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ELECTROCARDIOGRAPHY

Lecture outline
Part one  Information provided by ECG  Cardiac conduction system: anatomy and physiology  (Normal) ECG interpretation Part two  Abnormal ECG

ECG is…?

Printout as a result of a particular electrical function of the heart The standard 12-lead electrocardiogram is a representation of the heart's electrical activity recorded from electrodes on the body surface

Information provided by ECG: what do you think? .

Cardiac conduction system SA node AV node Bundle His    .

Impulse Transmission SA Node  Internodal branch  AV Node  Hiss Bundle  Purkinje Fiber  Contraction .

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One ‘complex’ of ECG waveform right and left ventricular depolarization (normally the ventricles are activated simultaneously) the sequentialactivation (depolarization) of the right and left atria ventricular repolarization .

Leads position .

Limb leads .

Einthoven Triangle .

Chest lead .

Chest lead .

Chest lead .

6. BBB.ECG interpretation…? 1. LV strain. 15. 11. 2. Calibration Rhythm Rate QRS axis P morphology PR interval QRS duration QRS morphology Abnormal Q wave R wave progression ST segment morphology QT interval T morphology U morphology Others: LVH. 10. 3. 12. 9. 5. 4. 13. 14. 16. 7. Conclusion: normal/abnormal . 8.

Calibration   1 mV = 1 cm Important in assessing tall waves in hypertrophic state .

12’’ .04 s One large box: 0.0.Paper speed and normal value One small box: 0.20’’ QRS duration: 0.0.12’’ .2 s PR Interval: 0.04’’ .

– Number of QRS complexes in 6 seconds times 10.Rate calculation  Method: – 300 divided by number of large boxes between R-R – 1500 divided by number of small boxes between R-R. .

Rate calculation paper 25 mm/s .

20 s) –QRS: Normal (<0. precede each QRS –PR: Normal (0.Sinus Rhythm  Sinus Rhythm –Rhythm: Regular –Rate: 60 – 100 –P wave: Normal in configuration.12 s) . 12 – 0.

QRS Axis (N:.30 s/d + 110) .

Wave of atrial depolarization Normal characteristic: Smooth and rounded ≤ 3 mm tall Upright in leads I. 2.P wave   1. II avF . 3.

2 seconds   .PR interval Including P wave until the beginning of QRS complex Normal duration is 0.12-0.

QRS complex Wave of ventricular depolarization 5-20 mm tall Duration 0.10 seconds    .06-0.

QRS morphology qRs Rs R rS QR Q/QS RsR’ rSr’ .

ST segment Begins at J point Between ventricular depolarization and ventricular repolarization Generally isoelectric    .

II. followed by ventricular relaxation Positive in lead : I. V3-V6 Negative in lead avR    .T wave Ventricular repolarization.

Interpret this ECG. ..

.And this. .

Abnormal ECG     Myocardial ischemia/infarct Hyperthrophy Hyperkalemia Arrhythmia .

ACUTE CORONARY SYNDROME No ST Elevation ST Elevation NSTEMI Unstable Angina .

Acute myocardial infarction .

STEMI Non STEMI .

Mid LAD occlusion after the first septal perforator (arrow)

ECG : large anterior MI

Occlusion of diagonal branch ( arrow ) ST elevation in I and aVL .

ECG demonstrates large anterior infarction .

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and V6 with precordial ST depression . III. aVF.Proximal large RCA occlusion ST elevation in leads II. V5.

Small inferior distal RCA occlusion ECG changes in leads II. and aVF . III.

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Acute inferoposterior MI .

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QRS complex • Prolongation PR interval .HIPERKALEMIA • Peaking T • Shortening QT interval • Widening P wave.

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PPM .

How to identify arrhythmias ? .

QRS complex Regular / irregular ? QRS complex Normal-looking QRS complex? Wide / narrow ? P wave ? Relationship between P and QRS ? .

NORMAL SINUS RHYTHM .

PSVT : -due to re-entry mechanism -narrow QRS complex -regular -retrograde atrial depolarization -P wave ? .

PSVT .

-no uniform atrial depolarization . narrow QRS complex -very rapid atrial electrical activity (400-700 x/min).Atrial Fibrillation : -from multiple area of re-entry within atria -or from multiple ectopic foci -irregular.

Atrial Flutter : -The result of a re-entry circuit within the atria -Irregular / regular QRS rate -Narrow QRS complex -Rapid P waves (300x/min). “sawtooth” .

-retrograde P wave. coincide with. -due to the failure of sinus node to initiate time impulse or conduction problem. -normal-looking QRS. -P wave may preceede. or follow the QRS .Junctional rhythm: -AV junction can function as a pace maker (40-60 x/min).

SR VES .

Sinus rhythm with Multifocal VES VES VES SR SR SR SR SR SR .

Sinus rhythm with VES couplet .

R on T .Sinus Rhythm with VES.

Ventricular Tachycardia .

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Torsade de Pointes .

Ventricular Fibrillation .

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1st degree AV block Prolonged PR interval .

type 1 Missing QRS Missing QRS .2nd degree AV block.

2nd degree AV block. type 2 Missing QRS .

Total AV Block / 3rd degree AV block QRS QRS QRS P P P P P P P .