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

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

ECG interpretation?
1.
2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

12.
13. 14. 15. 16.

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, LV strain, BBB, Conclusion: normal/abnormal

Calibration

1 mV = 1 cm Important in assessing tall waves in hypertrophic state

Paper speed and normal value

One small box: 0.04 s One large box: 0.2 s PR Interval: 0,12 - 0,20 QRS duration: 0,04 - 0,12

Rate calculation

Method:
300 divided by number of large boxes between R-R 1500 divided by number of small boxes between R-R,

Number of QRS complexes in 6 seconds times 10.

Rate calculation
paper 25 mm/s

Sinus Rhythm

Sinus Rhythm
Rhythm: Regular Rate: 60 100 P wave: Normal in configuration; precede each QRS PR: Normal (0. 12 0.20 s) QRS: Normal (<0.12 s)

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

P wave

1. 2. 3.

Wave of atrial depolarization Normal characteristic: Smooth and rounded 3 mm tall Upright in leads I, II avF

PR interval
Including P wave until the beginning of QRS complex Normal duration is 0.12-0.2 seconds

QRS complex
Wave of ventricular depolarization 5-20 mm tall Duration 0.06-0.10 seconds

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

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

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

Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6 with precordial ST depression

Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Acute inferoposterior MI

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

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

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

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

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

SR

VES

Sinus rhythm
with

Multifocal VES

VES

VES

SR

SR

SR

SR

SR

SR

Sinus rhythm with VES couplet

Sinus Rhythm with VES, R on T

Ventricular Tachycardia

Torsade de Pointes

Ventricular Fibrillation

1st degree AV block

Prolonged PR interval

2nd degree AV block, type 1

Missing QRS

Missing QRS

2nd degree AV block, type 2

Missing QRS

Total AV Block / 3rd degree AV block

QRS QRS QRS