CHEST X-

RAY
GROUP H
GROUP MEMBERS
KUMI LAURITA SUNNY

KONDUA NANA ESI

ELLIS CORDELIA

ASEYORO DEBORAH ASALIWE

SASRAKU–MENSAH SAMUEL

KYEREMEH KOFI NANA POKU’

VISKA JENNIFER DANIEL

OUTLINE
PRINCIPLES OF CHEST X-RAY

INDICATIONS

MAJOR VIEWS AND POSITIONING IN A CHEST X-RAY

NORMAL CHEST X-RAY

CHEST X-RAY PATHOLOGIES

REFERENCES
WHAT ARE X-RAYS AND HOW ARE
THEY PRODUCED?
X-RAYS are a form of ionizing radiation that forms part of the electromagnetic spectrum and has
sufficient energy to cause ionization.
They are produced by focusing a high-energy beam of electrons from the X-ray tube onto a
tungsten target. if the electron has enough energy it can knock out another electron from the inner
shell of a tungsten atom emitting X-rays
The emitted X-rays then pass through the patient and onto the detector, producing an image.

Collimator light helps to know where the rays will be passing

THE RESULTING IMAGE ON THE X-
RAY FILM
The resulting image on the x-ray is a two-dimensional view of a 3-dimensional structure.

X-rays absorbed whilst passing through a person is in direct proportion to the density of the
structure.
 the greater the amount of radiation hitting a detector the darker it will appear. Materials of low
density appear darker than materials of high density.
Structures can be seen if there is sufficient contrast with the surrounding tissue.
HOW ARE THEY STORED?
In some hospitals radiographs are printed onto X-rays fim but presently there is the emergence of
a system known as PAC(Picture Archiving and Communication System).
This system enables one to view the images(radiograph) on the computer screen making it easy
to manipulate (example;- changing contrast, magnification)
There are many views, some of which are;- PA(posterior-anterior) erect- standard view.

AP(anterior-posterior) view

Lateral view

Oblique etc
HAZARDS AND PRECAUTION
Radiation hazards occur as a result of damage to cells by radiation and it depends on the
radiation dose and dose rate, volume of tissue irradiated, and type of radiation.

A. IRMER 2000 known as ionizing radiation medical regulations 2000 lay down the basic
measures for radiation protection for patients. There are three persons involved in protecting the
patient
1, the referrer;- an accredited health professional who must provide adequate and relevant
clinical information to enable the practitioner to justify the exposure
HAZARDS AND PRECAUTION
CONT’D
2;- the practitioner;- usually a radiologist who decides on the appropriate imaging and justifies
the exposure to radiation on a case-by-case basis.
3;-The operator;- usually a radiographer who performs the practical aspects. They keep all
justifiable exposure as low as reasonably possible.

B. Pregnant women; should avoid radiating the abdomen and pelvis and if not possible should be
done post-24 weeks gestation.
INDICATIONS
Evaluation of chest symptoms(cough, chest pain, shortness of breath, hemoptysis , fever,
unexplained weight loss.
 Evaluation of physical sign(e.g. hypoxemia , abnormal pulmonary examination.

Evaluation of nasogastric, endotracheal tubes and central venous lines.

screening for pneumothorax after lung biopsy and pacemaker placement.

 Evaluation of pacemaker lead fracture

MAJOR VIEWS AND POSITIONING OF A CHEST RADIOGRAPH

MAJOR VIEWS AND POSITIONING OF A CHEST RADIOGRAPH

MAJOR VIEWS AND POSITIONING OF A CHEST RADIOGRAPH

MAJOR VIEWS AND POSITIONING OF A CHEST RADIOGRAPH

MAJOR VIEWS AND POSITIONING IN A CHEST-XRAY

1. POSTERIOR-ANTERIOR (PA) VIEW

2. ANTERIOR-POSTERIOR (AP)

3. LATERAL VIEW

4. LATERAL DECUBITUS
POSTERIOR-ANTERIOR(PA)
POSITION
The standard position for obtaining a routine adult chest radiograph

Patient stands upright with the anterior wall of the chest placed against the front of the film

The shoulders are rotated enough to touch the film, ensuring that the scapulae do not obscure a
portion of the lung field
Usually taken with the patient in full inspiration

The PA film is viewed as if the patient is standing in front of you

PA POSITIONING
ANTERIOR-POSTERIOR(AP)
POSITION
 Used when the patient is debilitated, immobilized, or unable to cooperate with the PA procedure

Film is placed behind the patient’s back with the patient in the supine position

Heart is a great distance from the film hence appear more magnified than in a PA

The scapulae are usually visible in the lung fields because they are not rotated out of the view as
they are in the PA
ANTERIOR-POSTERIOR
POSITIONING
LATERAL POSITION
Patient stands upright with the left side of the chest against the film and the arms raised over the
head
Allows the viewer to see behind the heart and diaphragmatic dome

Typically a lateral view usually accompanies a PA/AP chest X-ray.

This can be helpful in settings where the single view is limited in localizing pathology

The position of the spine on the lateral view can help inform its direction (if the image is taken
from the right, the spine will be on the right side of the film vice versa)
LATERAL POSITION
In the image below a left lower lobar pneumonia
can be seen on both PA and right lateral views
LATERAL DECUBITUS POSITION
The patient lies on the right or left side rather than in the standing position as with the regular
radiograph
The radiograph is labeled according to the side that is placed down (a left lateral decubitus
radiograph would have the patient’s left side down against the film)
Is done for logistical reasons or to evaluate for the effect of gravity on the pathological findings
(i.e to assess for layering of pleural effusion that cannot be easily observed in an upright view)
LAYERING OF PLEURAL EFFUSION
IN LLDP
LATERAL DECUBITUS VIEW
In the images above, a small pleural effusion is suspected on the upright X-ray (left pane)

When the patient is put in the LLDP, layering of the fluid is observed (right pane) which further
supports the diagnosis of a likely pleural effusion
Alternating between these positions can help utilize gravity to help confirm suspicions of fluid in
the pleural space.
NORMAL CHEST X-RAY
EVALUATING CHEST X-RAY
QUALITY
On a CHEST X-RAY film look out for
◦ Name, age, and sex of patient
◦ Date X-Ray was taken
◦ Side markers (left/right side)

Review CHEST X-RAY film for

◦ Field of view/Projection
◦ Inspiration/Expiration
◦ Penetration
◦ Rotation/Positioning
IDENTIFY RIBS
© OFCP

Correct Contrast/ Penetration:

Pulmonary vessels visible in the lungs, behind the diaphragm and the hea

Para-aortic line visible

Vertebra contours visible behind the mediastinum

BAD CHEST X-
RAY FILM
POSITIONING
INTERPRETATION OF CHEST X-RAY
Observe and compare (where applicable to the other side)
◦ Trachea
◦ Mediastinum
◦ Hilum
◦ Heart and major vessels
◦ Parenchyma and pleura
◦ Diaphragm
◦ Sub-diaphragmatic
◦ Bones and soft tissue

Always request a lateral view to observe sternal and cardiac clear spaces
LUNG
FIELDS
CARDIAC DIAMETER

(a+b)/c

Normal = 0.42-0.50
CHEST X-RAY
PATHOLOGIES
 RIGHT LOBAR
CONSOLIDATION/PNEUMONIA

 Presence of air bronchogram with

opacification.

 Obliteration of the right mediastinal

border with reticulonodular opacities.

 The right hilum is obscured by the
consolidation.

 Differential Diagnoses: TB/ Miliary

lymphangitic
carcinomatosis/sarcoidosis
  Plain chest radiograph
PNEUMONIA was taken at 19:45.
 Erect AP view is taken
with a portable
machine.
 Visible ECG leads
seen.
 Lesion is in the middle
zone, the bottom has a
well-defined
demarcation and the
top has an ill-defined
Oblique fissure: separates middle demarcation. Found in
from lower lobe. the middle and upper
zone but predominantly
in the mid-zone.
 Air bronchogram

Air bronchogram  Diagnosis: right lobar

pneumonia.
 PNEUMONIA
 Plain chest x-ray in the PA view,
prominent hilar markings.

 The left cardiac border is

obliterated/obscured by ill-defined
irregular opacification in the left
lower lung zone.

 There is the presence of air

bronchogram

 Diagnosis: left lower zone

pneumonia
PNEUMONIA
 Portable plain chest x-ray in the AP
view in the supine position. The film is
rotated to the left.

 Patchy opacification in mid to lower

zones bilaterally which is obscuring
left the cardiac border.

 The presence of ECG leads left

internal jugular venous catheter, and
NG tube

 Diagnosis: bronchopneumonia

 Differential, ARDS, alveolar

pulmonary edema
PLEURAL EFFUSION  Plain chest x-ray in the PA view. There is
homogenous opacification of the middle and
lower zones of the right lung with a
meniscus.

 There is obliteration of the right cardiac

border, right dome of the diaphragm, right
costo-phrenic angle. The trachea is deviated
to the right.

 Diagnosis: right pleural effusion

 It is possible that the left lung may collapsed

or the head may be tilted
• A plain chest x-ray was taken
in the AP view. There are ECG
leads present.

• There is homogenous
opacification in the left middle
and lower lung zone with a
meniscus.

• There is nodular and reticular

(net-like) opacification
(reticulo-nodular opacities).

• Obliteration of the left costo-

phrenic angle left cardiac
border, and left diaphragm
dome.

• Diagnosis: para pneumonic

effusion, TB, metastasis to the
breast
PLEURAL EFFUSION
 Plain chest x-ray in the PA view. It
shows homogenous opacification of
the middle and lower lung zones
bilaterally with menisci.

 There is cardiac enlargement and

dilation of the great vessels.

 Obliteration of the left and right
cardiac borders, left and right hemi
diaphragm, and blunting of costo-
phrenic angle

 Diagnosis: bilateral pleural effusion

(secondary to heart failure)
 Causes of bilateral pleural effusion:
heart failure
Blunting of the costo-
phrenic angle
SUBPULMONIC EFFUSION  A plain chest x-ray was taken in the PA view.
 There is a homogenous opacification in the right
lower lung zone. There is also a sharp upper
border of the opacification.
 There is also obliteration of the right cardiac
border.
 Elevation of the right hemidiaphragm (>3 cm).

 Differentials: hepatomegaly, sub-pulmonic

effusion (fluid underneath the lung but above the
diaphragm), injury to the phrenic nerve, sub-
diaphragmatic collection (hemorrhage, abscess),
the collapse of the lower lobe of the right lung,
loculated ascites
 Injury to phrenic nerve, diaphragmatic
eventration.
 How to confirm: ultrasound

 If phrenic nerve palsy: look at the hilum

(relationship between hilum and phrenic nerve)
Dome is more lateral, this is
suggestive of sub-pulmonic effusion  DIAG: Subpulmonic effusion.
If effusion is small, the most dependent side would be the posterior recess of the lung
Views to help diagnose lateral, lateral decubitus
PLEURAL MASS  Plain chest x-ray was taken in the PA view.
 Well-defined homogenous opacification in the mid to
lower zone of the right hemithorax. It is dome-shaped
with a broad base attached to the pleura.
 There is an obtuse angle at the superior end of the base
and an acute angle at the inferior end of the base.
 Clear lung field, visible cardiac border

 Mass: > 3cm

Obtuse  Nodule: < 3cm
angle  If unsure, a lesion can be used.
 If both angles are obtuse then the lesion is in the
pleura.
 If both angles are acute then the lesion is in the lung.
Mass
 Differential: pleural mass, breast mass, metastasis,
Acute angle lipoma, loculated collected (abscess, effusion)

 It turned out to be a loculated effusion, insisted fluid

in the fissure
PLEURAL MASS

Homogenous opacification (same as next picture)

Differential; sub-pulmonic effusion, pleural mass
TENSION
PNEUMOTHORAX
 RIGHT PNEUMOTHORAX
 This is a plain chest X-ray showing the PA view.
 Absent lung markings on the right side compared to
the left.
 There's a linear shadow or demarcation of the right
lung (partial collapse so it’s moved medially)
 Trachea deviation to the left contralateral side.
 There's a deep sulcus sign on the left hemi
diaphragm. Mediastinum is also shifted to the left
side (the right border of the heart is obscured)
 There is also hyperinflation of the lung crossing over
to the left side- tension. The height of the diaphragm
is also depressed.

 Diagnosis: Right Tension Pneumothorax.

 Causes: Traumatic
 Spontaneous
 Ventilation of patient
pneumothorax

Right Tension Pneumothorax;

Langerhans cell histiocytosis
 RIGHT PNEUMOTHORAX
 B: There is a curvilinear opacity beyond
which there is absence of lung markings
at the upper zone of the right lung.
 Lung collapse.
 Hypertranslucency above.
 A was taken before B.
 Trachea is central.
 A is at inspiration and B is at expiration.
 To prove it they did an expiratory film
B to confirm diagnosis
Left Pneumothorax:
deep sulcus sign Rib fractures
HYDROPNEUMOTHO
RAX
 Pericardial Effusion:

Pericardial effusions occur when excess

fluid collects in the pericardial space 
A normal pericardial sac contains
approximately 30-50 mL of fluid).
 Pericardial effusion
Small pericardial effusions are often occult on plain film. Greater
than 200 mL of pericardial fluid is usually required to become
radiographically visible.

Radiographic signs include:

globular enlargement of the cardiac shadow giving a 

water bottle configuration

Lateral CHEST X-RAY may show a vertical opaque line (pericardial

fluid) separating a vertical lucent line directly behind the sternum
(pericardial fat) anteriorly from a similar lucent vertical lucent line
(epicardial fat) posteriorly; this is known as the Oreo cookie sign 5

serially enlarging cardiothoracic ratio

haemodynamic compromise may manifest with signs of cardiogenic 

pulmonary oedema
ALVEOLAR PULMONARY OEDEMA
PULMONARY EDEMA GRADING

Pulmonary edema grading based on chest radiograph appearances and pulmonary capillary

wedge pressure (PCWP) is as follows:

grade 0: normal chest radiograph, PCWP 8-12 mmHg

grade 1: shows evidence of upper lobe diversion on a chest radiograph, PCWP 13-18 mmHg

grade 2: shows interstitial edema on a chest radiograph, PCWP 19-25 mmHg

grade 3: shows alveolar edema on a chest radiograph, PCWP >25 mmHg

SEPTAL/KERLEY LINES IN LUNG
Are seen when the interlobular septa in the pulmonary interstitium become prominent.

This may be because of lymphatic engorgement or oedema of the connective tissues of the
interlobular septa.

They usually occur when pulmonary capillary wedge pressure reaches 20-25 mmHg.
 CLASSIFICATION OF KERLEY
LINES
Kerley A lines

These are 2-6 cm long oblique lines that are <1 mm thick and course towards the hila. They represent
thickening of the interlobular septa that contain lymphatic connections between the perivenous and
bronchoarterial lymphatics deep within the lung parenchyma.
On chest radiographs they are seen to cross normal vascular markings and extend radially from the hilum to
the upper lobes. HRCT is the best modality for the demonstration of Kerley A lines.
Kerley B lines

These are thin lines 1-2 cm in length in the periphery of the lung(s). They are perpendicular to the pleural
surface and extend out to it. They represent thickened subpleural interlobular septa and are usually seen at
the lung bases. 
CLASSIFICATION OF KERLEY
LINES CONT’D
Kerley C lines

Kerley C lines are short lines which do not reach the pleura (i.e. not B or D lines) and do not
course radially away from the hila (i.e. not A lines).
Kerley D lines

Kerley D lines are exactly the same as Kerley B lines, except that they are seen on lateral chest
radiographs in the retrosternal air gap. 
 Kerley B

 Linear horizontal short opacities.

 Found mostly in lower zone of lung or the
costophrenic angle. 1-2cm in length.
 Starts from pleura and goes to
mediastinum.

 Interstitial pulmonary oedema.

 HEART FAILURE
Approximately 70% accuracy using CHEST X-
RAY
With left-sided congestive cardiac failure, the
features are that of pulmonary oedema which
includes
◦ pulmonary venous congestion
◦ cephalisation of pulmonary veins
◦ pulmonary interstitial oedema
◦ pulmonary alveolar oedema
◦ cardiomegaly (may or may not be present
depending on aetiology)
◦ pleural effusion
Pacemaker generator.
Linear opacification in
the mid and lower zone.
Heart is enlarged.

Heart failure.
Enlargement Of Heart.
Dilatation Of Pulmonary
Vessels. Septal Thickening

Heart Failure With

Interstitial Pulmonary
Oedema
Perihilar Opacification.
Batwing Sign.
ECG
GROUP H
PRINCIPLES OF ECG
WHAT IS
ELECTROCARDIOGRAM(ECG)
It is a graphical representation of the electrical activity of the heart.

By examining changes from normal on the ECG, clinicians can identify a multitude of cardiac
disease processes.

06/06/2023 73
CARDIAC CONDUCTING SYSTEM

06/06/2023 74
ECG PHYSIOLOGY
The nodal tissues form the intrinsic electrical system within the heart that causes it to beat at the
correct rhythm in a coordinated fashion.

These nodal tissue are cardiomyocytes, with modified cell membrane proteins that allow them to
generate impulses rather than contract when they depolarise.

06/06/2023 75
ECG PHYSIOLOGY
The electrical signals generated from one nodal tissue is transmitted via gap junctions to the next.

This results in a very rapid transmission of electrical signals between the nodal tissue from the
fastest to the slowest

06/06/2023 76
ECG PHYSIOLOGY
The sinoatrial (SA) node depolarises the fastest thus is the pacemaker of the
heart

The atrioventricular (AV) node slows the electrical current from the SA node
before the current continues through the His Bundle, right and left bundle
branches and the Purkinje fibres.

06/06/2023 77
 THE NORMAL ECG
The normal ECG contains waves, intervals, segments and one complex.

Waves:
 A positive or negative deflection from baseline that indicates a specific electrical
event.

 The waves on a normal ECG include a normal P wave, Q wave, R wave, S wave ,T
wave and U wave.

06/06/2023 78
ELEMENTS OF THE ECG:

P wave: Depolarization of both atria;

 Relationship between P and QRS helps distinguish various cardiac arrhythmias

 Shape and duration of P may indicate atrial enlargement

 QRS complex: Ventricular depolarization
 The combination of multiple waves grouped together.
 The only main complex on an ECG is the QRS complex
 Larger than P wave because of greater muscle mass of ventricles
 Normal duration = 0.08-0.12 seconds
 Its duration, amplitude, and morphology are useful in diagnosing cardiac arrhythmias,
ventricular hypertrophy, MI, electrolyte derangement, etc.
 Q wave greater than 1/3 the height of the R wave, greater than 0.04 sec are abnormal and may
represent MI
T wave:
 Represents repolarization or recovery of ventricles

U wave:
 It is thought to be due to repolarization of the papillary muscles
 This wave is not always seen on the ECG of normal patients.
 Prominent U waves are seen in hypokalaemia and also hypercalcaemia
THE NORMAL ECG

06/06/2023 83
THE NORMAL ECG
Interval:
 The time between two specific ECG events.

 The intervals commonly measured on an ECG include PR interval, QRS interval (also called QRS duration),
QT interval and RR interval.

PR interval: from onset of P wave to onset of QRS

 Normal duration = 0.12-2.0 sec (120-200 ms) (3-4 horizontal boxes)
 Represents atria to ventricular conduction time (through the AV node to the His bundle)
 Prolonged PR interval may indicate a 1st degree heart block

06/06/2023 84
 ST Interval
 Measured from the end of the S wave to the end of the T wave

 QT Interval
 Measured from beginning of QRS to the end of the T wave
 Normal QT is usually about 0.40 sec
 QT interval varies based on heart rate

 RR Interval
 Measured from the peak of one R wave to the peak of the next R wave.
 This is a measure of the heart rate
THE NORMAL ECG

06/06/2023 86
THE NORMAL ECG
Segment:
 The length between two specific points on an ECG that are supposed to be at the baseline amplitude (not
negative or positive).

 The segments on an ECG include the PR segment, ST segment and TP segment

 ST segment:
• Connects the QRS complex and T wave
• Duration of 0.08-0.12 sec (80-120 msec)

06/06/2023 87
The Normal ECG

06/06/2023 88
INDICATIONS FOR ECG
To determine the cause of chest pain

To evaluate other signs and symptoms which may be heart-related , such as fatigue, shortness of
breath, dizziness, or fainting
To identify irregular heartbeats (Cardiac arrhythmias)
INDICATIONS FOR ECG
To determine the status of the heart prior to procedures such as surgery and /or after treatment for
conditions such as a heart attack (myocardial infarction), endocarditis or after procedures such as
heart surgery or cardiac catheterization.
To assess the function of an implanted pacemaker

Assessment of patients with electrolyte abnormalities and drug toxicities.

 ECG: LEADS PLACEMENT AND
POSITIONING
The heart muscle is capable of conducting an electrical impulse and initiating a spontaneous electrical
discharge

The 12-lead ECG is a graphical representation of these activities

The 12 lead ECG uses a series of electrodes placed on extremities and chest wall to assess the heart
from 12 different views.
ECG LEADS
The 12 lead ECG involves the use of 10 electrodes, six on the chest and four on the limbs

Three standard limb or bipolar leads(I, II, III) utilize three electrodes; these leads form a triangle
known as Einthoven’s Triangle

Three augmented leads (avR, avL, avF)

Six precordial unipolar leads (V1, V2, V3, V4, V5, and V6)
ELECTRODE PLACEMENT
STANDARD LIMB LEADS
These are bipolar leads.

Lead I: electrode on right arm(-ve) and left arm (+ve)

Lead II: electrode on the right arm (-ve) and left leg (+ve)

Lead III: electrode on left arm (-ve) and left leg (+ve)
STANDARD LIMB LEADS
With standard leads, when the electrical impulse is going towards the positive electrode, a
positive deflection occurs and when the impulse is going towards the negative electrode, a
negative deflection occurs.

For monitoring, the leads are usually placed on the right shoulder, left shoulder and left side of
the chest.
UNIPOLAR LEADS
With the unipolar leads, a potential difference is recorded between the exploring electrode and
indifferent electrod
Unipolar augmented limb leads aVR (right arm), aVL (left arm), aVF (left foot).

Augmented limb leads are recorded between one limb and the other 2 limbs. This increases the
size of the potential by 50%.
Unipolar chest leads V1-V6

With unipolar leads, when the electrical impulse is travelling towards electrode, the deflection is
positive and negative when is travelling away from the electrode
POSITIONING OF PATIENT
The standard 12-leads ECG is generally performed with the patient lying quietly in the supine
position
Care should be taken to ensure that the skin is clean and trimmed of excess hair in the areas in
which the leads are placed
In some instances, a mild abrasive pad can be used to prepare the skin in these areas to aid in
application of the lead
 NORMAL SINUS RHYTHM
 Rhythm is regular
 Normal P wave visible before each QRS complex
 PR interval normal
 QRS normal
 Normal T wave
CALCULATION OF HEART RATE
ECG recording normally runs at 25mm/sec

Therefore one small square (1mm) represents 0.04sec

1 big square (5mm) represents 0.2sec

 CALCULATION OF HEART RATE –
REGULAR RHYTHM
300/N where n is the number of big square between two R waves

1 big square represents 0.2 sec

Therefore, 1 second is represented by 5 big squares

1 minute represented by

 5 x 60 = 300 big squares

 Therefore,

 Heart Rate = 300/N

 OR
Heart rate = 1500/n

Where n is number of small squares between 2 R waves

 CALCULATION OF HEART RATE
The rhythm strip (usually in Lead II)

Choose a period in which to count the number of beats (e.g. 6 secs)

Number of big squares representing 6 second

= 6 secs / 0.2

= 30 big squares

Count the number of QRS complexes in 30 big squares

Multiply by 10 to get beats per minutes

 OR
Choose a period in which to count the number of beats (e.g. 10 secs)

Number of big squares representing 10 second

= 10 secs / 0.2

= 50 big squares

Count the number of QRS complexes in 50 big squares

Multiply by 6 to get beats per minutes

Atrial rate (P-P interval)

Count the number of P waves between 30 big squares

Take that number and multiply it by 10 to get beats/ minutes

In a normal sinus rhythm the atrial and ventricular rates are the same
SINUS BRADYCARDIA
Sinus rhythm

Rhythm regular

Rate < 60 bpm

QRS normal
SINUS TACHYCARDIA
Sinus rhythm

Rate >100 bpm

PR interval is normal

QRS complex normal

ATRIAL FIBRILLATION
Irregularly irregular rhythm

No P waves

Variable ventricular rate

Fibrillatory waves may be present

Fibrillatory waves may mimic P waves

ATRIAL FLUTTER
Atrial flutter with variable block

Saw tooth appearance of p wave

 SUPRAVENTRICULAR
TACHYCARDIA
Regular

No P waves

Narrow complexes

Heart rate >100 bpm

 VENTRICULAR TACHYCARDIA

A wide QRS complex heart rhythm (QRS duration beyond 120 milliseconds)

≥ 3consecutive ventricular beats with rate 100-250 bpm (If rate >250 bpm, it is a ventricular flutter)
 VENTRICULAR ECTOPIC
A premature beat arising from an ectopic focus within the ventricle

QRS widened >0.11sec

( Bigeminy, Couplets, Trigeminy)

 VENTRICULAR FIBRILLATION
Ventricles do not produce any meaningful contractions; they just fibrillate

Irregular waves with varying morphology and amplitude

No P-wave, QRS complex or T-wave can be seen

Relatively unstable baseline

 HEART BLOCK

First Degree Heart Block

Prolonged PR interval (>0.2)
 SECOND DEGREE HEART BLOCK
A) Mobitz Type I (Wenckebach)

Progressively increasing PR interval with

missed beats
i.e. P waves with no QRS complexes

B) Mobitz Type II

Missing a beat at regular interval

 THIRD DEGREE HEART BLOCK
(COMPLETE HEART BLOCK)
Complete dissociation between ‘P’ waves and ‘QRS’ complexes
 PACE-MAKER SPIKES
Indications For Preoperative Pacing

Symptomatic 1st Degree of Heart Block

Symptomatic second-degree heart block – Mobitz 1

 Second-degree heart block – Mobitz 2

Complete Heart Block / Third Degree Heart Block

 RIGHT BUNDLE BRANCH BLOCK
Broad QRS complexes (> 0.12 secs)

Appears to have 2 QRS

RSR pattern in V1 (M shaped)

Widened, Slurred S wave in V6 (W shaped)

LEFT BUNDLE BRANCH BLOCK
Inverted T wave and M pattern in V6

Dominant S in V1
 HYPERKALEMIA
Tented/Peaked T Waves, Flattening Of P Waves, Widening Of QRS Complex
 HYPOKALEMIA
Flattening and inversion of T waves (mild hypokalemia)

Prolonged QT interval

Visible U wave and mild ST segment depression (severe hypokalemia)

 WOLFF PARKINSON WHITE SYNDROME

Presence of a short PR interval (<1.2 secs)

Wide QRS complex (> 1.2 secs)

Delta wave (slurred QRS upstrokes)

Common sign Heart rate > 100 bpm

 LEFT VENTRICULAR FAILURE

QRS complex is increased and maybe widened

Deviation of ST segment in opposite direction of QRS

T wave inversion
MYOCARDIAL INFARCTION
ST elevation in some leads; II, III, V5
 PULSELESS ELECTRICAL ACTIVITY
(PEA)
Organized ECG rhythm NOT accompanied by a detectable pulse

Electromechanical dissociation - the hearts electrical activity is dissociated from mechanical activity

Rapid Heart rate

Broad QRS complexes

ASYSTOLE
No electrical activity / no atrial or ventricular depolarizations
MANAGEMENT
 NARROW COMPLEX TACHYCARDIA
If there is no pulse, start ACLS

If there is a pulse:

•ABC

•Establish monitoring

•Correct electrolytes problems

If patient is stable, initiate vagal maneuvers or give adenosine

 Carotid sinus massage

 Valsalva maneuver

 Ice cold water to face

 ATRIAL FIBRILLATION
TREATMENT

ABC

Wide bore cannula- investigations

Diuretics

Rhythm control: Amiodarone 5mg/kg bolus

 10mg/kg continuous

Rate control: Beta-blockers, digoxin

Cardioversion

LMW Heparin

MANAGEMENT IS SIMILAR TO ATRIAL FLUTTER

 BROAD COMPLEX TACHYCARDIA
If there is no pulse, start ACLS

If there is a pulse:

ABC

Establish monitoring

Correct electrolytes problems

If the patient is not stable (hypotensive, Heart rate >150, impaired sensorium), synchronized
direct current cardioversion shock

If the patient is stable, give Amiodarone 1v 300mg over 20 minutes to one hour and then 900 mg
over 24 hours
HYPERKALEMIA
Treat if K+ >6.5 mmol/L or ECG changes (e.g. tall tented T waves present)

ABC

Establish monitoring including

IV access

Insulin: 10 IU in 50ml of 50% dextrose to run over 30 mins to 1 hour

5-10ml of 10% Calcium gluconate OR 3-5ml of 10% of Calcium chloride

If severe hyperkalemia and or acidosis, consider dialysis

Others:

B2 agonist (Salbutamol)

Ion exchange resins

 HYPOKALEMIA
Mild to moderate hypokalemia

Oral Potassium supplements 60 – 80 mmol/day

Diets rich in K+

Severe hypokalemia

Nurse in ER/HDU

Establish monitoring including ECG

Central line
 Give KCL via central line
Urethral catheter and monitor urine output

Monitoring
 ECG
 Hourly blood K+ measurement
HEART BLOCKS
ABC

Second degree or third degree heart block

Insert a pacemaker

If surgery is urgent, you may insert a temporary transvenous wire

 MYOCARDIAL INFARCTION
Nurse in HDU/ICU

MONA

O2 enriched air

IV Morphine (given little at a time to prevent hypotension)

Aspirin (orally)

Nitrates (Glyceryl trinitrate- sublingual)

Cardiology review

Treat heart failure if present

MANAGEMENT OF HEART FAILURE
ACC/AHA NYHA STAGING DESCRIPTION MANAGEMENT
STAGING

A Pre-failure No symptoms but risk Treat obesity, HPT, Dm,

factors present Hyperlipidemia

B I Symptoms with severe ACEIs/ARBs, Beta-

exercise blockers, Diuretics

C II/III Symptoms with marked Add aldosterone antagonist,

(Class II) or mild (Class III) CRT, Hydralazine/nitrate
exercise

D IV Severe symptoms at rest Transplant, LVAD

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