Basic Ecg Unisma 2011

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Basic

Electrocardiography

dr. Andi Sulistyo Haribowo, Sp.PD.

Program Studi Pendidikan Dokter UNIVERSITAS ISLAM MALANG

2011



Learning Objectives

• Describe the basic physiology of the

conduction system.

• Describe the origin of a normal EKG.

• Identify the systematic approach to reading

an EKG.

• Recognize major abnormalities whenreading an EKG.



EKG Basics



What is an EKG?

The electrocardiogram (EKG) is a

representation of the electrical events of the

cardiac cycle.

Each event has a distinctive waveform, the

study of which can lead to greater insight intoa patient’s cardiac pathophysiology.



What types of pathology can we identify

and study from EKGs?

• Arrhythmias

• Myocardial ischemia and infarction

• Pericarditis

• Chamber hypertrophy

• Electrolyte disturbances (i.e. hyperkalemia,

hypokalemia)• Drug toxicity (i.e. digoxin and drugs which

prolong the QT interval)



Waveforms and Intervals



Cardiac Conduction



Cardiac Conduction

P

Q

R

S

T



Cardiac Conduction

PR

.12 - .20 s

Q

R

S<.12 s

ST

Seg.



Normal Sinus R hythm



Normal features of the electrocardiogram.



EKG Paper

• Measures time – horizontal in seconds

• Measures amplitude – vertical in milliamps

• Uses the Metric system• Is very good for accuracy



EKG Paper

1 mm

.04 sec.

.2 sec.



EKG Leads

Leads are electrodes which measure the

difference in electrical potential between either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point with

zero electrical potential, located in the center of the heart

(unipolar leads)



EKG Leads

The standard EKG has 12 leads: 3 Standard Limb Leads

3 Augmented Limb Leads

6 Precordial Leads

The axis of a particular lead represents the viewpoint from which

it looks at the heart.



Standard Limb Leads



Augmented Limb Leads



All Limb Leads



Precordial Leads

Adapted from: www.numed.co.uk/electrodepl.html



Precordial Leads



Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III(standard limb leads)

-

Unipolar aVR, aVL, aVF(augmented limb leads)

V1-V6



The Normal Conduction System



Conduction System

• SA node – Pacemaker

– 60-100 bpm

– P waves up in I, II, aVF

• Internodal Pathways

– AVN; RA contraction – Interatrial Pathways

– LA to depolarize



Conduction System• AV node

• Delays impulse by .1s

• PR segment

• AV junction

• AV node & His

• 40-60 bpm

• Purkinje/bundles• Ventricular depol

• 20-40 bpm



Conduction System



Conduction System

• Repolarization

– Direction is same as depolarization

• Autonomic Nervous System (ANS)

• Sympathetic Nervous System (SNS)

• Parasympathetic Nervous System (PNS)



EKG Basics



EKG Basics: P Wave

• Normal

– Width < .11 secs

– Height .5 to 2.5 mm

– Morphology

• Flat• Biphasic

• Absent



EKG Basics: P Wave

• Abnormal – Inversions

– Amplitude

• P-Pulmonale > 2.5 mm

– Duration

• P-Mitrale > .1 sec (or 2 ½ boxes)

– Absence



EKG Basics: QRS Complex

• Impulse travels quicker down the left bundle branch (LBB) than the right bundle branch

(RBB). Septum depolarizes L to R resulting in

a downward deflection• Both ventricles are activated simultaneously.

Since the RV is smaller, depolarizes quicker

resulting in the downward deflection• LV depolarizes resulting in the R wave



EKG Basics: QRS Complexes



6 Features of QRS• Duration: .05 - .10 secs

• Amplitude: > 5mm;

< 20 mm in limb, < 25 in anterior leads

• Presence of Q waves < 0.04 msec and< 2 mm normal in I, aVL, aVF, V5

• Axis

• Progression: Zone of transition V3-V4

• Configuration



EKG Basics: T waves and

U waves

• T waves occur in

– Same direction as QRS

– Height: < 5 mm in limb leads, <10 mm in

anterior leads

• U waves

– After T wave – Best seen in lead III

– Hypothermia/hypokalemia



EKG Basics



Chest Leads



Standard EKG

• 12 leads and rhythm strip

• Limb leads

– I, II, III, aVR, aVL, aVF• Anterior leads

– V1-V6

• Speed = 25 mm/sec

• Height = 10 mm



Variants of EKG• Source

– Age, Sex

– Body weight

– Chest configuration

– Heart position

– Food intake

– Temperature, Exercise

– Smoking, Hyperventilation

– Position of precordial leads



Variants of EKG

• Ideal time for EKG

• Bayes’ Theorem • Normal hearts have abnl EKGs

• Normal EKG does not r/o heartdisease



Systematic Approach

• Rate• Rhythm

• Axis

• Wave Morphology

– P, T, and U waves and QRS complex

• Intervals

– PR, QRS, QT

• ST Segment



Determining the Heart Rate

• Rule of 300

• 10 Second Rule



Rule of 300

Take the number of “big boxes” between

neighboring QRS complexes, and divide this

into 300. The result will be approximatelyequal to the rate

Although fast, this method only works for regular rhythms.



What is the heart rate?

(300 / 6) = 50 bpm

www.uptodate.com




(300 / ~ 4) = ~ 75 bpm

www.uptodate.com




(300 / 1.5) = 200 bpm



The Rule of 300

It may be easiest to memorize the following table:

# of big

boxes

Rate

1 300

2 150

3 100

4 75

5 60

6 50




33 x 6 = 198 bpm

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/



Rate Determination

• On 6 sec strip, count QRS complexes, X 10

• QRS on dark line of tracing, count large

boxes,÷

into 300



Rate Determination



Depolarization



Depolarization

EKG B i



EKG Basics

P W i L d II



P Waves in Lead II



D t i i th A i



Determining the Axis

• The Quadrant Approach

• The Equiphasic Approach

D t i i th A i



Determining the Axis

Predominantly

Positive

Predominantly

Negative

Equiphasic

Th Q d t A h



The Quadrant Approach

1. 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.



Q d A h E l 1



Quadrant Approach: Example 1

Negative in I, positive in aVF

RAD

The Alan E. Lindsay ECG

Learning Center

http://medstat.med.utah.ed

u/kw/ecg/

Q d t A h E l 2



Quadrant Approach: Example 2

Positive in I, negative in aVF Predominantly positive in II

Normal Axis (non-pathologic LAD)

The Alan E. Lindsay ECGLearning Center

http://medstat.med.utah.ed

u/kw/ecg/

Th E i h i A h



The Equiphasic Approach

1. Determine which lead contains the most equiphasic QRScomplex. The fact that the QRS complex in this lead isequally positive and negative indicates that the netelectrical vector (i.e. overall QRS axis) is perpendicular tothe axis of this particular lead.

2. Examine the QRS complex in whichever lead lies 90° awayfrom the lead identified in step 1. If the QRS complex in

this second lead is predominantly positive, than the axis of this lead is approximately the same as the net QRS axis. If the QRS complex is predominantly negative, than the netQRS axis lies 180° from the axis of this lead.



Eq iphasic Approach: E ample 2



Equiphasic Approach: Example 2

Equiphasic in II

Predominantly negative in aVL

QRS axis ≈ +150

°

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

A is



Axis

• Find the quadrant

• Isolate the isoelectric lead

– Smallest QRS voltage• Isolate the perpendicular lead

• Isolate the vector

• Double check your findings

Fi d th Q d t



Find the Quadrant

Fi d th Q d t



Find the Quadrant

1.

3.

Fi d th I l t i L d



Find the Isoelectric Lead

Fi di th A i



Finding the Axis

Fi di th A i



Finding the Axis

Rhythms/Arrhythmias



Rhythms/Arrhythmias

• Sinus

• Atrial

• Junctional

• Ventricular

Rhythms/Arrhythmias



CONTRIBUTING FACTORS (ACLS):

6H’s: Hypovolemia, Hydrogen ions

(Acidosis), Hypoxia, Hypo-/hyperkalemia,Hypoglycemia, Hypothermia

5T’s: Toxins, Tamponade (cardiac), Tension

pneumothorax, Thrombosis(coronary/pulmonary), Trauma

(hypovolemia)

Rhythms/Arrhythmias



Sinus Arrhythmias: Criteria/Types

• P waves upright in I, II, aVF

• Constant P-P/R-R interval

• Rate

• Narrow QRS complex

• P:QRS ratio 1:1

• P-R interval is normal and constant



Sinus Arrhythmias: Criteria/Types

• Normal Sinus Rhythm

• Sinus Bradycardia

• Sinus Tachycardia

• Sinus Arrhythmia

Normal Sinus Rhythm



Normal Sinus Rhythm

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:• (Q)RS Complex:

Regular

60-100 BPM

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Normal Sinus Rhythm



Normal Sinus Rhythm

• Rate is 60 to 100

Sinus Bradycardia



Sinus Bradycardia

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular

< 60 BPM

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Sinus Bradycardia



Sinus Bradycardia

• Can be normal variant

• Can result from medication

• Look for underlying cause

Sinus Tachycardia



Sinus Tachycardia

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular

> 100 and < 160 BPM

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Sinus Tachycardia



Sinus Tachycardia

• May be caused by exercise, fever,

hyperthyroidism

• Look for underlying cause, slow the rate

Sinus Dysrhythmia



Sinus Dysrhythmia

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Irregular

60-100 BPM

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Sinus Arrhythmia



Sinus Arrhythmia

• Seen in young patients

•Secondary to breathing

• Heart beats faster

Sinus Arrest



Sinus Arrest

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Irregular

Normal - slow

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

A i l A h h i C i i /



Atrial Arrhythmias: Criteria/Types

• P waves inverted in I, II and aVF

• Abnormal shape

– Notched

– Flattened

– Diphasic


A i l A h h i C i i /T



Atrial Arrhythmias: Criteria/Types

• Premature Atrial Contractions

• Ectopic Atrial Rhythm

• Wandering Atrial Pacemaker

• Multifocal Atrial Tachycardia

• Atrial Flutter

• Atrial Fibrillation

Premature Atrial Contractions



Premature Atrial Contractions

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Irregular (PACs);Non-compensatory

Depends on underlying rhythm

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Premature Atrial Contraction



Premature Atrial Contraction

• QRS complex narrow

• RR interval shorter than sinus QRS

complexes• P wave shows different morphology

than sinus P wave

Ectopic Atrial Rhythm



Ectopic Atrial Rhythm


• P wave inverted

Wandering Atrial Pacemaker



Wandering Atrial Pacemaker

• 3 different P wave morphologies

possible with ventricular rate < 100 bpm

Multifocal Atrial Tachycardia



Multifocal Atrial Tachycardia

• 3 different P wave morphologies

with ventricular rate> 100 bpm

Atrial Flutter



Atrial Flutter

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Atrial: Regular; Ventr.: Varies

Atrial: 250-300; Ventr.: Varies

Big F-Waves – Saw tooth pattern

Normally constant – may vary

.04-.12 s (40-120 ms)

Atrial Flutter



Atrial Flutter

• Regular ventricular rate 150 bpm

• Varying ratios of F waves to QRS

complexes, most common is 4:1

• Tracing shows 2:1 conduction

Atrial Flutter



Atrial Flutter

•Tracing shows 6:1 conduction

Atrial Fibrillation



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Irregularly irregular ventricular

Atrial: 350-750; Ventr.: Varies

Little F-Waves – no pattern

No discernable P waves

.04-.12 s (40-120 ms)

Atrial Fibrillation



Atrial Fibrillation

• Tracing shows irregularly irregular

rhythm with no P waves

• Ventricular rate usually > 100 bpm

Atrial Fibrillation



Atrial Fibrillation

• Tracing shows irregularly irregular

rhythm with no P waves

• Ventricular rate is 40

(Paroxysmal) Atrial Tachycardia



( y ) y

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular

> 150-250 BPM

Upright/Normal

.12-.20 s (120-200 ms)

.04-.12 s (40-120 ms)

Supraventricular Tachycardia



p y

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular

> 150-250 BPM

Indiscernible

None seen

.04-.12 s (40-120 ms)

Atrial Tachycardia



Atrial Tachycardia

• Tracing shows regular ventricular rate

with P waves that are different from sinus

P waves

• Ventricular rate is usually 150 to 250 bpm

Junctional Arrhythmias: Criteria



• P wave

– May be absent

• Buried in QRS

– If present

• inverted in leads I, II, and aVF

• Inverted after QRS





• PR interval < 0.12 secs

• Rate: Varies


Ju ct o a yt as: C te a

Junctional Arrhythmias: Types



y yp

• Premature Junctional Contractions

• Junctional Escape Rhythm

• Accelerated Junctional Tachycardia

• Junctional Tachycardia

• Reentrant Tachycardia

• AVNRT

Premature Junctional



Contractions

•R-R interval is shorter

• Beat is early, narrow QRS complex

•Inverted P wave

• P wave can be buried in QRS complex

Junctional Rhythm



y

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular

40-60 BPM

Inverted – prior to or after; absent

< .12s if present

.04-.12 s (40-120 ms)

Junctional Escape Rhythm



p y

• Junctional origin


Accelerated Junctional



Tachycardia



Junctional Tachycardia




• Rate is > 100

Rate Summary



• Sinus Tachycardia - 100-160 BPM

• Atrial Tachycardia - 150-250 BPM

• Atrial Flutter - 150-250 BPM

• Junctional Tachycardia - 100-180 BPM

AV Nodal Blocks



• Delay conduction of impulses from

sinus node

• If AV node does not let impulse

through, no QRS complex is seen

• AV nodal block classes:1st, 2nd, 3rd degree

First Degree AV Block



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Regular; can be irregular

Usually 60-100 BPM; Rhythm dep.

Upright/Normal

> .20 s (200 ms); Constant

.04-.12 s (40-120 ms)

1st Degree AV Block



1 Degree AV Block

• PR interval constant

• >.2 sec

• All impulses conducted

Second Degree AV Block (Type I)



(Type I)

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Atrial: Reg.; Ventr.: Regularly irreg.

Atrial: Normal; Vent.: Norm./Slow

Normal: extra P waves

Not constant; Lengthens - drops beat

Usually .04-.12 s (40-120 ms)

2nd Degree AV Block Type 1



g yp

• AV node conducted each impulse

slower and finally no impulse is

conducted

• Longer PR interval, finally no QRS

complex

Second Degree AV Block (Type II) Classical



(Type II) Classical

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Atrial: Reg.; Ventr.: Regular or irreg.

Atrial: Normal; Ventricular: Slow

Normal; extra P waves

Constant on conducted beats

Usually .04-.12 s (40-120 ms)

Second Degree AV Block (Type II) Variable



(Type II) Variable

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Atrial: Reg.; Ventr.: Regular or irreg.

Atrial: Normal; Ventricular: Slow

Normal; extra P waves

Constant on conducted beats

Usually .04-.12 s (40-120 ms)

2nd Degree AV Block Type 2



• Constant PR interval

• AV node intermittently conducts

no impulse

Third-Degree AV Block



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Atrial & Ventricular: Regular

Atrial: Normal; Vent.: 40-60; < 40

Normal: extra P waves

No Atrial/Ventricular Relationship

<.12 s (120 ms) Junct.;> .12 Ventr.

3rd Degree AV Block



• AV node conducts no impulse

• Atria and ventricles beat at intrinsicrate (80 and 40 respectively)

• No association between P waves andQRS complexes

Another Consideration:Wolfe Parkinson White (WPW)



• Caused by bypass

tract

•AV node is bypassed,delay

• EKG shows short PR

interval <.11 sec

• Upsloping to QRS

complex (delta wave)

Wolfe-Parkinson-White (WPW)

WPW



• Delta wave, short PR interval

Ventricular Arrhythmias:



Criteria/Types

• Wide QRS

complex

• Rate :variable

• No P waves

• Premature Ventricular Contractions

• Idioventricular Rhythm

• Accelerated IVR

• Ventricular Tachycardia

• Ventricular Fibrillation

Premature Ventricular Contractions



Contractions

• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Irregular (PVCs); Compensatory

Depends on underlying rhythm

None on premature beat

None on PVCs

> .12s (120 ms) on PVC

Premature Ventricular Contraction



• Occurs earlier than sinus beat

• Wide, no P wave



Idioventricular Rhythm



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Usually Regular

15-40 BPM

None

None

> .12 s (120 ms);exaggerated

Idioventricular Rhythm



• Escape rhythm

• Rate is 20 to 40 bpm

Accelerated Idioventricular Rhythm



• Rate is 40 to 100 bpm

Ventricular Tachycardia



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Usually Regular

100-250 BPM

If present, not associated

None

> .12s (120 ms)

Ventricular Tachycardia



• Rate is > than 100 bpm

Torsades de Pointes



• Occurs secondary to prolongedQT interval

Ventricular Tachycardia/Fibrillation



• Unorganized activity of ventricle

Ventricular Fibrillation



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Chaotic;no set rhythm;fine/coarse

None

Absent

Absent

No discernable; medium F-waves

Ventricular Fibrillation



Asystole



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

No electrical activity

No electrical rhythm

Absent

Absent

Absent

Pacemaker Rhythm



• Rhythm:

• Rate:

• P Waves:

• P-R Interval:

• (Q)RS Complex:

Paced: Reg.; Demand: Irregular

Varies with pacemaker rate

May be present

No relationship

> .12 s (120 ms);Ventricular



Chamber Enlargements

Left Ventricular Hypertrophy (LVH)



• Differential Diagnosis – Hypertension (HTN)

– Aortis Stenosis (AS)

– Aortic Insufficiency (AI)

– Hypertrophic Cardiomyopathy (HCM)

– Mitral Regurgitation (MR) – Coarctation of the Aorta (COA)

– Physiologic

Left Ventricular Hypertrophy (LVH)



• False positive – Thin chest wall

– Status post mastectomy

– Race, Sex, Age

– Left Bundle Branch Block (LBBB)

– Acute MI

– Left Anterior Fascicular Block

– Incorrect standardization

Estes Criteria: Diagnosis of LVH



Right Ventricular Hypertrophy: Causes



• Chronic Obstructive Pulmonary Disease

• Pulmonary HTN

– Primary• Pulmonary Embolus

• Mitral Stenosis

• Mitral Regurgitation

• Chronic LV failure

Right Ventricular Hypertrophy: Causes



• Tricuspid Regurgitation

• Atrial Septal Defect

• Pulmonary Stenosis

• Tetralogy of Fallot• Ventricular Septal Defect

Right Ventricular Hypertrophy



Right Ventricular Hypertrophy



• Reversal of precordial pattern

– R waves prominent in V1 and V2 – S waves smaller in V1 and V2

– S waves become prominent in V5 and V6

Strain



Left Atrial Enlargement: Causes



• Mitral Stenosis

• Mitral Regurgitation

• Left ventricular hypertrophy

• Hypertension

• Aortic Stenosis

• Aortic Insufficiency

• Hypertrophic Cardiomyopathy

Left Atrial Enlargement: Criteria



• P wave

• Notch in P wave

– Any lead – Peaks > 0.04 secs

• V1 – Terminal portion of P wave > 1mm deep

and > 0.04 sec wide

Lead II



P Wave: Left Atrial Enlargement



Left Atrial Enlargement



Right Atrial Enlargement: Causes



• CHD – Tricuspid Stenosis

– Pulmonary Stenosis

• COPD

• Pulmonary HTN

• Pulmonary Embolus• Mitral Regurgitation

• Mitral Stenosis

Right Atrial Enlargement: Criteria



• Tall, peaked P wave

> 2.5 mm in any lead

• Most prominent P waves in leads I, II

and aVF

Right Atrial Enlargement



Bundle Branch Blocks

Bundle Branch Blocks



• Complete

– QRS > .12 secs

• Incomplete

– QRS .10 - .12 secs

• Left – Complete

– Incomplete

• Right

– Complete – Incomplete

Left Bundle Branch Block: Causes



• Normal variant

• Idiopathic degeneration of the

conduction system

• Cardiomyopathy

• Ischemic heart disease

• Aortic Stenosis

• Hyperkalemia

• Left Ventricular Hypertrophy

Criteria for Left Bundle Branch

Block (LBBB)



Block (LBBB)

• Bizarre QRS Morphology

– High voltage S wave in V1, V2 & V3

– Tall R wave in leads I, aVL and V5-6• Often LAD

• QRS Interval

• ST depression in leads I, aVL, & V5-V6• T wave inversion in I, aVL, & V5-V6

Left Bundle Branch Block



Right Bundle Branch Block:

Causes



Causes

• Idiopathic degeneration of the conduction

system

• Ischemic heart disease• Cardiomyopathy

• Massive Pulmonary Embolus

• Ventricular Hypertrophy• Normal Variant

Criteria for Right Bundle Branch

Block (RBBB)



Block (RBBB)

• QRS morphology

– Wide S wave in leads I and V4-V6

– RSR’ pattern in leads V1, V2 and V3

• QRS duration

• ST depression in leads V1 and V2

• T wave inversion in leads V1 and V2

Right Bundle Branch Block



Anterior Septal with RBBB



Ischemia and Infarction



Ischemia



•

T wave inversion, ST segment depression•Acute injury: ST segment elevation

•Dead tissue: Q wave



Chest Leads



Position of Anterior Leads



• V1 – Right 4th ICS

• V2

– Left 4th

ICS• V3

– Left Sternal border

– Between V2 andV4

• V4

– Left MCL

– 5th ICS

• V5

– Anterior axillary line

– 5th ICS

• V6

– Mid axillary line

– 5th ICS

Blood Supply to the Myocardium



• Left Anterior Descending (LAD) artery

– Bulk of LV

• Anterior wall

• Apex

• Part of lateral wall• Part of septum




• Right Coronary Artery (RCA)

– Right Ventricle

– Sinus Node 60% of the time

– Right Atrium

– Posterior Descending Artery (PAD) 90% of the time




• Left Circumflex (LCFLX) artery

– Lateral Wall & Posterior Wall of LV & LA

– SA node 40% of the time

– PDA 10% of the time

• Posterior Descending Artery (PAD)

– Off RCA 90%/LCFLX 40%

– AVN, prox BB, IW/PW, basal septum

View of the Leads

• II III aVF • V1 & V2



• II, III, aVF

– Inferior Wall//RV

– RCA distribution

• I, aVL

– Lateral Wall

– LCFLX/distal LAD

distribution

• aVR

– R side of heart

V1 & V2

– Intraventricular septum

– Proximal LAD

• V3 & V4 – Anterior wall

– Mid LAD

• V5 & V6 – Lateral wall

– Distal LAD

Arrangement of Leads on the EKG



Anatomic Groups(Septum)



Anatomic Groups(Anterior Wall)



Anatomic Groups(Lateral Wall)



Anatomic Groups(Inferior Wall)



Anatomic Groups(Summary)



Standard EKG



Anterior MI



Anterior-septal MI



Inferior AMI



Right Sided Leads



Right Ventricular AMI



Lateral MI



Posterior Leads



Posterior AMI



Inferior-RV-Posterior AMI



ST-T Wave Changes

Strain in Hypertrophy



Strain in LVH



Strain in RVH



Strain vs Infarction



Pericarditis



Digoxin Changes



Ventricular Aneurysm



T waves



TIME FOR

SOME



REMEMBER!!!



• Use a systematic approach

• Go through all the steps

• Take your time!• Compare with your characteristics list

• Interpret the dysrhythmia

Atrial Flutter



• Rhythm:

• Rate:

• P Waves:


Irregular

70

Big F (Flutter) Waves

.20 s Normal; .04-.12 s

Sinus Dysrhythmia



• Rhythm:

• Rate:

• P Waves:


Irregular

60 BPM

Normal; upright

.16 s Normal

Third Degree Heart Block



• Rhythm:

• Rate:

• P Waves:


Regular

37 BPM

Normal; upright; extra

Non-constant; No relationship Normal

Sinus Tachy with PVCs (UF)



• Rhythm:

• Rate:

• P Waves:


Irregular (due to ectopics)

110 BPM

Present underlying; none ectopics

.16 s Normal; .16 for ectopics

Sinus Arrest



• Rhythm:

• Rate:

• P Waves:


Regularly Irregular; loses complexes

40 BPM

Normal; upright

.16 s Normal

Sinus Rhythm with PAC



• Rhythm:

• Rate:

• P Waves:



60

Normal; upright; present for ectopic

.18 s; .14 s for ectopic Normal for all complexes

Sinus Rhythm with V-Tach



• Rhythm:

• Rate:

• P Waves:



80 BPM

Normal; upright – none for ectopics

.14 s; none on ectopics Normal; .14 s on ectopics

Acute Anterior MI



Summary



• You need to learn the definitive

characteristics

• Use a complete, systematic approach to

dissect the rhythm

• Take your time

• Mistakes are made when steps are skipped

• Practice! Practice! Practice!

Basic Ecg Unisma 2011

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Transcript of Basic Ecg Unisma 2011