All things ECG
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Transcript of All things ECG
All things ECG
Basics - ECG LeadsThe standard EKG has 12 leads:
3 Standard Limb Leads3 Augmented Limb Leads6 Precordial Leads
The axis of a particular lead represents the viewpoint from which it looks at the heart.
Basics – precordial leads
Precordial leads
Standard Limb Leads
Lead I: • Left arm to right armLead II: • Left leg to right armLead III: • Left leg to left arm
Waveforms
P Wave. Caused by depolarization of the atria. With normal sinus rhythm, the P wave is upright in leads I, II,
aVF, V4, V5, and V6 and inverted in aVR. QRS Complex.
Represents ventricular depolarization Q Wave.
The first negative deflection of the QRS complex (not always present and, if present, may be pathologic).
To be significant, the Q wave should be > 25% of the QRS complex.
T Wave. Caused by repolarization of the ventricles and follows the
QRS complex Normally upright in leads I, II, V3, V4, V5, and V6 and inverted
in aVR
What do they mean?
ECG paper
1. Rate 2. Rhythm3. Axis4. Interval
How to read an ECG systematically
1. Rate- Rule of 300
Take the number of “big boxes” between neighboring QRS complexes, and divide this into 300. The result will be approximately equal to the rate
Although fast, this method only works for regular rhythms.
Bradycardia: Heart rate < 50 beats/min Tachycardia: Heart rate > 100 beats/min
Abnormalities
What is the heart rate?
(300 / 6) = 50 bpm
www.uptodate.com
What is the heart rate?
(300 / 1.5) = 200 bpm
The Rule of 300It may be easiest to memorize the following
table:# of big boxes
Rate
1 3002 1503 1004 755 606 50
Sinus Rhythms Normal: Each QRS preceded by a P wave (which is
positive in II and negative in aVR) with a regular PR and RR interval and a rate between 60 and 100 beats/min
2. Rhythm
http://www.bem.fi/book/19/19.htm
Lead II : sinus arrhythmia in a healthy 26 year-old woman. Note the marked variation in the P-P intervals induced by respiration. Courtesy of Morton Arnsdorf, MD.http://www.uptodate.com/contents/image?imageKey=CARD/2987
Normal rhythm strip in lead II. The PR interval is 0.15 sec and the QRS duration is 0.08 sec. Both the P and T waves are upright. Courtesy of Morton Arnsdorf, MD.http://www.uptodate.com/contents/image?imageKey=CARD/2987
3. The QRS AxisThe QRS axis represents the net overall direction of
the heart’s electrical activity.
Abnormalities of axis can hint at:Ventricular enlargementConduction blocks (i.e. hemiblocks)
The QRS AxisBy 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)
Determining the Axis
Predominantly Positive
Predominantly Negative
Equiphasic
The Quadrant Approach1. Examine the QRS complex in leads I and aVF to
determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.
The Quadrant Approach2. In the event that LAD is present, examine lead II to
determine if this deviation is pathologic. If the QRS in II is predominantly positive, the LAD is non-pathologic (in other words, the axis is normal). If it is predominantly negative, it is pathologic.
Quadrant Approach: Example 1
Negative in I, positive in aVF RAD
The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.edu/kw/ecg/
Quadrant Approach: Example 2
Positive in I, negative in aVF Predominantly positive in II
Normal Axis (non-pathologic LAD)
The Alan E. Lindsay ECG Learning Center http://medstat.med.utah.edu/kw/ecg/
PR <0.2 sec, QRS <0.12 sec, QT <0.4 sec P wave
Always positive in leads I and II Always negative in lead aVR <3 small squares in duration <2.5 small squares in amplitude
QRS A normal QRS width should be less than 0.12 s.
ST segment Normally isoelectric
4. Intervals
What are these?
ST elevation
Normal T wave is asymmetrical First half having more gradual slope than the
second half Amplitude rarely exceeds 10 mm Abnormal T waves are symmetrical, tall,
peaked, biphasic or inverted As a rule T waves follows direction of main
QRS deflection Normal T wave is always negative in lead
aVR and positive in lead II
T waves
QT interval decreases when HR increases Should not be more than half of the interval
between adjacent R waves (R-R interval)
QT interval http://www.slideshare.net/cksheng74/tutorial-in-basic-ecg-for-medical-students
Acute anterior wall ST elevation MI (STEMI) Note the marked ST elevations and hyperacute T waves in the anterior/lateral leads, including V2-V5, I and aVL.
Acute transmural anterior wall myocardial infarction
Chronic anterior wall myocardial infarctionA chronic anterior wall infarction is diagnosed by the presence of initial deep and broad Q waves in any of the precordial leads; in this case they are present in leads V1 to V4.
http://www.uptodate.com/contents/ecg-tutorial-basic-principles-of-ecg-analysis?source=related_link#H18
ECG made easy page 138 (7th edn.) has list of all problems and what to expect on an ECG