Basic EKG 1

Dr. Wattana Wongtheptien M.D. Cardiologist Chiangrai Regional hospital

EKG 1
Basic Electrophysiology Basic heart anatomy and conduction system Normal EKG Systemic EKG interpretation

EKG 2
EKG in clinical application Cardiac chamber enlargement Myocardial ischemia (in CAD lecture) Electrolyte imbalance Intraventricular conduction disturbance Pre-excitation syndrome Miscellaneous Cardiac arrhythmia (in Arrhythmia lecture)

Myocardial cell
Electrical cell Mechanical cell

Conduction system
Sinoatrial node (SA ) Internodal pathway
Anterior internodal pathway Middle internodal pathway Posterior internodal pathway

AV node
Right bundle branch Left bundle branch
Anterior division Posterior division

Autonomic nervous system

Sympathetic Parasympathetic

Autonomic nervous system

Sympathetic Parasympathetic

Autonomic nervous system

Sympathetic Parasympathetic
SA node AV junction Ventricular 60-100 /min 40-60 /min 15-40 /min

Electrocardiography
Electrocardiography : ECG EKG? : Electrokardiography (German)

History : EKG
1911 Augustus Waller
(St Marry hospital,London)
heart generated electricity Capillary galvanometer

Willem Einthoven (Netherland)

letters P, Q, R, S and T to the various deflections described the EKG features of a number of cardiovascular disorders String galvanometer Nobel prize for Physiology of medicine in 1924

Some of the first EKG machines were bulky, table-sized apparatus built about 1920

Leads
12 leads Limb electrodes I,II,III, aVR,aVL,aVF Precordial electrodes V1 -6

 P wave PR interval

atrial depolarization atrial depolarization to ventricular depolarization QRS complex ventricular depolarization T wave ventricular repolarization U wave depolarization of papillary muscle or Purkinje system

Normal EKG
P
Amplitude < 2.5 mV Duration <3 mm P from SA node
Upright in II,III,aVF Inverted in aVR

PR interval
>0.2 sec First degree AV block

Normal EKG
QRS complex
Duration 0.06-0.10 sec

ST segment T wave

Normal EKG

EKG

Rhythm Rate P wave PR interval QRS complex

Axis Wide or narrow

STsegment T wave U wave QT

Rhythm
Sinus rhythm Atrial rhythm Atrial tachycardia Atrial flutter Atrial fibrillation Junctional rhythm Ventricular rhythm Ventricular tachycardia Ventricular fibrillation

Normal sinus rhythm

P wave is followed by a QRS P upward in II,III,AVF P invert in aVR
P wave rate 60 - 100 bpm with <10% variation
rate <60 = Sinus bradycardia rate >100 = Sinus tachycardia variation >10% = sinus arrhythmia

Rate

300/xx large box or

1500/xx small box = heart rate / min

HR 1500 /18 = 83 /min

The rate is 150 beats/min (300/2=150)

 Rate ? In irregular rhythm

Normal sinus rhythm

Sinus bradycardia

Sinus Tachycardia

Normal P waves
Height < 2.5 mm in lead II Width < 0.11 s in lead II Abnormal P waves
RA enlargement LA enlargement Hyperkalemia

LA enlargement

RA enlargement

P wave in lead II taller then 2.5 mm (2.5 small squares).

PR interval
Normal : 0.12 to 0.20 s (3 - 5 small squares) Short PR segment
Wolff-Parkinson-White syndrom Lown-Ganong-Levine syndrome

Long PR interval
First degree AV block Trifascicular block

Wolf-Parkinson-White syndrome
Short PR interval, less than 3 small squares (120 ms) slurred upstroke to the QRS indicating pre-excitation (delta wave) broad QRS secondary ST and T wave changes

Wolf-Parkinson-White syndrome

Lown-Ganong-Levine syndrome
short PR interval, less than 3 small squares (120 ms) no delta wave

Lown-Ganong-Levine syndrome

First degree AV block

Trifascicular block

EKG

Rhythm Rate P wave PR interval QRS complex

Axis Wide or narrow

STsegment T wave U wave QT

Axis

Axis
both I and aVF +ve = normal axis both I and aVF -ve = axis in the Northwest Territory lead I -ve and aVF +ve = Right axis deviation lead I +ve and aVF -ve lead II +ve = normal axis lead II -ve = Left axis deviation

Axis

Normal QRS complex

< 0.12 s duration Abnormally wide QRS consider left or right bundle branch block, ventricular rhythm, hyperkalemia, etc. no Pathologic Q waves no evidence of left or right ventricular hypertrophy

RBBB

LBBB

Hyperkalemia

Pathologic Q wave

Normal ST segment
No elevation or depression Elevation
Acute MI LBBB Acute pericarditis

Depression
Myocardial ischaemia Digitalis effect Entricuar hypertrophy LBBB Acute posterior wall MI

Anterior wall MI

Inferior wall MI

LBBB

Digitalis effect

Posterior wall MI

Normal QT interval
Calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceeding R - R interval. Normal = 0.42 s.
Causes of long QT interval
myocardial infarction, myocarditis, diffuse myocardial disease hypocalcaemia, hypothyrodism subarachnoid haemorrhage, intracerebral haemorrhage drugs (e.g. sotalol, amiodarone) hereditary
Romano Ward syndrome (autosomal dominant)

Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineural deafness

QT prolongation

QT prolongation

The QT interval normally varies with heart rate becoming shorter at faster rates It is usually corrected using the cycle length (R-R interval) as shown opposite. normal QTc = 0.42 seconds

Romano-Ward syndrome

T wave
Tall T wave Tall T waves Hyperkalemia Hyperacute MI LBBB include

T wave
Small, flattened or inverted T waves Myocardial ischemia Age Race Hyperventilation Anxiety Drinking iced water LVH Drugs (e.g. Digoxin) Pericarditis PE Intraventricular conduction delay (e.g.RBBB) Electrolyte disturbance

Hyperacute T in AMI

T wave invertion

U wave
Normal Hypokalemia

Hypokalemia

Hypokalemia

Dyskalemia

Thank you For your attention