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Cholid T Tjahjono,
MD
Heny Martini, MD
Upon completion one
will be able to:
Describe what an ECG is.
Describe the proper hook-up
procedure for a 12-Lead ECG
Identify basic normal ECG
waveform morphology.
Distinguish between basic ECG
arrhythmia and artifact.
2
QUICK REVIEW OF
HEART
Purpose
Pumps blood
Basic Anatomy
4 chambers
2 sides
4 valves
3
THE CONDUCTINGY
SYSTEM
SA Node
Inter-nodal
pathway
AV Node
Bundle of HIS
Bundle Branches
Purkinje Fibers
4
RELATIONSHIP
5
CARDIAC CYCLES
6
12 LEAD ECG
Learning objectives:
Electrocardiograph is the
instrument that records the
electrical activity of the heart
Electrocardiogram (ECG) is the
record of that activity
8
HOOKING UP THE
12-LEAD ECG
9
SKIN PREPARATION
10
ELECTRODE
PLACEMENT
LIMB LEADS
CHEST LEAD
11
LIMB LEADS
Bipolar leads
I II III
Augment leads
aVR aVL aVF
12
CHEST LEADS
6 UNIPOLAR
LEADS
V1
V2
V3
V4
V5
V6
13
LETS REVIEW
What is an ECG
What are the limb leads?
What are the chest leads?
Why do skin prep?
14
12-LEAD ECG LAYOUT
15
INFORMATION ON THE
ECG
Patients demographics
Heart rate and measurements
Speed ECG is recorded at
Voltage ECG is recorded at
What the filter is set on
16
INFORMATION ON THE 12-
LEAD ECG
17
WHAT YOU NEED TO
LOOK FOR
18
IS the ECG HOOKED UP
CORRECTLY?
LIMB LEADS CHEST LEADS
Normal 12-lead COLUMN III
AVR always R wave progression
negative Small to Tall
Lead I always
positive COLUMN IV
Lead II, III R wave progression
positive or Tall to Small
biphasic
19
RULING OUT LIMB LEAD
REVERSAL
COLUMN IV
R wave progression
Tall to Small
21
LIMB LEADS
22
CHEST LEADS
23
The eight-step method
to read an ECG
Step 1: Determine rhythm
27
BASIC CRITICAL
VALUES
28
The eight-step method
to read an ECG
Step 3: Evaluate P wave
Are P waves present?
Do the P waves have a normal
configuration?
Do all the P waves have a
similar size and shape?
Is there one P wave for every
QRS complex?
The eight-step method
to read an ECG
Step 4: Determine PR-interval
Does the duration of the PR
interval fall within normal limits,
0.12 to 0.20 second (or 3 to 5
small squares)?
Is the PR interval constant?
The eight-step method
to read an ECG
Step 5: Determine QRS-complex
duration
Does the duration of the QRS
complex fall within normal
limits, 0.06 to 0.10 second?
Are all QRS complexes the same
size and shape?
Does a QRS complex appear
after every P wave?
The eight-step method
to read an ECG
Step 6: Evaluate T wave
Are T waves present?
Do all of the T waves have a
normal shape?
Could a P wave be hidden in a T
wave?
Do all T waves have a normal
amplitude?
The eight-step method
to read an ECG
Step 7: Determine QT-interval
duration
Does the duration of the QT
interval fall within normal limits,
0.36 to 0.44 second?
The eight-step method
to read an ECG
Step 8: Evaluate other
components
Normal ECG
Abnormal ECG
Abnormal ECG
Left Bundle Branch Block
Acute ST Depression
Acute ST Elevation Inferior MI
Acute ST Elevation Posterior MI
Atrial Flutter
Atrial Fibrillation
Ventricular Fibrillation
OTHER PROBLEMS
WITH THE ECG
Artifact
Electrical interference
Somatic tremor
Wandering baseline
49
EINTHOVENS TRIANGLE
50
ARTIFACT ON THE ECG
51
FIND THE ARTEFACT
52
WANDERIN BASELINE
53
SOMATIC TREMOR
54
ELECTRICAL
INTERFERANCE
55
56
57
Ventricular Tachycardia
58
LBBB and Old anteroseptal MI
59
ECTOPIC BEATS
60
ECTOPIC BEATS
61
LETS SUMMARIZE
How do we produce an excellent
12-lead ECG?
Proper skin prep
Correct electrode placement
Recognize and know how to
correct problems
Recognize basic critical values
62