EKG Review.ppt

8/18/2019 EKG Review.ppt

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EKG REVIEW



Lead Placement

aVF



Marian Williams RN



EKG Distributions

• Anteroseptal V!" V#" V$"V%

• Anterior V!&V%• Anterolateral V%&V'" I"aVL

• Lateral I and aVL

• Inferior II" III" and aVF• Inferolateral II" III" aVF"and V( and V'



Sistematika Membaca EKG

•Rate

•Ritme

•A)sis

•Interval

•Infar)•*ipertro+



,inus R-.t-ms

• /ri0inate in t-e ,A node• 1ormal sinus r-.t-m 21,R3

• ,inus brad.cardia 2,43

• ,inus tac-.cardia 2,53

• ,inus arr-.t-mia

• In-erent rate of '6 & !66

• 4ase all ot-er r-.t-ms on deviations from sinus r-.t-m



,inus R-.t-m



Marian Williams RN



,inus 4rad.cardia



Marian Williams RN



,inus 5ac-.cardia



Marian Williams RN



,inus Arr-.t-mia



Marian Williams RN



Atrial R-.t-ms

• /ri0inate in t-e atria • Atrial +brillation 2A Fib3

• Atrial 7utter

• Wanderin0 pacema)er

• 8ultifocal atrial tac-.cardia 28A53• ,upraventricular tac-.cardia 2,V53

• PAC9s

• Wol:&Par)inson&W-ite s.ndrome 2WPW3



A ; Fib



A ; Flutter



Wanderin0 Pacema)er



8ultifocal Atrial 5ac-.cardia28A532Rapid Wanderin0 Pacema)er3• Similar to wandering pacemaker (< 100)• MAT rate is >100• s!all" d!e to p!lmonar" iss!e

• #$%&

• '"poia acidotic intoicated etc*• $+ten re+erred to as S,T -" .MS

• Recogni/e it is a tac"cardia and RS is narrow



,V5



PAC9s



Wol:&Par)inson&W-ite2AKA ; Pree<citation ,.ndrome3



AV=>unctional R-.t-ms

• /ri0inate in t-e AV node• >unctional r-.t-m rate %6;'6

• Accelerated ?unctional r-.t-m rate '6;!66

• >unctional tac-.cardia rate over !66

• P>C9s• In-erent rate of %6 ; '6



>unctional R-.t-m



Accelerated >unctional



>unctional 5ac-.cardia/ften di@cult to pic) out so often identi+ed as

,V5B



Ventricular R-.t-ms

• /ri0inate in t-e ventricles = pur)in?e +bers

• Ventricular escape r-.t-m 2idioventricular3 rate#6;%6

• Accelerated idioventricular rate %# ; !66• Ventricular tac-.cardia 2V53 rate over !6#

• 8onomorp-ic & re0ular" similar s-aped ide R,comple<es

• Pol.morp-ic 2ie 5orsades de Pointes3 & lifet-reatenin0 if sustained for more t-an a fe seconds

due to poor cardiac output from t-e ta-c-.cardia3

• Ventricular +brillation 2VF3• Fine coarse

• PVC9s



Idioventricular



Accelerated Idioventricular



V5 28onomorp-ic3



V5 2Pol.morp-ic3

Note te 2twisting o+ te points3

Tis r"tm pattern looks like

Ri--on in it4s +l!ct!ations



VF



PVC9s



A=V *eart 4loc)s

•!st de0ree• A condition of a r-.t-m" not a true r-.t-m

• 1eed to ala.s state underl.in0 r-.t-m

•#nd de0ree• 5.pe I ; Wenc)ebac-• 5.pe II & Classic & dan0erous to t-e patient

•Can be variable 2periodic3 or -ave a setconduction ratio 2e< #!3

•$rd de0ree 2Complete3 & dan0erous to t-epatient



!st De0ree 4loc)



#nd De0ree 5.pe I



#nd De0ree 5.pe II 2constant3

% Wa5e %R 6nter5al RS #aracteristics

ni+orm *17 8 *70 Narrow 9 ni+orm Missing RS a+ter

e5er" oter % wa5e

(7:1 cond!ction)

Note: Ratio can -e ;:1 :1 etc* Te iger te ratio te 2sicker3 te eart*

(Ratio is %:RS)



#nd De0ree 5.pe II 2periodic3

% Wa5e %R 6nter5al RS #aracteristics

ni+orm *17 8 *70 Narrow 9 ni+orm Missing RS a+ter

some % wa5es



Sin!s w= 1st

degree lockNo s"mptoms are d!e to te +irst degree eart

-lock? s"mptoms wo!ld -e related to te

!nderl"ing r"tm



7nd

&egree T"pe 1 @ Wencke-ac%R getting longer and +inall" 1 RS drops?

patient generall" as"mptomatic? can -e

normal r"tm +or some patients



7nd &egree T"pe 66 (7:1 cond!ction)

So!ld -e preparing te T#% +or tis patient



,5 Elevation and non;,5Elevation 8Is

•W-en m.ocardial blood suppl. is abruptl.reduced or cut o: to a re0ion of t-e -eart"a seuence of events occur be0innin0 it-

isc-emia 2inadeuate tissue perfusion3"folloed b. necrosis 2infarction3" andeventual +brosis 2scarrin03 if t-e bloodsuppl. isnHt restored in an appropriateperiod of time

• 5-e ECG c-an0es over time it- eac- oft-ese events



ECG C-an0es

Wa.s t-e ECG can c-an0e include

Appearance

o+ patologic

8wa5es

T8wa5es

peaked +lattenedin5erted

ST ele5ation 9

depression



ECG C-an0es t-e Evolvin08I

5-ere are todistinct patterns

of ECG c-an0edependin0 if t-einfarction is

@ST .le5ation (Transm!ral or 8wa5e) or

@Non8ST .le5ation (S!-endocardial or non88wa5e)

Non-ST Elevation

ST Elevation



,5 Elevation Infarction

ST depression, peaked T-waves,then T-wave inversion

The ECG changes seen with a ST elevation infarction are:

e+ore in!r" Normal ECG

ST elevation & appearance of

Q-waves

ST segments and T-waves return to

normal, ut Q-waves persist

6scemia

6n+arction

Bi-rosis




!ere"s a diagram depicting an evolving infarction:

A 1ormal ECG prior to 8I

4 Isc-emia from coronar. arter.occlusion results in ,5 depression 2nots-on3 and pea)ed 5;aves

C Infarction from on0oin0 isc-emiaresults in mar)ed ,5 elevation

D=E /n0oin0 infarction it- appearanceof pat-olo0ic ;aves and 5;aveinversion

F Fibrosis 2mont-s later3 it- persistent; aves" but normal ,5 se0ment and

5; aves




!ere"s an ECG of an acute inferior wall #$:

Loo) at t-einferior leads

2II" III" aVF3

!estion:

Wat .#C

canges do

"o! seeD

ST ele5ation

and 8wa5es

.tra credit: Wat is te

r"tmD Atrial +i-rillation (irreg!larl" irreg!lar wit narrow RS)E



1on;,5 Elevation Infarction

ST depression & T-wave inversion

The ECG changes seen with a non-ST elevation infarction are:

e+ore in!r" Normal ECG

ST depression & T-wave inversion

ST returns to aseline, ut T-wave

inversion persists

6scemia

6n+arction

Bi-rosis



!# & Lead Comparison C-art28ain ones are -i0-li0-ted3



,5 elevation in V# & V(2Anterior all3



,5 elevation in II" III aVF2Inferior all it- L4443

,5 Ele ation



,5 ElevationInferior Wall & II" III" aVF

,5 l ti i II III VF

http://www.cardiologycommons.org/photo/st-elevation-mi-inferior-wall/next?context=latest



,5 elevation in II" III" aVF2Inferior all ; note reciprocal c-an0es3Watc- for -.potension



,5 elevation in V! & V'" I aVL2Anteroseptal it- lateral e<tension3

E<tensive anteroseptalWatc- for -eart bloc)



,5 elevation V#;V(Watc- for -eart bloc)

http://upload.wikimedia.org/wikipedia/commons/8/8d/12_Lead_EKG_ST_Elevation_tracing_only.jpg



Left Ventricular

*.pertrop-.



Left Ventricular *.pertrop-.

Compare t-ese to !#;lead ECGs W-atstands out as di:erent it- t-e second oneJ

Normal Fe+t ,entric!lar '"pertrop"

Answer: Te RS complees are 5er" tall

(increased 5oltage)




W-. is left ventricular -.pertrop-. c-aracteriedb. tall R, comple<esJ

F,' .#'$cardiogram6ncreased RS 5oltage

As te eart m!scle wall tickens tere is an increase in

electrical +orces mo5ing tro!g te m"ocardi!m res!lting

in increased RS 5oltage*




• ,peci+c criteria e<ists to dia0nose LV* usin0 a!#;lead ECG

• For e<ample• 5-e R ave in V( or V' plus t-e , ave in V! or V#

e<ceeds $( mm

'owe5er +or now all

"o! need to know is

tat te RS5oltage increases

wit F,'*



,88ARM Rate R-.t-m A<is Intervals *.pertrop-.

Infarct

A 1G "o "o!ng man ran into a g!ardrail wile riding a motorc"cle*

6n te .& e is comatose and d"spneic* Tis is is .#C*




Infarct

Wat is te rateD Approx. 132 bpm (22 R waves x 6)




Infarct

Wat is te r"tmD Sinus tachycardia




Infarct

Wat is te RS aisD Right axis deviation ( in !" # in !!)




Infarct

Wat are te %R RS

and T inter5alsD$R % &.12 s" 'RS % &.& s" 'c % &.*2 s




Infarct

6s tere e5idence o+

atrial enlargementD+o (no pea,ed" notched or negative-y

de-ected $ waves)




Infarct

6s tere e5idence o+

5entric!lar "pertrop"D+o (no ta-- R waves in /10/2 or /0/6)




Infarct

6n+arct: Are tere a-normal

wa5esDes !n -eads /1/6 and !" av4

%n

%n

%n

'(

)(

)(

)(

)()(

)(

*+(

*(




Infarct

6n+arct: 6s te ST ele5ation

or depressionDes 5-evation in /2/6" ! and av4.

epression in !!" !!! and av7.




Infarct

6n+arct: Are tere T wa5e

cangesD+o




Infarct

.#C anal"sis: Sinus tachycardia at 132 bpm" right axis deviation"

-ong '" and evidence o S e-evation inarction in the

antero-atera- -eads (/1/6" !" av4) with reciproca- changes (the

S depression) in the inerior -eads (!!" !!!" av7).

Tis "o!ng man s!++ered anac!te m"ocardial in+arction a+ter

-l!nt tra!ma* An

ecocardiogram sowed

anteroseptal akinesia in te le+t

5entricle wit se5erel"

depressed F, +!nction(.BH7IJ)* An angiogram

sowed total occl!sion in te

proimal FA& wit collaterals

+rom te R#A and F#K*



End of 8odule VII b

Readin0 !#;Lead ECGsProceed to 8odule VII b Practice ui on your iROCKET

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EKG Review.ppt

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