the criteria for heart blocks and WPWList the criteria for heart blocks and WPW
Recognize arrhythmia type during sustained tachycardiaRecognize arrhythmia type during sustained tachycardia
Identify main ECG abnormalities caused by MI and ischemiaIdentify main ECG abnormalities caused by MI and ischemia
common technical pitfallscommon technical pitfalls
Lead placementLead placement
FFIILLTTEERR
OONN
Paper SpeedPaper Speed
50 mm/sec 25 mm/sec
0,04 sec 0,2 sec
TEMPS
VO
LT
AG
E
25mm/sec
10 m
m/m
V 0,04 sec
motion motion artifactartifact
--breathingbreathing
stop breathingstop breathing
Auto modeAuto mode
Lead InversionLead Inversion
L R
Normal ECG ??Normal ECG ??
•• 62 y 62 y •• emergency departmentemergency department•• chest painchest pain
•• 62 y 62 y •• emergency departmentemergency department•• chest painchest pain
T wave polarity depends on T wave polarity depends on
T wave axisT wave axis
I
II
III
Frontal PlaneFrontal Plane
T wave is always positive in leads I and IIT wave is always positive in leads I and II
may be negative in lead III.may be negative in lead III.
T wave is always positive in T wave is always positive in precordialprecordialleads.leads.
(except V1: may be negative)(except V1: may be negative)
• 75 y W• elective cholecystectomy• pre op ECG
Normal ECG ??Normal ECG ??
I
ExpirationExpiration InspirationInspiration
Positional Q waves (Positional Q waves (septalseptal Q waves)Q waves) often disappears with often disappears with change in heart orientation associated with deep inspiration change in heart orientation associated with deep inspiration
• 33 y M• ER• chest pain x 3 hours
Normal ECG ??Normal ECG ??
““Early Repolarisation SyndromeEarly Repolarisation Syndrome”” ““High takeHigh take--off ST segmentoff ST segment””
TachycardiaTachycardia
Atrial Fibrillation
TachycardiaTachycardia (HR > 100/min)(HR > 100/min)
RegularRegularIrregularIrregular
Atrial Fibrillation
SVTSVT
TachycardiaTachycardia (HR > 100/min)(HR > 100/min)
RegularRegularIrregularIrregular
Atrial Fibrillation
NarrowNarrow QRS tachycardiaQRS tachycardia(< 0.12 sec)(< 0.12 sec)
WideWide QRS tachycardiaQRS tachycardia(> 0.12 sec)(> 0.12 sec)
““ SVTsSVTs ””
Sinus Tachycardia
Atrial Tachycardia
Atrial Flutter
AVNRT-AVRT(Bouveret)
VTVT
““ SVTsSVTs ””
+ WPW
+ BBB
VTVT
P wave ?
Identifying P wave: several approaches
- Spontaneous on surface ECG(compare with previous tracings)
- Lewis lead (DI on chest)- Esophageal lead- Epicardiac lead (post open heart)- CSM, ATP, AdenosineAdenosine
Analyze P wave- Morphology- Timing- Rate
““ SVTsSVTs ”” (Regular, Narrow QRS tachycardia)
Analyze P wave- Morphology- Timing- Rate
“sinus” morphology: positive P wave in leads I and Vf
P P wavewave
II
aVfaVf
Analyze P wave- Morphology- Timing- Rate
“P” wave rate
120-150 250 350 /min
Sinus Atrial Atrial Atrialtachy tachy flutter fibrillation
sinus tachycardia
Regular narrow QRS tachycardia at 150/minRegular narrow QRS tachycardia at 150/min AdenosineAdenosine
Regular P waves at 150/minRegular P waves at 150/minAdenosineAdenosine
1/1 Atrial Tachycardia
ATPATP Regular P waves at 300/minRegular P waves at 300/min
Regular tachycardia at 150 / minRegular tachycardia at 150 / min 2/1 Atrial Flutter
AVNRT
AdenosineAdenosine
Adenosine
2003 ACC/AHA/ESC Guidelines for Management of SVA
ECG in CADECG in CAD
definedefine
-- typetype of ischemic changesof ischemic changes-- localizationlocalization of ischemic changesof ischemic changes
ECG in CADECG in CAD
Q waveQ wave
ST changesST changes
T wave T wave changeschanges
depolarization depolarization abnormalitiesabnormalitiesirreversibleirreversibleInfarction:Infarction:
1/ elevated ST1/ elevated ST
2/ depressed ST2/ depressed STrepolarisation repolarisation abnormalitiesabnormalitiesreversiblereversibleInjury :Injury :
1/ inverted T wave1/ inverted T wave
2/ Peaked T wave2/ Peaked T waverepolarisation repolarisation abnormalitiesabnormalitiesreversiblereversibleIschemia :Ischemia :
-- typetype of ischemic changesof ischemic changes
ECG in CADECG in CAD
Inverted T waveInverted T wave
Peaked T wavePeaked T wave
Elevated STElevated ST
Depressed STDepressed ST
IschemiaIschemia
InjuryInjury
antero-apical postero-inferior
antero-lateral
anterior
antero-septal
RV
postero-basal
Lateral Lateral viewview
Localization of ischemic changesLocalization of ischemic changes
anterioranteriorviewview
V1V1V2V2 V3V3
V4V4
V5V5
V6V6
VL VL leadlead I I
II III VFII III VF
V4rV4rV3rV3r
++
++antero-septal : V1 V2
apical : V3 V4
lateral : V5 V6
high lateral : I -VL
anterior : V1 - V6
postero-inferior : II -III -VF
postero-basal : V7 V8 V9
RV : V3r V4r
Localization of ischemic changesLocalization of ischemic changes
Heart blocks and WPWHeart blocks and WPW
AV node
His
-- Sinus dysfunctionSinus dysfunction
-- AV BlockAV Block
Heart blocksHeart blocks
PR > 0,2 secPR > 0,2 sec
1st degree AV block
«« progressiveprogressive »» AV blockAV block
Mobitz 1 AV block
constant PRconstant PRblocked P waveblocked P wave
Mobitz 2 AV block
P waveP wave
QRSQRS
Complete AV block
AV dissociationAV dissociation
sinus arrestsinus arrest
junctionaljunctional escape rhythmescape rhythm
Sinus dysfunction
KENTKENT
Wolf Parkinson White Syndrome Wolf Parkinson White Syndrome
Zone ventriculaire préexcitée
Zone excitée normalement
Wolf Parkinson White Syndrome Wolf Parkinson White Syndrome