1.BASIC ECG WORKSHOP FOR PARAMEDICDr. Rashidi Ahmad MD USM, MMED USM, FADUSMLecturer/EmergentistDept. of Emergency Medicine School of Medical SciencesUSM Health Campus Kelantan, Peninsular of Malaysia

2. What is an ECG? An ECG is a method of measuring, displaying and recording the electrical activity of a heart Electrical stimuli is amplified to create a rhythm strip by a machine that consistently produces representations of the hearts electrical activity 3. 1st ECG machine - 1920 4. Indications ECG is used as a baseline and screening test for CAD, cardiomyopathies, or left ventricular hypertrophy Preoperatively, TRO silent coronary artery disease. To detect metabolic alterations To evaluate patients with chest pain and in the management of patients with suspected or known ACS. To demonstrate ECG abnormalities in patients with myocardial, valvular, and congenital heart disease will eventually demonstrate. To evaluate rhythm disorders 5. EKG Precordial Leads 6. Vertical and horizontal perspectiveof the ECG LeadsLeads AnatomicalII, III, aVF Inferior surface of heart V1 to V4 Anterior surface of heart I, aVL, V5, and V6 Lateral surface of heart V1 and aVR Right atrium 7. Electrical impulse traveling directly towards the electrode produces an upright (positive) deflection relative to the isoelectric baseline 8. Components of a NSR 9. How to Read an EKG Strip 10. Electrocardiographic diagnosis Rate of waves Rhythm of waves Sequence of the waves in one cardiac cycle Presence or absence of waves within each cardiac cycle Duration of the waves Distance between waves in one cardiac cycle Configuration of waves 11. Sequence of reading ECG Identify P, QRS and T Rate Rhythm P wave PR interval QRS complex ST segment T wave QT interval U wave Morphological changes 12. Identify P, QRS and T 13. Rate determination Method I - Times Ten- Simplest, quickest, most commonlyused technique that is particularly usefulif the rhythm is irregular. Method II 1500 or 300 Method - Use only if cardiac rhythm is regular. If P & QRS are independent calculate atrial rate & ventricular rate separately 14. Determine the rate 15. Rhythm Regular, irregular, irregularly irregular 16. P wave P waves usually precede each QRS complex < 3 small squares in duration < 2.5 small squares in amplitude Commonly biphasic in lead V1 Best seen in leads II 17. I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 The P waves should be upright in I, II, and V2 to V6& negative in lead aVR 18. More P waves than QRS complexP waves entirely absent 19. QRS complex without P wave in front of them Abnormal P wave configuration 20. PR interval 21. 1.0 R PR interval0.5 T PR interval should be Millivolts P 0.12-0.20s or 3 to 5 littleQ0squares -0.5S 0200400 600 Milliseconds 22. QRS Complex 23. 1.0R 0.5 The width of the QRS MillivoltsT Pcomplex should not exceed0 Q0.12s or less than 3 littlesquares-0.5 S QRS0 200400 600Milliseconds 24. I II III aVR aVL aVF The QRS complex should bedominantly upright in leads Iand II 25. I II III aVR aVL aVFV1 V2 V3 V4 V5 V6 Non-pathological Q waves: < 2 small squares deep, < 1 small square wide, < 25% of the amplitude of the corresponding R wave There should be no Q wave or only a small q in I, II, V2 to V6 26. V6V5V4 V3V2 V1 The height of the R wave: variable & increases progressively across the precordial leads; < 27 mm in leads V5 and V6The R wave in lead V6,is often smaller than the R wave in V5 27. S wave S wave - Deepest in the right precordial leads Decreases in amplitude across the precordium, and is often absent in leads V5 and V6 The depth of the S wave should not exceed 30 mm in a normal individual 28. Which one are normal, RBB, LBB? 29. ST Segment Normal ST Segment is flat (isoelectric) Elevation or depression of ST segment by 1 mm or more, measured 0.08 s (or 2 small squares) past the J point is ABNORMAL 30. J point or a point up to 40 msec (one small square) beyond the J pointwere the favoured points of measurement. 31. I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 The ST segment should start isoelectric except in V1 and V2 where it may be elevated 32. Non-specific T and ST changes T-wave flattening: T-wave inversion: ST-segment scooping: ST-segment depression 33. T wave Asymmetrical: first half has a more gradual slope than second half < than 2/3 of R amplitude T wave amplitude rarely exceeds 10 mm 34. I II III aVR aVL aVFT and QRS tend to have thesame general direction inthe limb leads 35. I II IIIaVR aVL aVFV1 V2 V3 V4 V5 V6 The T wave must be upright in I, II, V2 to V6 36. Hyperacute T wave- Earliest change of AMI- Lasting only 5- 30 minutes from onset of pain 37. QT interval QT interval decreases when heart rate increases QT interval should be 0.35- 0.45 s, and should not be more than half of the interval between adjacent R waves (R-R interval). 38. U wave Normal U waves are small, round, symmetrical and positive in lead II, with amplitude < 2 mm (amplitude is usually < 1/3 T wave amplitude in same lead) U wave direction is the same as T wave direction in that lead More prominent at slow heart rates and usually best seen in the right precordial leads. 39. Summary 40. Sequence of reading ECG Identify P, QRS and T Rate Rhythm P wave PR interval QRS complex ST segment T wave QT interval U wave Morphological changes 41. Electrocardiographic diagnosis Rate of waves Rhythm of waves Sequence of the waves in one cardiac cycle Presence or absence of waves within each cardiac cycle Duration of the waves Distance between waves in one cardiac cycle Configuration of waves 42. Dr. Rashidi AhmadMD USM, MMED USM, FADUSM Pensyarah/Pakar Perubatan kecemasan Pusat Pengajian Sains Perubatan USM Kampus Kesihatan, Malaysia shidee_ahmad@yahoo.com+609 7663244