اصول ekg سیستم هدایتی sa node pacemaker 60-100 bpm p waves up in i, ii, avf ...

EKGEKGاصول اصول

EKGاصول

سیستم هدایتیسیستم هدایتی

SA node Pacemaker 60-100 bpm P waves up in I, II, aVF

Internodal Pathways AVN; RA contraction Interatrial Pathways LA to depolarize


AV node Delays impulse by .1s PR segment

AV junction AV node & His 40-60 bpm

Purkinje/bundles Ventricular depol 20-40 bpm


Repolarization

Direction is same as depolarization

Autonomic Nervous System (ANS)

Sympathetic Nervous System (SNS)

Parasympathetic Nervous System (PNS)

PP: موج : موج EKGEKGاصول اصول

Normal

Width < .11 secs Height .5 to 2.5 mm

Morphology Flat Biphasic Absent

PP: موج : موج EKGEKGاصول اصول

Abnormal Inversions

Amplitude

P-Pulmonale > 2.5 mm

Duration

P-Mitrale > .1 sec (or 2 ½ boxes)

Absence

QRSQRS: موج : موج EKGEKGاصول اصول

Impulse travels quicker down the left bundle branch (LBB) than the right bundle branch (RBB). Septum depolarizes L to R resulting in a downward deflection

Both ventricles are activated simultaneously. Since the RV is smaller, depolarizes quicker resulting in the downward deflection

LV depolarizes resulting in the R wave

QRSQRS: موج : موج EKGEKGاصول اصول

QRSQRS ویژگی موج ویژگی موج 66

1. Duration: .05 - .12 Secs

2. Amplitude: > 5mm;

< 20 mm in limb, < 25 in anterior leads

3. Presence of Q waves < 0.04 msec and

< 2 mm normal in I, aVL, aVF, V5

4. Axis

5. Progression: Zone of transition V3-V4

6. Configuration

UU و و TT: موج : موج EKGEKGاصول اصول

T waves occur in Same direction as QRS Height: < 5 mm in limb leads, <10

mm in anterior leads

U waves After T wave Best seen in lead III Hypothermia/hypokalemia

لیدهای قفسه سینهلیدهای قفسه سینه

EKGEKGاستاندارداستاندارد

12 leads and rhythm strip

Limb leads I, II, III, aVR, aVL, aVF

Anterior leads V1-V6

Speed = 25 mm/sec

Height = 10 mm

متغیرهای نوار قلبمتغیرهای نوار قلب Source

Age, Sex Body weight Chest configuration Heart position Food intake Temperature, Exercise Smoking, Hyperventilation Position of precordial leads

متغیرهای نوار قلبمتغیرهای نوار قلب

Ideal time for EKG

Bayes’ Theorem

Normal hearts have abnl EKGs

Normal EKG does not r/o heart

disease

رویکرد منظمرویکرد منظم

Rate Rhythm Axis Wave Morphology

P, T, and U waves and QRS complex

Intervals PR, QRS, QT

ST Segment

تعیین ریت قلبتعیین ریت قلب

• On 6 sec strip, count QRS complexes, X 10

• QRS on dark line of tracing, count large boxes, ÷ into 300

تعیین ریت قلبتعیین ریت قلب

دپالریزاسیوندپالریزاسیون

IIII در لید در لید PPموج موج

دپالریزاسیون بطن ها در لید قفسه دپالریزاسیون بطن ها در لید قفسه سینهسینه

محور قلبمحور قلب

Find the quadrant

Isolate the isoelectric lead

Smallest QRS voltage

Isolate the perpendicular lead

Isolate the vector

Double check your findings

پیدا کردن ربعپیدا کردن ربع

پیدا کردن ربعپیدا کردن ربع

1.

3.

پیدا کردن لید ایزوالکتریکپیدا کردن لید ایزوالکتریک

پیدا کردن محورپیدا کردن محور

ریتم/ آریتمیریتم/ آریتمی

Sinus

Atrial

Junctional

Ventricular

آریتمی سینوسی: معیار و انواعآریتمی سینوسی: معیار و انواع

P waves upright in I, II, aVF

Constant P-P/R-R interval

Rate

Narrow QRS complex

P:QRS ratio 1:1

P-R interval is normal and constant

آریتمی سینوسی: معیار و انواعآریتمی سینوسی: معیار و انواع

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrhythmia

Normal Sinus RhythmNormal Sinus Rhythm

• Rate is 60 to 100

Sinus BradycardiaSinus Bradycardia

• Can be normal variant

• Can result from medication

• Look for underlying cause

Sinus TachycardiaSinus Tachycardia

• May be caused by exercise, fever, hyperthyroidism

• Look for underlying cause, slow the rate

Sinus ArrhythmiaSinus Arrhythmia

• Seen in young patients

• Secondary to breathing

• Heart beats faster

آریتمی دهلیزی: معیار و انواعآریتمی دهلیزی: معیار و انواع

P waves inverted in I, II and aVF

Abnormal shape Notched

Flattened

Biphasic

Narrow QRS complex

آریتمی دهلیزی: معیار و انواعآریتمی دهلیزی: معیار و انواع

Premature Atrial Contractions

Ectopic Atrial Rhythm

Wandering Atrial Pacemaker

Multifocal Atrial Tachycardia

Atrial Flutter

Atrial Fibrillation

Premature Atrial ContractionPremature Atrial Contraction

• QRS complex narrow

• RR interval shorter than sinus QRS complexes

• P wave shows different morphology than sinus P wave

Ectopic Atrial RhythmEctopic Atrial Rhythm

• Narrow QRS complex

• P wave inverted

Wandering Atrial PacemakerWandering Atrial Pacemaker

• 3 different P wave morphologies

possible with ventricular rate < 100 bpm

Multifocal Atrial TachycardiaMultifocal Atrial Tachycardia

• 3 different P wave morphologies

with ventricular rate> 100 bpm

Atrial FlutterAtrial Flutter

• Regular ventricular rate 150 bpm

• Varying ratios of F waves to QRS

complexes, most common is 4:1

• Tracing shows 2:1 conduction

Atrial FlutterAtrial Flutter

• Tracing shows 6:1 conduction

Atrial FibrillationAtrial Fibrillation

• Tracing shows irregularly irregular rhythm with no P waves

• Ventricular rate usually > 100 bpm

Atrial FibrillationAtrial Fibrillation

• Tracing shows irregularly irregular

rhythm with no P waves

• Ventricular rate is 40

Atrial TachycardiaAtrial Tachycardia

• Tracing shows regular ventricular rate with P waves that are different from sinus

P waves

• Ventricular rate is usually 150 to 250 bpm

P wave

May be absent Buried in QRS

If present inverted in leads I, II, and aVF

Inverted after QRS

آریتمی جانکشنال: معیارآریتمی جانکشنال: معیار

PR interval < 0.12 Secs

Rate: Varies

Narrow QRS complex

آریتمی جانکشنال: معیار و انواعآریتمی جانکشنال: معیار و انواع

آریتمی جانکشنال: انواعآریتمی جانکشنال: انواع

Premature Junctional Contractions

Junctional Escape Rhythm

Accelerated Junctional Tachycardia

Junctional Tachycardia

Reentrant Tachycardia

AVNRT

Premature Junctional Premature Junctional ContractionsContractions

• R-R interval is shorter

• Beat is early, narrow QRS complex

• Inverted P wave

• P wave can be buried in QRS complex

Junctional Escape RhythmJunctional Escape Rhythm

• Junctional origin


Accelerated Junctional Accelerated Junctional TachycardiaTachycardia



Junctional TachycardiaJunctional Tachycardia


• Rate is > 100

• Secondary to bypass tract within AV node

• Premature Atrial Contraction (PAC) depolarizes

AV Nodal Reentrant Tachycardia AV Nodal Reentrant Tachycardia (AVNRT)(AVNRT)

Rate SummaryRate Summary

Sinus Tachycardia - 100-160 BPM

Atrial Tachycardia - 150-250 BPM

Atrial Flutter - 150-250 BPM

Junctional Tachycardia - 100-180 BPM

AVAVبلوک های گره بلوک های گره

• Delay conduction of impulses from

sinus node

• If AV node does not let impulse

through, no QRS complex is seen

• AV nodal block classes:

1st, 2nd, 3rd degree

11stst Degree AV Block Degree AV Block

• PR interval constant

• >.2 sec

• All impulses conducted

22ndnd Degree AV Block Type 1 Degree AV Block Type 1

• AV node conducted each impulse slower and finally no impulse is conducted

• Longer PR interval, finally no QRS complex

22ndnd Degree AV Block Type 2 Degree AV Block Type 2

• Constant PR interval

• AV node intermittently conducts no impulse

• AV node conducts no impulse

• Atria and ventricles beat at intrinsic rate (80 and 40 respectively)

• No association between P waves and QRS complexes

33rdrd Degree AV Block Degree AV Block

• Caused by bypass tract

• AV node is bypassed, delay

• EKG shows short PR interval <.11 sec

• Upsloping to QRS complex (delta wave)

Wolfe-Parkinson-White (WPW)Wolfe-Parkinson-White (WPW)

• Delta wave, short PR interval

WPWWPW

آریتمی های بطنی: معیار و انواعآریتمی های بطنی: معیار و انواع

Wide QRS complex

Rate : variable

No P waves

Premature Ventricular Contractions

Idioventricular Rhythm

Accelerated IVR

Ventricular Tachycardia

Ventricular Fibrillation

• Occurs earlier than sinus beat

• Wide, no P wave

Premature Ventricular ContractionPremature Ventricular Contraction

• Escape rhythm

• Rate is 20 to 40 bpm

Idioventricular RhythmIdioventricular Rhythm

• Rate is 40 to 100 bpm

Accelerated Idioventricular RhythmAccelerated Idioventricular Rhythm

• Rate is > than 100 bpm

Ventricular TachycardiaVentricular Tachycardia

Torsades de PointesTorsades de Pointes

• Occurs secondary to prolonged QT interval

• Unorganized activity of ventricle

Ventricular Tachycardia/FibrillationVentricular Tachycardia/Fibrillation

Ventricular FibrillationVentricular Fibrillation

هایپرتروفی هایپرتروفی بطن هابطن ها

و و دهلیزهادهلیزها

Differential Diagnosis

Hypertension (HTN)

Aortic Stenosis (AS)

Aortic Insufficiency (AI)

Hypertrophic Cardiomyopathy (HCM)

Mitral Regurgitation (MR)

Coarctation of the Aorta (COA)

Physiologic

Left Ventricular Hypertrophy (LVH)Left Ventricular Hypertrophy (LVH)

False positive

Thin chest wall

Status post mastectomy

Race, Sex, Age

Left Bundle Branch Block (LBBB)

Acute MI

Left Anterior Fascicular Block

Incorrect standardization

Left Ventricular Hypertrophy (LVH)Left Ventricular Hypertrophy (LVH)

Estes Criteria: Diagnosis of LVHEstes Criteria: Diagnosis of LVH

Right Ventricular Hypertrophy: CausesRight Ventricular Hypertrophy: Causes

Chronic Obstructive Pulmonary Disease Pulmonary HTN

Primary Pulmonary Embolus Mitral Stenosis Mitral Regurgitation Chronic LV failure

Right Ventricular Hypertrophy: CausesRight Ventricular Hypertrophy: Causes

Tricuspid Regurgitation

Atrial Septal Defect

Pulmonary Stenosis

Tetralogy of Fallot

Ventricular Septal Defect

Right Ventricular HypertrophyRight Ventricular Hypertrophy

Right Ventricular HypertrophyRight Ventricular Hypertrophy

Reversal of precordial pattern

R waves prominent in V1 and V2

S waves smaller in V1 and V2

S waves become prominent in V5 and V6

StrainStrain

Mitral Stenosis

Mitral Regurgitation

Left ventricular hypertrophy

Hypertension

Aortic Stenosis

Aortic Insufficiency

Hypertrophic Cardiomyopathy

بزرگی دهلیز چپ: عللبزرگی دهلیز چپ: علل

بزرگی دهلیز چپ: معیاربزرگی دهلیز چپ: معیار

P wave

Notch in P wave Any lead Peaks > 0.04 secs

V1 Terminal portion of P wave > 1mm

deep and > 0.04 sec wide

Lead IILead II

: بزرگی دهلیز چپ: بزرگی دهلیز چپPPموج موج

بزرگی دهلیز چپبزرگی دهلیز چپ

CHD

Tricuspid Stenosis

Pulmonary Stenosis

COPD

Pulmonary HTN

Pulmonary Embolus

Mitral Regurgitation

Mitral Stenosis

بزرگی دهلیز راست: عللبزرگی دهلیز راست: علل

Tall, peaked P wave

> 2.5 mm in any lead

Most prominent P waves in leads

I, II and aVF

بزرگی دهلیز چپ: معیاربزرگی دهلیز چپ: معیار

بزرگی دهلیز راستبزرگی دهلیز راست

Bundle Branch Bundle Branch BlocksBlocks

بلوک شاخه ای دسته ایبلوک شاخه ای دسته ای

Normal variant

Idiopathic degeneration of

the conduction system

Cardiomyopathy

Ischemic heart disease

Aortic Stenosis

Hyperkalemia

Left Ventricular Hypertrophy

بلوک شاخه ای دسته ای چپ: عللبلوک شاخه ای دسته ای چپ: علل

بلوک شاخه ای دسته ای چپ: معیاربلوک شاخه ای دسته ای چپ: معیار

Bizarre QRS Morphology High voltage S wave in V1, V2 & V3 Tall R wave in leads I, aVL and V5-6

Often LAD QRS Interval ST depression in leads I, aVL, & V5-V6 T wave inversion in I, aVL, & V5-V6

Left Bundle Branch BlockLeft Bundle Branch Block

بلوک شاخه ای دسته ای راست: عللبلوک شاخه ای دسته ای راست: علل

Idiopathic degeneration of the conduction system

Ischemic heart disease Cardiomyopathy Massive Pulmonary Embolus Ventricular Hypertrophy Normal Variant

بلوک شاخه ای دسته ای راست: معیاربلوک شاخه ای دسته ای راست: معیار

QRS morphology Wide S wave in leads I and V4-V6 RSR’ pattern in leads V1, V2 and

V3 QRS duration ST depression in leads V1 and V2 T wave inversion in leads V1 and V2

بلوک شاخه ای دسته ای راستبلوک شاخه ای دسته ای راست

ایسکمی و انفارکتوسایسکمی و انفارکتوس

Normal Complexes and SegmentsNormal Complexes and Segments

J PointJ Point

اندازه گیریاندازه گیری

ایسکمیایسکمی

•T wave inversion, ST segment depression

•Acute injury: ST segment elevation

•Dead tissue: Q wave

EKG Changes: Ischemia EKG Changes: Ischemia → → Acute Injury→ InfarctionAcute Injury→ Infarction

لیدهای قفسه سینهلیدهای قفسه سینه

محل لیدهای قدامیمحل لیدهای قدامی

V1 Right 4th ICS

V2 Left 4th ICS

V3 Left Sternal

border Between V2

and V4

V4 Left MCL 5th ICS

V5 Anterior axillary

line 5th ICS

V6 Mid axillary line 5th ICS

خونرسانی به قلبخونرسانی به قلب

Left Anterior Descending (LAD) artery Bulk of LV

Anterior wall Apex Part of lateral wall Part of septum


Right Coronary Artery (RCA)

Right Ventricle

Sinus Node 60% of the time

Right Atrium

Posterior Descending Artery (PAD)

90% of the time


Left Circumflex (LCFLX) artery

Lateral Wall & Posterior Wall of LV & LA

SA node 40% of the time

PDA 10% of the time

Posterior Descending Artery (PAD)

Off RCA 90%/LCFLX 40%

AVN, prox BB, IW/PW, basal septum

View of the LeadsView of the Leads II, III, aVF

Inferior Wall//RV RCA distribution

I, aVL Lateral Wall LCFLX/distal LAD

distribution aVR

R side of heart

V1 & V2 Intraventricular

septum Proximal LAD

V3 & V4 Anterior wall Mid LAD

V5 & V6 Lateral wall Distal LAD

Standard EKGStandard EKG

Anterior MIAnterior MI

Anterior-septal MIAnterior-septal MI

Inferior AMIInferior AMI

Right Sided LeadsRight Sided Leads

Right Ventricular AMIRight Ventricular AMI

Lateral MILateral MI

Posterior LeadsPosterior Leads

Posterior AMIPosterior AMI

Inferior-RV-Posterior AMIInferior-RV-Posterior AMI

ST-TST-T تغییرات موجتغییرات موج

Strain in HypertrophyStrain in Hypertrophy

Strain in LVHStrain in LVH

Strain in RVHStrain in RVH

Strain vs. InfarctionStrain vs. Infarction

پریکاردیتپریکاردیت

تغییرات دیوگسینتغییرات دیوگسین

TTموج موج

خسته خسته نباشیدنباشید

اصول ekg سیستم هدایتی sa node pacemaker 60-100 bpm p waves up in i, ii, avf ...

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