ekg panum or osce

8/10/2019 Ekg Panum or Osce

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Tips and Tricks for EKGInterpretation

Cardiology and Vascular Medicine Laboratory

Faculty of Medicine

University of Brawijaya


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Objectives The Basics

Interpretation

Clinical Pearls

Practice Recognition


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The Normal Conduction System


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Lead Placement

aVF


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All Limb Leads


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Precordial Leads


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EKG Distributions Anteroseptal: V1, V2, V3, V4

Anterior: V1V4

Anterolateral: V4V6, I, aVL Lateral: I and aVL

Inferior: II, III, and aVF

Inferolateral: II, III, aVF, andV5 and V6


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Waveforms


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Introduction

ECG Interpretation


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ECG

Rates

Determination heart rate

(normal paper speed 25

mm/s): 300 / Count number of large

square (bold boxes in one R R

interval)

1500 / Count number of small

square in one R R intervals

Number of QRS complex in 6

seconds, multiply by 10


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Rate HR of 60-100 per minute is normal

HR > 100 = tachycardia

HR < 60 = bradycardia


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Differential Diagnosis of TachycardiaTachycardia Narrow Complex Wide Complex

Regular ST

SVT

Atrial flutter

ST w/ aberrancy

SVT w/ aberrancy

VT

Irregular A-fib

A-flutter w/variable conduction

MAT

A-fib w/ aberrancy

A-fib w/ WPWVT


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What is the heart rate?

(300 / 6) = 50 bpm

www.uptodate.com


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ECGRates ?


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ECG

RHYTHYM

SA NodeNormal Impulse

60 100 x / minute

AV Node40 -60 x / minute

Ventrikel


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RhythmSinus (SA node)

Originating from SAnode

Rate 60-100 bpm

P wave before everyQRS

P wave in same

direction as QRS Negative P wave in

aVR and positive di II


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Langkah 1: Adakah gelombang P ?

Langkah 2: Adakah kompleks QRS ?

Langkah 3: Apakah gelombang P dan kompleksQRS berhubungan ?


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What is this rhythm?Normal sinus rhythm


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Atrial Fibrillation- No visible P waves

- Irregular R R interval


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Normal Intervals PR

0.20 sec (less than onelarge box)

QRS 0.08 0.10 sec (1-2

small boxes)

QT 450 ms in men, 460 ms

in women

Based on sex / heart rate

Half the R-R interval withnormal HR


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Prolonged QT Normal

Men 450ms

Women 460ms

Corrected QT (QTc) QTm/(R-R)

Causes Drugs (Na channel blockers)

Hypocalcemia, hypomagnesemia, hypokalemia Hypothermia

AMI

Congenital

Increased ICP


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BlocksAV blocks

First degree block

PR interval fixed and > 0.2 sec Second degree block, Mobitz type 1

PR gradually lengthened, then drop QRS

Second degree block, Mobitz type 2 PR fixed, but drop QRS randomly

Type 3 block PR and QRS dissociated


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What is this rhythm?First degree AV blockPR is fixed and longer than 0.2 sec


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What is this rhythm?Type 1 second degree block (Wenckebach)


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What is this rhythm?Type 2 second degree AV block

Dropped QRS


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What is this rhythm?3rd degree heart block (complete)


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The QRS Axis Represents the overall direction of the hearts activity

Axis of30 to +90 degrees is normal


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I

aVFII

I

aV

RaVL

II

Normal Axes- 30 s/d + 90

RAD

+ 90 s/d + 180

LAD- 90 s/d - 30

Superior Axes

- 180 s/d -90


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The Quadrant Approach QRS up in I and up in aVF = Normal


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What is the axis?Normal- QRS up in I and aVF


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Hypertrophy Add the larger S wave of V1 or V2 in

mm, to the larger R wave of V5 or V6.

Sum is > 35mm = LVH


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Ischemia Usually indicated by ST changes

Elevation = Acute infarction

Depression = Ischemia

Can manifest as T wave changes

Remote ischemia shown by q waves


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What is the diagnosis?Acute inferior MI with ST elevationin leads II, III, aVF


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What do you see in this EKG?ST depression II, III, aVF, V3-V6 = ischemia


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ARTIFACT ON THE ECG


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FIND THE ARTEFACT


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WANDERIN BASELINE


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SOMATIC TREMOR


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ELECTRICAL INTERFERANCE


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Lets Practice


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Normal Sinus Rhythm

Mattu, 2003


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First Degree Heart Block

PR interval >200ms


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Accelerated Idioventricular

Ventricular escape rhythm, 40-110 bpm

Seen in AMI, a marker of reperfusion


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Junctional Rhythm

Rate 40-60, no p waves, narrow complex QRS


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Hyperkalemia

Tall, narrow and symmetric T waves


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Wellens Sign

ST elevation and biphasic T wave in V2 and V3

Sign of large proximal LAD lesion


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Brugada Syndrome

RBBB or incomplete RBBB in V1-V3 with convex ST elevation


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Brugada SyndromeAutosomal dominant genetic mutation

of sodium channels

Causes syncope, v-fib, self terminatingVT, and sudden cardiac death

Can be intermittent on EKG

Most common in middle-aged males Can be induced in EP lab

Need ICD


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Premature Atrial Contractions

Trigeminy pattern


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Atrial Flutter with Variable Block

Sawtooth waves

Typically at HR of 150


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Torsades de Pointes

Notice twisting pattern

Treatment: Magnesium 2 grams IV


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Digitalis

Dubin, 4th ed. 1989


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Lateral MI

Reciprocal changes


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Inferolateral MI

ST elevation II, III, aVF

ST depression in aVL, V1-V3 are reciprocal changes


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Anterolateral / Inferior Ischemia

LVH, AV junctional rhythm, bradycardia


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Left Bundle Branch Block

Monophasic R wave in I and V6, QRS > 0.12 secLoss of R wave in precordial leadsQRS T wave discordance I, V1, V6

Consider cardiac ischemia if a new finding


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Right Bundle Branch Block

V1: RSR prime pattern with inverted T wave

V6: Wide deep slurred S wave


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First Degree Heart Block, Mobitz Type I (Wenckebach)

PR progressively lengthens until QRS drops


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Supraventricular Tachycardia

Narrow complex, regular; retrograde P waves, rate


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Right Ventricular Myocardial Infarction

Found in 1/3 of patients with inferior MI

Increased morbidity and mortality

ST elevation in V4-V6 of Right-sided EKG


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Ventricular Tachycardia


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Prolonged QT

QT > 450 ms

Inferior and anterolateral ischemia


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Second Degree Heart Block, Mobitz Type II

PR interval fixed, QRS dropped intermittently


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Left Ventricular Hypertrophy

Compare these two 12-lead ECGs. What standsout as different with the second one?

Normal Left Ventricular Hypertrophy

Answer: The QRS complexes are very tall

(increased voltage)


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Left Ventricular HypertrophyWhy is left ventricular hypertrophy characterized by tallQRS complexes?

LVH ECHOcardiogramIncreased QRS voltage

As the heart muscle wall thickens there is an increase in

electrical forces moving through the myocardium resulting

in increased QRS voltage.


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Left Ventricular Hypertrophy Specific criteria exists to diagnose LVH using a 12-lead

ECG.

For example: The R wave in V5 or V6 plus the S wave in V1 or V2

exceeds 35 mm.

However for now, all

you need to know is

that the QRSvoltage increases

with LVH.


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Acute Pulmonary Embolism

SIQIIITIII in 10-15%

T-wave inversions, especially occurring ininferior and anteroseptal simultaneously

RAD


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Wolff-Parkinson-White Syndrome

Short PR interval 0.10 secDelta wave

Can simulate ventricular hypertrophy, BBB and previous MI


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Hypokalemia

U wavesCan also see PVCs, ST depression, small T waves


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Thank You

Any Questions?

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