Basic EKG for Dummies | Heart Valve | Electrocardiography

Basic EKG For Dummies

R. Javelosa, Jr., MD. FPCP. FPCC
Section of Cardiology Department of Medicine UERMMMC

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Cardiac Anatomy .

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Cardiac Cycle Step 1: Rapid filling of ventricles • Ventricular pressure drops below atrial pressure • AV valves are open. semilunar valves are closed • Rapid ventricular filling occurs • 70-90% of the ventricles fill with blood .

Cardiac Cycle Step 2: Atrial systole • P wave occurs • Atrial contraction • Pushed 10-30% more blood into ventricle .

• AV valves close • Ventricular pressure is still less than aortic pressure • Semilunar valves are closed • Volume of blood in the ventricle is EDV .Cardiac Cycle Step 3: Isovolumetric contraction • QRS just occurred • Contraction of the ventricles causes ventricular pressure to rise above atrial pressure.

• Semilunar valves open • Ventricular pressure is still greater than atrial pressure • AV valves are still closed • Volume of blood ejected by the ventricles: stroke volume (SV) .Cardiac Cycle Step 4: Ejection • Contraction of the ventricles causes ventricular pressure to rise above aortic pressure.

Cardiac Cycle Step 5: • T-wave occurs • Ventricular pressure drops below aortic pressure • Back pressure causes semilunar valves to close .

Cardiac Cycle Step 6: Isovolumetric relaxation • AV valves are still closed • Semilunar valves are still closed • Volume of blood in ventricles: ESV .

QRS P T .

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The Limb Leads .

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The Precordial Leads .

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The Precordial Leads .

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7. 6. 5.Sequence of ECG Interpretation 1. 2. Rate Rhythm Axis Hypertrophy Infarction Injury Ischemia . 3. 4.

is the ECG correctly labelled? • What is the rate? • Is this sinus rhythm? If not.Interpretation Sequence • Check the patient details . what is going on? • What is the mean frontal plane QRS axis (You may wish at this stage to glance at the P and T wave axes too) • Are the P waves normal (Good places to look are II and V1) • What is the PR interval? .

depressed or elevated? Quantify abnormalities.Interpretation Sequence • Are the QRS complexes normal? Specifically. are there: – – – – significant Q waves? voltage criteria for LV hypertrophy? predominant R waves in V1? widened QRS complexes? • Are the ST segments normal. • Are the T waves normal? What is the QT interval? • Are there abnormal U waves? .

75.What is the Rate? • • • • Identify an R wave that falls on the marker of a `big block' Count the number of big blocks to the next R wave. 100. 150. 300 / # of big squares or 300. 50 sequence 1500 / # of small squares .

What is the Rate? .

What is the Rate?

Step 2. What is the Rhythm?
• • • • • • Sinus? Junctional? Ventricular? Pacemaker? AF? VF?

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Junctional or AV Nodal Rhythm .

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What is the QRS Axis? .Step 3.

Frontal QRS Axis Extreme RAD NW axis Right axis deviation Left axis deviation Normal axis .

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.Using leads I and aVF the axis can be calculated to within one of the four quadrants at a glance.

The QRS Axis • Normal axis : both I and aVF (+) • Right axis deviation : lead I (-) and aVF (+) • Left axis deviation: lead I (+) and aVF (-) • Northwest Territory : both I and aVF (-) .

Causes of left axis deviation • • • • • • Left ventricular hypertophy Inferior myocardial infarction Artificial cardiac pacing Emphysema Hyperkalemia Wolff-Parkinson-White syndrome .right sided accessory pathway • Tricuspid atresia • Ostium primum ASD .

left sided accessory pathway • Atrial septal defect • Ventricular septal defect .Causes of right axis deviation • • • • • • • Normal finding in children and tall thin adults Right ventricular hypertrophy Chronic lung disease even without pulmonary hypertension Anterolateral myocardial infarction Left posterior hemiblock Pulmonary embolism Wolff-Parkinson-White syndrome .

Causes of a Northwest axis • • • • • Emphysema Hyperkalemia Lead transposition Artificial cardiac pacing Ventricular tachycardia .

Step 4. Check the P-R Interval for AV blocks .

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Second Degree AV Block • Mobitz Type I (Wenckebach) • Mobitz Type II .

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Causes of AV Blocks • Autonomic Carotid sinus hypersensitivity • Drug-related Beta blockers Adenosine Ca channel blockers Antiarrhythmics (class I & III) Digitalis Lithium • Metabolic/endocrine Hyperkalemia Hypothyroidism Hypermagnesemia Adrenal insufficiency .

Causes of AV Blocks • Infectious Endocarditis Tuberculosis Lyme disease Diphtheria Chagas disease Toxoplasmosis Syphilis • Heritable/congenital Congenital heart disease Maternal SLE Kearns-Sayre syndrome Emery-Dreifuss MD Myotonic dystrophy Progressive familial heart block .

Causes of AV Blocks • Inflammatory SLE MCTD Rheumatoid arthritis Scleroderma • Infiltrative Amyloidosis Hemochromatosis Sarcoidosis • Coronary artery disease Acute MI • Neoplastic/traumatic Lymphoma Radiation Mesothelioma Catheter ablation Melanoma • Degenerative Lev disease Lenègre disease .

Look for Ectopic beats • Atrial? • Ventricular? .Step 5.

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Is there Chamber Enlargement? .Step 6.

Notched. b. c.12 sec. . slurred P wave in lead I and II (P mitrale). P wave duration equal or more than 0.Left atrial enlargement a. Biphasic P wave in lead V1 with a wide deep and negative terminal component.

peaked T wave equal or more than 2.11 sec. Mean P wave axis shifted to the right (more than +70 degrees). . P wave duration equal or less than 0. b. Tall. c.Right atrial enlargement a.5 mm in amplitude in lead II.III or aVF (P pulmonale).

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Ventricular Hypertrophy .

Left Ventricular Hypertrophy .

Left ventricular enlargement a. Left axis of -30 degree or more. e. . d. b. S wave in V1. R wave in V4.V5 or V6 equal or more than 30mm. Time of onset of the intrinsicoid deflection ( time from the beginning of the QRS to the peak of the R wave ) equal or more than 0. c.more reliable in the absence of digitalis therapy.09 sec.05 sec in lead V5 or V6. "Voltage criteria": 1. QRS duration equal or more than 0. R or S wave in limb lead equal or more than 20mm 2. Depressed ST segment with inverted T waves in lateral leads(strain pattern .V2 or V3 equal or more than 30mm 3.

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. Right axis deviation.Right ventricular enlargement a. e. ST-T "strain" pattern over the right precordium. Normal QRS duration (if no bundle branch block) c. Tall R waves over the right precordium and deep S waves over the left precordium ( R:S ratio in lead V1 > 1. d.0) b. Late intrinsicoid deflection in lead V1 or V2.

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Examine QRS Duration .Step 7.

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12 sec. aVL . notched or slurred R wave in lateral leads( I.Left bundle branch block a. QS or rS pattern in the anterior precordium. Broad . d. b. e. QRS duration equal or more than 0. Late intrinsicoid deflection in lead V5 and V6.V6 ) c. Secondary ST-T wave changes ( ST and T wave vectors are opposite to the terminal QRS vectors). V5. .

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b. QRS duration equal or more than 0. . Large R' wave in lead V1( rsR' ). Normal septal Q wave.12 sec. Late intinsicoid deflection in lead V1 and V2.Right bundle branch block a. c. Deep terminal S wave in lead V6. e. Inverted T wave in lead V1 ( secondary T wave changes ). f. d.

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Look for ST Segment Abnormalities .Step 8.

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Localization of Infarction .

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Localization of MI with the help of EKG • Anterior wall V1 through V6 V1 through V3 II. III. V3R V7 through V9 V1 through V3 ( ST depression) • Anteroseptal • Inferior • Right ventricular • Posterior wall . aVF V4R.

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Thank you for not sleeping! .

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