ECG made easy - GenesisCare
Transcript of ECG made easy - GenesisCare
![Page 1: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/1.jpg)
ECG made easy
1
• Presented by:• Dr Randall Hendriks, Interventional Cardiologist – Western Australia
![Page 2: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/2.jpg)
Reading an ECG
•The ECG does not have to be intimidating•Establish a consistent approach to interpreting ECGs•Do not rely on machine reads• Interpret the ECG in the context of the clinical history
![Page 3: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/3.jpg)
The Normal Conduction System
![Page 4: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/4.jpg)
Lead Placement
aVF
![Page 5: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/5.jpg)
All Limb Leads
![Page 6: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/6.jpg)
Precordial Leads
![Page 7: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/7.jpg)
Components of a normal ECG
•P wave - atrial depolarisation•PR interval - AV node + His-P•QRS - ventricular depolarisation•T wave - ventricular repolarisation
![Page 8: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/8.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments•T waves (and others)
![Page 9: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/9.jpg)
Rate
• Rule of 300 - divide 300 by the number of boxes between each QRS = rate
• Count QRS in10 second rhythm strip x 6
![Page 10: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/10.jpg)
Rate
•HR of 60-100 per minute is normal•HR > 100 = tachycardia•HR < 60 = bradycardia
![Page 11: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/11.jpg)
Single Lead ECG: Provides
Heart rate: normal 60 – 100
Remember:Pulse rate may not equal heart rate
![Page 12: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/12.jpg)
ECG interpretation
•Rate
•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments•T waves (and others)
![Page 13: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/13.jpg)
Rhythm
•Sinus •Originating from SA node•P wave before every QRS•P wave in same direction as QRS
![Page 14: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/14.jpg)
ECG interpretation
•Rate•Rhythm
•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments•T waves (and others)
![Page 15: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/15.jpg)
![Page 16: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/16.jpg)
Left axis deviation: check lead II
![Page 17: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/17.jpg)
Right axis deviation: check lead I
![Page 18: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/18.jpg)
ECG interpretation
•Rate•Rhythm•Axis
•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments•T waves (and others)
![Page 19: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/19.jpg)
P wave
![Page 20: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/20.jpg)
RA enlargement
![Page 21: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/21.jpg)
LA enlargement
![Page 22: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/22.jpg)
Bi-atrial enlargement
![Page 23: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/23.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave
•Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments•T waves (and others)
![Page 24: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/24.jpg)
Normal Intervals
•PR• 0.20 sec (less than one large box)
![Page 25: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/25.jpg)
Blocks
•AV blocks•First degree block •PR interval fixed and > 0.2 sec •Second degree block, Mobitz type 1 •PR gradually lengthened, then drop QRS •Second degree block, Mobitz type 2 •PR fixed, but drop QRS randomly•Type 3 block •PR and QRS dissociated
![Page 26: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/26.jpg)
First Degree Heart Block
Page 26
![Page 27: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/27.jpg)
Page 27
2nd degree, Mobitz I (Wenckebach phenomenon)
![Page 28: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/28.jpg)
2nd degree, Mobitz II
![Page 29: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/29.jpg)
2nd degree, “high-grade AV block”
![Page 30: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/30.jpg)
Page 30
3rd degree (complete heart block)
![Page 31: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/31.jpg)
Normal Intervals
•PR• 0.20 sec (less than one large box)
•QRS• 0.08 – 0.10 sec (1-2 small boxes)
![Page 32: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/32.jpg)
LBBB: QRS >120ms
![Page 33: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/33.jpg)
RBBB: QRS >120ms
![Page 34: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/34.jpg)
Incomplete RBBB: QRS < 120ms
![Page 35: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/35.jpg)
Normal Intervals
•PR• 0.20 sec (less than one large box)•QRS• 0.08 – 0.10 sec (1-2 small boxes)•QT• 450 ms in men, 460 ms in women• Based on sex / heart rate•Half the R-R interval with normal HR
![Page 36: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/36.jpg)
QT interval (lead II or V5-6)
![Page 37: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/37.jpg)
Prolonged QT
•Normal •Men 450ms•Women 460ms•Corrected QT (QTc)•QTm/√(R-R)•Causes•Drugs (Na channel blockers)•Hypocalcemia, hypomagnesemia, hypokalemia•Hypothermia •AMI•Congenital• Increased ICP
![Page 38: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/38.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval
•Q waves•R wave transition•ST segments•T waves (and others)
![Page 39: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/39.jpg)
Pathological Q waves
•> 40 ms (1mm) wide•> 2 mm deep•> 25% of depth of QRS complex•Seen in leads V1-3
![Page 40: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/40.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves
•R wave transition•ST segments•T waves (and others)
![Page 41: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/41.jpg)
R wave transition
![Page 42: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/42.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition
•ST segments•T waves (and others)
![Page 43: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/43.jpg)
ST Segment
![Page 44: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/44.jpg)
ECG interpretation
•Rate•Rhythm•Axis•P wave• Intervals•PR interval•QRS duration •QT interval•Q waves•R wave transition•ST segments
•T waves (and others)
![Page 45: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/45.jpg)
T waves
•Hyperacute / peaked• Inverted (symmetrical and deep: > 3mm)•Children (normal), MI, ischaemia, BBB, ventricular hypertrophy, PTE, HCM, raised ICP
•Biphasic•Myocardial ischaemia, hypokalaemia•“Camel hump”•Prominent U or hidden P wave•Flattened•Nonspecific, ischaemia, hypokalaemia
![Page 46: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/46.jpg)
U waves
•? Delayed Purkinje fibre repolarisation•Prolonged repolarisation of mid-myocardial “M-cells”•After potentials from mechanical forces in ventricular wall
•Same direction as T wave•< 25% of T wave voltage•Max amplitude is 1-2 mm
![Page 47: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/47.jpg)
U waves
•Prominent• Bradycardia, hypokalaemia, hypocalcaemia, hypomagnesaemia, hypothermia, raised ICP, LVH, HCM, digoxin
• Inverted• IHD, HBP, valvular HD, congenital HD, cardiomyopathy, hyperthyroidism
![Page 48: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/48.jpg)
AMI evolution
48
![Page 49: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/49.jpg)
AMI ECG evolution
![Page 50: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/50.jpg)
ECG Distributions
•Septal: V1, V2•Anterior: V3, V4•Anteroseptal: V1, V2, V3, V4•Anterolateral: V4–V6, I, aVL•Lateral: I and aVL• Inferior: II, III, and aVF• Inferolateral: II, III, aVF, and V5 and V6
![Page 51: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/51.jpg)
Precordial Leads
![Page 52: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/52.jpg)
Sgarbossa’s criteria
![Page 53: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/53.jpg)
Sgarbossa’s criteria
•Concordant ST depression > 1mm in V1-3 (score 3)•Concordant ST elevation > 1mm in leads with positive QRS complex (score 5)•Excessively discordant ST elevation > 5mm with a negative QRS complex (score 2)
•A score ≥ 3 has a specificity of 90% for diagnosing myocardial infarction
Page 53
![Page 54: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/54.jpg)
Sgarbossa’s criteria
Page 54
![Page 55: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/55.jpg)
Supraventricular arrhythmias
55
![Page 56: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/56.jpg)
Supraventricular arrhythmias
•Atrial fibrillation•Atrial flutter•Supraventricular tachycardias•Atrioventricular nodal re-entrant•Atrioventricular re-entrant•Atrial •Sinus•Physiological• Inappropriate•Postural orthostatic tachycardia syndrome•Others•Permanent junctional reciprocating•Junctional ectopic•Mahaim
Page 56
![Page 57: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/57.jpg)
Atrial fibrillation
![Page 58: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/58.jpg)
Atrial flutter
![Page 59: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/59.jpg)
Supraventricular tachycardias
•Most common SVT is AVNRT (60%), followed by AVRT (30%) and AT (10%)•AVNRT is more common in women (70%)•Mean age of onset 32 years•AVRT is more common in men•Mean age of onset 23 years•AT is more common in older age and structural disease
Page 59
![Page 60: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/60.jpg)
Supraventricular tachycardias (P wave)
Page 60
![Page 61: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/61.jpg)
AVNRT
![Page 62: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/62.jpg)
Wolff-Parkinson-White syndrome
![Page 63: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/63.jpg)
Page 63
Wolff-Parkinson-White syndrome
![Page 64: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/64.jpg)
Broad complex tachycardias
64
![Page 65: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/65.jpg)
Broad complex tachycardia
•VT•SVT with aberrant conduction due to bundle branch block•Pre-existing BBB•Rate related BBB•SVT with aberrant conduction due to Wolff-Parkinson-White Syndrome
Page 65
![Page 66: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/66.jpg)
VT Versus SVT with aberrancy - Brugada
• 1. Is there an absence of an RS complex in all precordial leads?• Yes = VT, No = next question
Page 66
![Page 67: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/67.jpg)
VT Versus SVT with aberrancy - Brugada
• 2. Is the R to S interval >100 msec?• Yes = VT, No = next question
Page 67
![Page 68: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/68.jpg)
VT Versus SVT with aberrancy - Brugada
• 3. Is there atrioventricular (AV) dissociation?• Yes = VT, No = next question
Page 68
![Page 69: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/69.jpg)
4. Is there morphology criteria for VT present in precordial leads V1/V2 and V6?
LBBB morphology VT
Page 69
![Page 70: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/70.jpg)
4. Is there morphology criteria for VT present in precordial leads V1/V2 and V6?
RBBB morphology VT
Page 70
![Page 71: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/71.jpg)
• LBBB morphology: dominant S wave in V1 or V2 • LBBB morphology: V6
Page 71
4. Is there morphology criteria for VT present in precordial leads V1/V2 and V6?
![Page 72: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/72.jpg)
• RBBB morphology: dominant R wave in V1 or V2 • RBBB morphology: V6
Page 72
4. Is there morphology criteria for VT present in precordial leads V1/V2 and V6?
![Page 73: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/73.jpg)
VT Versus SVT with aberrancy
• IF IN DOUBT, TREAT AS VT
Page 73
![Page 74: ECG made easy - GenesisCare](https://reader030.fdocuments.net/reader030/viewer/2022012712/61ab3ccf5d9d6071175932f4/html5/thumbnails/74.jpg)
ECG Quiz available as separate download
74