Understanding basics of EKG · PDF file•Basics –Rate ... ECG interpretations i....
Transcript of Understanding basics of EKG · PDF file•Basics –Rate ... ECG interpretations i....
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Understanding basics of EKG
By Alula A.(R III)
www.le.ac.uk
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Topic for discussion
• Understanding of cellular electrophysiology
• Basics – Rate
– Rhythm
– Axis
– Intervals
– P wave
– QRS
– ST/T wave
Abnormal EKGs
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Understanding electrophysiology
• The EKG is nothing more than a recording
of the heart's electrical activity
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Cardiac cells
•Resting state(mme pump)
•Depolarization
/Repolarization
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The Cells of the Heart and action potential
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EKG basics
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Electrode placement
Right precordial leads V1: right 4th intercostal space
V2: left 4th intercostal space
V3: halfway between V2 and V4
Left Precordial leads
V4: left 5th intercostal space, MCL
V5: horizontal to V4, anterior axillary
V6: horizontal to V5, mid-axillary line
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Limb leads
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EKG grid • The wave on EKG primarily reflect the electrical
activity of myocardial cell
• Three chief characteristics of the waves.
– Duration
– Amplitude
– Configuration
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EKG strip
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Einthoven's Triangle
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The Six Precordial Leads
• Record forces moving
anteriorly and posteriorly
12
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Order of depolarization
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Follow the way
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Interpretation steps
RRAI- P-QRS-T • Rate
• Rhythm
• Axis
• Intervals
• P wave
• QRS
• T
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Rate • Atrial/ Ventricular rate 60 - 90 bpm
•Regular RR; 1500/small box or 300/large box
•Irregular RR –# of QRS waves in 6 sec X 10
–# of QRS on the whole EKG(10 Sec) X6
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Rhythm •Normal sinus Rhythm( originated from SA)
The P waves in leads I and II –upright
Same morphology before each QRS
Read on the rhythm strip at lead II if not V1
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Axis
• Two technique; I. Identification of isoelectric lead or
II. Look for lead I and aVF
• If needed look for lead II
• QRS axis Frontal Plane QRS Axis: +90 o to -30 o (in the adult)
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Normal Axis
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Left axis
- LA fascicular block
- Inferior MI
- Pacemaker
lead I +ve and
aVF -ve
Look lead II
+ve = normal axis
-ve = left axis deviation
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Right axis
- RVH
- Left posterior fascicular block
- PE
lead I - ve and
aVF +ve
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Intervals
• PR interval
– Normal 0.12 - 0.20 sec
• QT interval QTc < 0.40 sec
– Bazett's Formula: QTc = (QT)/SqRoot RR (in
seconds)
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P wave • Bi atrial activation
Right to left
Lead II or V1
- duration < 0.12 sec
- 3 blocks wide - amplitude < 2.5 mm
2.5 blocks high
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P wave Normal
• Up in lead II
• Down in aVR
• Biphasic, up or down in V1, III
• Same morphology and PR before each QRS
Abnormal
• too wide, too tall, different, unclear, funny (i.e. LAE, RAE, wandering pacemaker/MAT, a fib respectfully)
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Wandering Pacemaker
at least 3 different P wave morphologies in a Ventricular response is irregularly irregular , COPD
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QRS – Duration < 0.10 sec
– QRS amplitude - variable from lead to lead and
from person to person
– Comment: pathologic Q waves, abnormal voltage
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QRS • Q wave
– Narrow (<0.04s duration) and
– Small (<25% the amplitude of the R wave)≈ 0.1mv
– Often seen in
leads I and aVL when the QRS axis is to the left of +60o, and
leads II, III, aVF when the QRS axis is to the right of +60o.
• R-waves begin in V1 or V2 and progress in size to V5. R-V6 < R-V5.
• In reverse, the S-waves begin in V6 or V5 and progress in size to V2. S-V1 is usually smaller than S-V2
• The usual transition from S>R in the right precordial leads to R>S in the left precordial leads is V3 or V4
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ST wave
• Normal V1-V3 concave upwards
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ST / ST- T wave
• Abnormal ST elevation and/or Depression
• ST elevation
– **compare J point to the TP level not PR**
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Early repolarization- concave upwards
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ST elevation
Convex or straight upward ST
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ST segment depression
abnormal but non specific
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T wave
•The normal T wave is usually in the same
direction as the QRS except in the right
precordial leads( V1-V3)
•T wave amplitude is 1/3-2/3 of R wave
• Always upright in leads I, II, V3-6, and
• Always inverted in lead aVR
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U wave
• Afterdepolarizations which interrupt or follow repolarization
• U wave amplitude is usually < 1/3 T wave amplitude in same lead
• U wave direction is the same as T wave direction in that lead
• more prominent at slow heart rates and usually best seen in the right precordial leads
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Conclusion ECG interpretations
i. Measurements
ii. Rhythm analysis
iii. Conduction analysis
iv. Waveform description
v. ECG interpretation
(normal, abnormal, bordeline)
i. Comparison with previous ECG (if any)
• Remember “RRAI P-QRS-T”
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