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Electrocardiograms (Ecgs)
Electrocardiograms (Ecgs)
(ECGs)
May 2019
LEAD PLACEMENT
Bipolar Augmented
- -
aVR + aVL
+
- + I
+ +
III II +
aVF
CHEST LEADS
His Bundle
Purkinje Fibers
VENTRICULAR DEPOLARIZATION
• Method 2
P WAVE
Normal:
• Height < 2.5 mm in lead II
• Width < 0.11 s in lead II
P WAVE ABNORMALITY
P WAVE ABNORMALITIES
Hyperkalemia:
• The following changes may be seen in hyperkalemia
- Small or absent P waves
- Atrial fibrillation
- Wide QRS
- Shortened or absent ST segment
- Wide, tall and tented T waves
- Ventricular fibrillation
P WAVE ABNORMALITIES
Normal PR interval:
Shorter PR interval:
• Wolf-Parkinson-White syndrome
- Short PR interval, less than 3 small squares
(120 ms)
- Slurred upstroke to the QRS indicating pre-
excitation (delta wave)
- Broad QRS
- Secondary ST and T wave changes
PR INTERVAL ABNORMALITIES
• QRS Axis
• Normal duration of complex is < 0.12 s (3 small
squares)
• NO pathological Q waves
• NO left or right ventricular hypertrophy
AXIS
• Using leads I and aVF, the axis can be
assigned to one of the four quadrants at a
glance
AXIS - NORMAL
• Both I and aVF +ve = NORMAL AXIS
• Lead I +ve and aVF -ve
-If the axis is in the "left" quadrant take your
second glance at lead II.
- Lead II +ve = NORMAL AXIS
- Lead II -ve = LEFT AXIS DEVIATION
AXIS - LEFT AXIS DEVIATION
Left anterior hemiblock
Left ventricular hypertrophy
Q waves of inferior myocardial infarction
Artificial cardiac pacing
Emphysema
Hyperkalemia
Wolff-Parkinson-White syndrome - right sided
accessory pathway
Tricuspid atresia
Ostium primum ASD
Injection of contrast into left coronary artery
AXIS - NORTHWEST TERRITORY
Anatomical Site Lead with Abnormal EKG complexes Coronary Artery most often responsible
Inferior II, III, aVf RCA
Antero Septal V1-V2 LAD
Antero Apical V3-V4 LAD (distal)
Antero Lateral V5-V6, I, aVL CFX
Posterior V1-V2 (Tall R, Not Q) RCA
PATHOLOGICAL Q WAVES
NON Q WAVE MI
• Not all MIs develop Q waves (up to 1/3 never do or
they develop and resolve)
• WHY?
• Infarct was not complete (transmural)
• Infarct occurred in a electrically “silent” area of
the heart, where an EKG cannot record the injury
• Acute Infarct (Q waves will eventually appear)
RIGHT VENTRICULAR
HYPERTROPHY (RVH)
Causes:
• Myocardial infarction, myocarditis, diffuse
myocardial disease
• Hypocalcemia, Hypercalcemia (Short QT),
hypothyrodism
• Subarachnoid hemorrhage, intracerebral
hemorrhage
• Drugs (e.g. Sotalol, Amiodarone)
• Heredity
ST SEGMENT
Normal ST segment:
• No elevation or depression
ST ELEVATION
Anatomical Site Lead with Abnormal EKG complexes Coronary Artery most often responsible
Inferior II, III, aVf RCA
Antero Septal V1-V2 LAD
Antero Apical V3-V4 LAD (distal)
Antero Lateral V5-V6, I, aVL CFX
Posterior V1-V2 (Tall R, Not Q) RCA
LOCATING THE DAMAGE
LOCATION: 12 LEAD
ST DEPRESSION
• Shortened QT interval
• Characteristic down-sloping ST depression
• Dysrhythmias
- Ventricular / atrial premature beats
- PAT (paroxysmal atrial tachycardia) with
variable AV block
- Ventricular tachycardia and fibrillation
- Many others
ACUTE POSTERIOR MI
• The mirror image of acute injury in leads V1 - 3
• (Fully evolved) tall R wave, tall upright T wave in leads
V1 -V3
• Usually associated with inferior and/or lateral wall MI
Mirror Test: Once you have determined an inferior (or other) MI has
occurred, you begin looking for reciprocal changes. If there is ST
depression in V1, V2, and V3, flip the EKG over and hold it up to the
light. Now read those leads flipped over. Are there significant Q
waves? Is the ST segment elevated with a coved appearance? Are
the T waves inverted? Answering yes tells you, there is a posterior
infarct as well.
ST DEPRESSION
Causes:
• Hyperkalemia
• Hyperacute MI
• LBBB
SMALL, FLATTENED OR
INVERTED T WAVES
Causes are plenty:
• Ischemia, age, race, hyperventilation, anxiety
• LVH, drugs, pericarditis, I-V conduction delay (RBBB),
• Electrolyte disturbances
• The most important thing to consider is INVERTED T waves
associated with Ischemia
COMMON ARRHYTHMIAS
Location Bradyarrythmia Tacharrythmia
SA node Sinus Bradycardia Sinus tachycardia
Sick Sinus Syndrome
Atria Atrial Premature Beats
Atrial Flutter
Atrial Fibrillation
Paroxysmal SVT
Multifocal Atrial Tachycardia
AV node Conduction Blocks (1,2 and 3)
Jxal escape rhythm
Ventricles Ventricular escape rhytm Ventricular premature Beats
VT
Torsades de pointes
Ventricular Fibrillation
SINUS BRADYCARDIA
• Treatment:
- Pacemaker
- Anti coagulation therapy
ATRIAL PREMATURE BEAT
• Treatment:
- Drugs (Digitalis, Verapamil, Beta blocker)
- Anticoagulation therapy
- Cardioversion
PAROXYSMAL ATRIAL TACHYCARDIA
OR SUPRAVENTRICULAR TACHYCARDIA
• Treatment:
- Cardioversion
- Lidocaine or Procainamide to get NSR
- Emergent care
- Long term care: ICD (implantable
cardioverter defibrillator)
TORSADES DE POINTES