| Electrocardiogram (ECG) = 4 ul fa Q < Q Wl = Le Oo o Wl Fk Oo Z 2010Summary of ECG | NMT10 en Tare | 1. Take a look at the leads & determine location of each wall: Strict anterior 7 a 7 weer ih a ee Pee Pee eee [Loe | 2. Make spot diagnosis 3, Use the scheme to: * Confirm diagnosis + Correct diagnosis + Complete diagnosis ‘Scheme for ECG ‘Abnormality StepT _AV block Arrhythmia Step I _Atrial enlargement Leads to look at Limb leads Chest leads Strip or 11 7 Vi Bundle Branch Block Ventricular enlargement Step 1 _Axis Hemiblock V1, V2, V5, V6 Til oravF Limb leads Step IV ' “ “PIV Myocardial infarction SiepV __Low voltage Digitalis ‘Hyperkalemia TL = high lateral wall 0, 11, F ~ inferior wall V1, V2 = septal wall V3, V4 ~ strict anterior wall V5. V6 + low lateral wall Tin it Tnalll limb Teads Tnalll limb Teads Pre-excitation syndrome Mall limb leads = Pwave: height <2.5 small squares ~ width < 3 small squares. ~ _ PRinterval (P wave + PR segment): width= 3-5 small squares. = _ QRS: width < 2.5 small squares —height in LI + Lil+ Lill > 15 small squares. 1| www.medadteam.orgSummary of ECG | NMT10 Step 1: 1.1 Atrioventricular Block All are conducted Some arent conducted Irregular Regular In second degree only (wenekebach & Mobitz type I1): 1+ Detect degree of block (P: QRS ratio -> 6:5 or 5:4 or 4:3 ete.. 2- If block is look at the width of the QRS: If wide > 2.5 = Mobitz type II. If narrow yenckebach. > If shortest PR > 5 in wenckebach or PR > 5 in Mobitz type I = 1" degree Av block is associated. First Degree AV Block Mobitz, Type II Second Degree AV Block Ho ee ft Mobitz Type I (Wenckebach) ‘3rd Degree (Complete) Heart Block Seconed Degree AV Block hte bh Via calcvenanl) Lo ee EN 2 | www.medadteam.orgSummary of ECG | NMT10 1.2 Arrhythmia: 1.Regularity: + Regular: Definition: uniform R-R intervals +/- 1mm How to decid By paper or divider “ENO strip: compare R-R intervals in different leads “IFNO R-R in leads: do NOT comment on regularity + Irregular: Definition: variable R-R Possibilities: - Regular irregularity = lrvegular irregularity + Regular with occasional irregularity: Definition: ALL R-R are regular except one ie. premature beat 2. Rate: (heart rate) + Ifregular R-R interval: Count number of squares (big or small) in R-R interval Rate = a Rinbigsquares OT RoRin small squares + Ifirregular R-R interval: no QRS P a f f 3) Monofocal premature beat: Scheme for Monofocal Premature Beat if ‘So TF (Strip) So oe Wl), “vatwieeminy : Li — Tad), Sal riseming Atrial quadrigeminy Ventricular bigeminy Ventricular trigeminy Atrial premature beats Wide QRS, Twave oppasite QRS. ventricular Ventricular premature beat Ventricular quadrigeminy Junctional a pigeminy Coo Junetional trigeminy Juncti Monofocal premature beat Decide whether premature beats are atrial or 1 Decide whether premature beats are bigeminy, trigeminy or quadrigeminy 3 7 Z : & i Hy e € 3 i 2 i t : z i £ premature J 7 | www.medadteam.orgSummary of ECG | NMT10 4) Couplet: ‘Scheme for Couplet How to know, Tt Teac It (Strip) ‘Sinus rhythm premature beat {So diagnosis Small Pwave LIAL po) Amal counter “premature Retrograde P wave Junetional couplet beat Wide QRS Ventricular couplet Laon Towave opposite QRS 5) Interpolated premature beat: ‘Scheme for Interpolated Premature Beat ‘How to know if ‘Lead TI (Strip) ‘So ‘Sinus rhythm ‘Small P wave Interpolated PAB “premature beat ice Retrograde P wave Interpolated PJB sinus beat (NO pause) Wide QRS DSS thterpotated Pv ‘Tovave opposite Premature cycle + return gycle rs Couplet Interpolated premature beat cycle = ONE normal sinus th Scheme for atrial enlargement ii Vi Positive, Wagmim, He 2.5mm ‘Biphasie Broad, ‘W>=amm A Tesi eal P mitral +/-notched Jaina) Vz Tall and peaked, H>2.5 7 em P pulmonale Ee Wea P mitral & P pulmonale 4ve Pistall>1.5 & -vePisboard>1 ee For diagnosis of atrial enlargement, a change in ONE lead is ENOUGH 8 | www.medadteam.orgSummary of ECG | NMT10 Il.2. Bundle Branch Block: Look at Spot diagnosis: WIDE QRS at V1, V2, V5, V6 i. Is QRS complex (Normal < 2.5mm) wide? If >3mm ~ complete BBB If2.5-gmm ~ incomplete BBB ii, In both cases, determine whether right or left: Scheme for Bundle Branch Block Vi, V2 V5, V6O&1 ors Monophasie Rwith secondary inversion of T wave ¥SR’ormonophasie Vp a ® ‘Rs (with slurred s) Rwith secondary 1 ory inversion of T wave * LBBB = RBBB + >If RBBB is diagnosed, NEVER diagnose: Ventricular enlargement Myocardial isehemia >If LBBB is diagnosed, NEVER diagnose : above conditions+ ‘Myocardial infaretion (disgnoved i ew onset LEE with typical ischemic chest p cunymes) Hemiblock. » Pacemaker: in LBBB ONLY (or IVCD) If LBBB is associated with spikes, this indicates pacemaker: - Ifone spike (before QRS) ~ ventricular pacemaker If TWO spikes (one before P, and other before QRS) + Dual pacemaker - If spike is NOT followed by QRS ~ malfunctioning pacemaker 9 | www.medadteam.orgSummary of ECG | NMT10 IL.3. Ventricular enlargement: Look at ‘Scheme for Ventricular Enlargement Vi, v2 V5, V6 TLVE _ 6 features (ANY one is diagnostic, but ALL must be excluded negative to exclude LVE) Rin V5 or V6 > 25 mm (5 big squares) Rin V5 orV6 +Sin Vi > 35 mm (7 big squares) Rin Vs or V6 + S in V2 > 45 mm (9 big squares Rin V6 > Rin V5 RinaVL>13 mm 4] ST depression( strain sign) = hypertrophy > RinaVF > 20mm dilatation Tall Rin Vi>7mmorRinVi=SinVi WA Pet mm Deep $ in V6 oe WS ratio> 1 +/-ST depression strain sign) = hypertrophy > dilatation om BVE Signs of LVE + tall Rin Vi or Signs of LVE + Rt Axis deviation, _—_— Step III TI.1. Axis Look at: a Scheme for Axis Normal axis, Teft axis deviation Rightaxis “Extreme axis deviation deviation deviation L Ls fs we ik i L ia IF THE AXIS IS DEVIATED, SEARCH FOR HEMIBLOCK 10 | www.medadteam.orgSummary of ECG | NMT10 III.2. Hemiblock: Look at: inferior and high lateral leads Search for hemiblock if axis is deviated Scheme for Hemiblock TAHB_Leftaxi a Deep’ jor eads (I, deviation especially (as normal in T11) eft anterior HB (NO need to exclude other causes of left axis deviation) TPHB Right Deep Sin high lateral leads (1, avi) Lan posterior uw 0°” tiOn (provided that itis NOT explained by RVE) Ifhemiblock + RBBB ~+ Bifascicular block hemiblock Ifhemiblock + RBBB + 1 HB ~ Trifascicular block hemiblock Step IV IV.1.2. Myocardial infarction and ischemi: Search for ALL changes in EACH lead Changes: ils there Pathological Q (or poor progression of R)? Is there ST elevation (or ST depression)? iii.Is there T inversion (or hyperacute, biphasic or flat T wave)? CHANGES must be in 2 SUCCESSIVE LEADS of the SAME WALL > Pathological Q: -Wide (2 1mm) & deep (2= 2mm or 2 ¥s the following R) In 2 successive lead of the same wall > Poor progression of R: in anterolateral infarction -Ris NOT >Sin V4 > ST elevation: -First mm afterJ point is elevated than isoelectric line -Isoelecttic lines (baseline) are P-R segment or T-P segment -Considered elevated i mm in limb leads = 2mm in chest leads 11 | www.medadteam.orgfiagnosis 3 3 5 a Summary of ECG | NMT10 -Determine straightened or coved according to T wave & J point elevation -These changes MUST be IN 2 SUCCESSIVE LEADS of the SAME WALL Tf: > ST elevation (+/- ST depression in other walls) + ST elevation Myocardial Infarction (+/- reciprocal ST depression) > ST depression ONLY + Myocardial ischemia If ST Elevation Myocardial Infarction, determine age & site: 1.Age: ‘Scheme for age of STEMI “Age of STEMI _ How to know ‘ST segment wave Typeracute STelevation NO pathological Twave “7- Hyperacute T wave ‘Acute ‘STelevation Pathological Or poor R progression 77- Hyperacute T wave Evolving ‘ST elevation Pathological Or poor R progression Inverted T NO ST elevation — Pathological Q Or poor R progression Normal T Anteroseptal = V1-V3 #\- V4 Anterolateral =V3-V6+18aVL Extensive anterior= Va-Ve4lgaVL Posterior wall MI: ‘Tall Rin V1, V2, V3 ~ ST depression ~ upright T dy - Associated with inferior myocardial infarction (to differentiate it form RVE) RVE Posterior MI Tall Rin Vi, V2, V3. Associated with Inferior MI 12 | www.medadteam.orgSummary of ECG | NMT10 ST depression in some leads: = Ifassociated with ST elevation in other leads + RECIPROCAL ST DEPRESSION associated with MI -If alone + MYOCARDIAL ISCHEMIA: ST depression: start after J point, is = 1mm in limb leads or 22mm in chest leads & last for >2mm. T wave: flat or symmetrically inverted or symmetrically upright. How to know * QRS in I+ 11+ III < 15mm Electrical alternans in pericardial effusion: -LOW voltage + (Pee V.2. Digitalis effect: in ALL LEADS Digitalis effect: NB | Normal QT # Short QT ie. QT < RR # Sagging ST depression: =} point is isoelectric (unlike ischemia) - ST depression + T inversion -Fused ST &T V.3- Hyperkalemia: in ALL LEADS How to know: Hyperacute T wave alone (tall, narrow & peaked) A V.4. Preexcitation syndrome: in ALL LEADs Scheme for prexcitation syndromes WPW-Wolf Parkinson White LGL-Lawn Ganong Levine > Short PRinterval ‘ Short PR interval * Delta wave * Wide QRS Ne ‘ 13 | www.medadteam.org