ECG Interpretations PDF

ECG - EKG interpretations MOHAMMED AHMED SENAN BS,RCP,MsRC RESPIRATORY THERAPIST SPICILIST Feb-24 Dr.Mohammed SeNaN-MsRC 1 What types of pathology can we identify and study from EKGs? Arrhythmias Myocardial ischemia and infarction Pericarditis C...

ECG - EKG interpretations MOHAMMED AHMED SENAN BS,RCP,MsRC RESPIRATORY THERAPIST SPICILIST Feb-24 Dr.Mohammed SeNaN-MsRC 1 What types of pathology can we identify and study from EKGs? Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances (i.e. hyperkalemia, hypokalemia) Drug toxicity (i.e. digoxin and drugs which prolong the QT interval) Evaluation of pacemaker function. Feb-24 Dr.Mohammed SeNaN-MsRC 2  What is an EKG - ECG? The electrocardiogram--Eng.(ECG) (Electrokardiogram –Ger. (EKG) * Is a representation of the electrical events of the cardiac cycle. *Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac pathophysiology. Feb-24 Dr.Mohammed SeNaN-MsRC 3 "I do not imagine that electrocardiography is likely to find any very extensive use in the hospital. It can at most be of rare and occasional use to afford a record of some rare anomaly of cardiac action.“ Augustus D. Waller Barker LF: Electrocardiography and phonocardiography: A collective review. Bull Johns Hopkins Hosp 1910;21:358–359 Feb-24 Dr.Mohammed SeNaN-MsRC 4  Why ECG's? Is the heart producing correct electric signals? ER, OR, CCU. Heart forces blood to flow Blood carries oxygen, energy, toxins  History 1876, A PhD student stuck wires on a patient's wrist and measured the electric current 1911, still no clinical application 1924, Einthoven awarded Nobel Prize Improved the sensitivity Different current sensor 3 components of EC Patient Machine ECG Paper. Feb-24 Dr.Mohammed SeNaN-MsRC 7 3 components of ECG Patient Machine ECG Paper. Feb-24 Dr.Mohammed SeNaN-MsRC 8 Feb-24 Dr.Mohammed SeNaN-MsRC 9 TYPES OF ECG RECORDER Single channel recorder. Three channel fifth channel 12 Channel recorder Vector or monitor electrocardiograph. ECG. System for Stress Testing. Holter ECG. Feb-24 Dr.Mohammed SeNaN-MsRC 10  intermittent USES continuous Types 3 leads LEADS 5 leads 12 leads Feb-24 Dr.Mohammed SeNaN-MsRC 11  3 LEADS 5 leads Rt. over Rt. over Lower Lt. Lower Lt. ribs ribs Lt. over Lt. over Lower Rt. ribs Mid chest Feb-24 Dr.Mohammed SeNaN-MsRC 12  12 leads The limb leads are labelled: R (right), L (left), F (foot) and N (neutral). (see fig 1.4). It is vital, however, to get the position of the chest electrodes correct (see fig 1.5): Feb-24 Dr.Mohammed SeNaN-MsRC 13  12 leads Standards I II leads III Augmented aVR RED avL YELLOW leads avF GREEN Pericardial leads V1 - V6 Feb-24 Dr.Mohammed SeNaN-MsRC 14  12 leads Chest lead It is vital, however, to get the position of the chest electrodes correct (see fig 1.5): 1.V1 should be positioned in the fourth intercostal space counting down from the patient’s right sternal notch on the right sternal edge; 2.V2 should be positioned in the fourth intercostal space counting down from the patient’s left sternal notch on the left sternal edge; 3.V3 should be positioned midway between V2 and V4; 4.V4 should be positioned in the fifth intercostal space, counting down from the middle of the patient’s clavicle; 5.V5 should be positioned in line with V4 but on the anterior axillary line; 6.V6 should be positioned in line with V4 but in the midaxillary line. Feb-24 Dr.Mohammed SeNaN-MsRC 15  12 leads Chest lead Feb-24 Dr.Mohammed SeNaN-MsRC 16 Feb-24 Dr.Mohammed SeNaN-MsRC 17 3 components of ECG Patient Machine ECG Paper. Feb-24 Dr.Mohammed SeNaN-MsRC 18 Feb-24 Dr.Mohammed SeNaN-MsRC 19  paper ECG graphs: 1 mm squares 5 mm squares Paper Speed: 25 mm/sec standard Voltage Calibration: 10 mm/mV standard Feb-24 Dr.Mohammed SeNaN-MsRC 20  ECG Paper: Dimensions 5 mm 1 mm Voltage ~Mass 0.1 mV 0.04 sec 0.2 sec Speed = rate Feb-24 Dr.Mohammed SeNaN-MsRC 21 ECG Graph Paper Y- Axis Amplitude in mill volts X- Axis time in seconds Feb-24 Dr.Mohammed SeNaN-MsRC 22  ECG Graph Paper X-Axis represents time - Scale X-Axis – 1 mm = 0.04 sec. Y-Axis represents voltage - Scale Y-Axis – 1 mm = 0.1 mV One big square on X-Axis = 0.2 sec (big box) Two big squares on Y-Axis = 1 milli volt (mV) Each small square is 0.04 sec (1 mm in size) Each big square on the ECG represents 5 small squares = 0.04 x 5 = 0.2 seconds. Y 5 big squares = 0.2 x 5 = 1sec = 25 mm One second is 25 mm or 5 big squares x One minute is 5 x 60 = 300 big squares Feb-24 Dr.Mohammed SeNaN-MsRC 23  ECG Graph Paper 1 Small Square = 1 mm (0.1 mV) Vertical Axis 1 Large Square = 5 mm (0.5 mV) ‘y’ 2 Large Squares = 10 mm (1 mV) Horizontal 1 Small Square = 0.04 sec Axis 1 Large Square = 0.2 sec ‘x’ 5 Large Squares = 1 sec Feb-24 Dr.Mohammed SeNaN-MsRC 24  Paper Speed 25mm/sec 50mm/sec Feb-24 Dr.Mohammed SeNaN-MsRC 25 3 components of ECG Patient Machine ECG Paper. Feb-24 Dr.Mohammed SeNaN-MsRC 26  Patient Identity Age :- child ECG & old man ECG. Race :- black (minor changes ) or white Height ,weight & body build (amplitude & complexes ) Pulmonary diseases (position of the heart & voltage + dis effect ) Medications :- Digitalis Bp & clinical impression. Feb-24 Dr.Mohammed SeNaN-MsRC 27 EKG Leads Leads are electrodes which measure the difference in electrical potential between either: ♥ 1. Two different points on the body (bipolar leads) ♥ 2. One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart (unipolar leads) Feb-24 Dr.Mohammed SeNaN-MsRC 28  EKG Leads The standard EKG has 12 leads: I Standards II III leads 3 Standard Limb Leads aVR RED Augmented avL YELLOW 3 Augmented Limb Leads avF GREEN leads 6 Precordial Leads Pericardial leads V1 - V6 The axis of a particular lead represents the viewpoint from which it looks at the heart. Feb-24 Dr.Mohammed SeNaN-MsRC 29  Frontal Plane Leads Feb-24 Dr.Mohammed SeNaN-MsRC 30 ECG (standard )Limb Leads Standard (bipolar) Leads: I: RA- to LA+ II: RA- to LL+ III: LA- to LL+ Feb-24 Dr.Mohammed SeNaN-MsRC 31 ECG Augmented Limb Leads Augmented Vector (Unipolar) Leads aVR: to RA+ aVL: to LA+ aVF: to LL+ Feb-24 Dr.Mohammed SeNaN-MsRC 32  Standard Limb Leads Feb-24 Dr.Mohammed SeNaN-MsRC 33 Feb-24 Dr.Mohammed SeNaN-MsRC 34  Hexaxial View In The Frontal Plane Feb-24 Dr.Mohammed SeNaN-MsRC 35  Horizontal Plane Leads Feb-24 Dr.Mohammed SeNaN-MsRC 36  ECG Precordial Leads Feb-24 Dr.Mohammed SeNaN-MsRC 37  Precordial Leads Adapted from: www.numed.co.uk/electrodepl.html Feb-24 Dr.Mohammed SeNaN-MsRC 38  V1 : 4th ICS & Rt sternal border V2 : 4th ICS & Lt sternal border V3 : midway, between V2 & V4 V4 : 5th ICS, mid clavicular line V5 : 5th ICS, anterior axillary line V6 : 5th ICS, mid axillary line Feb-24 Dr.Mohammed SeNaN-MsRC 39  Precordial Leads Feb-24 Dr.Mohammed SeNaN-MsRC 40 Feb-24 Dr.Mohammed SeNaN-MsRC 41  Exercise 12-Lead ECG Feb-24 Dr.Mohammed SeNaN-MsRC 42  Summary of Leads Limb Leads Precordial Leads Bipolar I, II, III - (standard limb leads) Unipolar aVR, aVL, aVF V1-V6 (augmented limb leads) Feb-24 Dr.Mohammed SeNaN-MsRC 43 Arrangement of Leads on the EKG Feb-24 Dr.Mohammed SeNaN-MsRC 44 Anatomic Groups (Septum) Feb-24 Dr.Mohammed SeNaN-MsRC 45  Anatomic Groups (Anterior Wall) Feb-24 Dr.Mohammed SeNaN-MsRC 46  Anatomic Groups (Lateral Wall) Feb-24 Dr.Mohammed SeNaN-MsRC 47  Anatomic Groups (Inferior Wall) Feb-24 Dr.Mohammed SeNaN-MsRC 48  Anatomic Groups (Summary) Feb-24 Dr.Mohammed SeNaN-MsRC 49 EXERCISE exercise Feb-24 Dr.Mohammed SeNaN-MsRC 50  Conduction System His bund. Septal Branch Feb-24 Dr.Mohammed SeNaN-MsRC 51 Cardiac Activation sequence QRS d PR Interval SA Node AV Node BBs Ventricles Feb-24 Dr.Mohammed SeNaN-MsRC 52  Cardiac Conduction System Feb-24 Dr.Mohammed SeNaN-MsRC 53 Feb-24 Dr.Mohammed SeNaN-MsRC 54 How it drown the ECG. P wave morphology PR interval QRS interval, QRS complex morph ST segment T wave U wave QT duration Feb-24 Dr.Mohammed SeNaN-MsRC 55 Waveforms and Intervals Feb-24 Dr.Mohammed SeNaN-MsRC 56  Identify the ECG Complex The Wave or Interval Duration # of Boxes P wave : Atrial contraction 0.12 sec (3) PR interval – P to begin. of QRS 0.20 sec (5) (p+ AV.delay ) QRS complex - Ventricular 0.08 sec (2) ST segment - Electrical silence Isoelectric QRS interval – Ventricular cont. 0.08 sec (2) T wave – ventricular repolarizing. 0.12 sec (3) QT interval - From Q to T end 0.40 sec (10) TP segment - Electrical silence 0.20 sec (5) (shorten in tachycardia ) Feb-24 Dr.Mohammed SeNaN-MsRC 57  Identify the QRS complex waves Q wave – Septal = < 3 mm, < 0.04 sec (1 small box) R wave – Ventricular contraction < 15 mm S wave – complimentary to R < 15 m. Feb-24 Dr.Mohammed SeNaN-MsRC 58 Feb-24 Dr.Mohammed SeNaN-MsRC 59  P W a v e ( u p r i g h t i n l e a d II) Im p u l s e initiated in the sinus n o d e Feb-24 Dr.Mohammed SeNaN-MsRC 60  PWave Beginningof artial excitation Feb-24 Dr.Mohammed SeNaN-MsRC 61  PWave Atrial excitation Feb-24 Dr.Mohammed SeNaN-MsRC 62  PWave Completion of atrial excitation Feb-24 Dr.Mohammed SeNaN-MsRC 63  P-R Interval Impulse delay at AV junction Feb-24 Dr.Mohammed SeNaN-MsRC 64  ORScomplex Electrical excitation of theventricles Feb-24 Dr.Mohammed SeNaN-MsRC 65  TWave Ventricular repolarization Feb-24 Dr.Mohammed SeNaN-MsRC 66  Overview of procedure Lay patient down Turn on machine Expose chest, wrists, Calibrate to 10mm/mV ankles ,remove any Rate at 25mm/s galleries Record and print Clean electrode sites Label the tracing May need to shave Disconnect if adequate Apply electrodes and remove electrodes Attach wires correctly Feb-24 Dr.Mohammed SeNaN-MsRC 67  Recording the trace Different ECG machines have different buttons that you have to press. Ask one of the staff on the ward if it is a machine that you are unfamiliar with. Ask the patient to relax completely. Any skeletal muscle activity will be picked up as interference. If the trace obtained is no good, check that all the dots are stuck down properly they have a tendency to fall off. Feb-24 Dr.Mohammed SeNaN-MsRC 68 Final results of reading ECG. 1-Normal tracing. 2-Borderline records Minor changes (enumerate them ) (need clinical data & serial ECG.) 3-Abnormal ECG Typical of (name the conditions). 4-Abnormal ECG. Not characteristics of any diagnosis. Feb-24 Dr.Mohammed SeNaN-MsRC 69 Problems with ECG recording Patient identity Lead position Paper speed and amplification Artefacts. NB: Misinterpretation is much more common than poor recording technique. Feb-24 Dr.Mohammed SeNaN-MsRC 70  Patient Identity Seven-year-old male American pit bull terrier (Spencer) Feb-24 Dr.Mohammed SeNaN-MsRC 71  Signal Amplification Feb-24 Dr.Mohammed SeNaN-MsRC 72  Artifact Feb-24 Dr.Mohammed SeNaN-MsRC 73  Artifact Feb-24 Dr.Mohammed SeNaN-MsRC 74 Feb-24 Dr.Mohammed SeNaN-MsRC 75  Look at all the leads? Feb-24 Dr.Mohammed SeNaN-MsRC 76  Wandering base line ▪In non co-operative child ▪Excessive movements of limbs ▪Movement disorders of CNS ▪Not properly earthed machine ▪Additional wet ground earth helps Feb-24 Dr.Mohammed SeNaN-MsRC 77 Muscle Tremor ▪Limb movements cause baseline fluctuations ▪Tense muscles cause tremor of baseline ▪Hairy chest interferes with proper contact of chest leads – better to shave the area if needed. ▪Reassurance, starting recording a few minutes after the leads are placed – reduce muscle tension Feb-24 Dr.Mohammed SeNaN-MsRC 78 AC Interference ▪Any electrical gadgets in the same line may interfere ▪Like Mixie, Motor, Musical tube lights etc ▪Proper earthing is essential ▪Dedicated direct line for ECG power point ▪Use battery mode, Artifacts are quite misleading Feb-24 Dr.Mohammed SeNaN-MsRC 79 Rhythm ID: Algorithm sinus rhythm 1-P-Wave: What is the atrial rhythm? < 0.12 sec (3 mm) 2-QRS: What is the ventricular rhythm? 35 – Not LVH – Normal ❖T↓ in V1, V2, V3 – Normal in child ❖Base line disturbances in V5, V6 – due to movement by child Feb-24 Dr.Mohammed SeNaN-MsRC 12  Juvenile ECG Feb-24 Dr.Mohammed SeNaN-MsRC 12  Early Repolarization This ECG has all normal features The ST-T (J) Junction point is elevated. T waves are tall, May be inverted in LIII, The ST segment initial portion is concave. This does not signify Ischemia Feb-24 Dr.Mohammed SeNaN-MsRC 12 Pseudo Normalization T↓ Before Chest pain T↑ During Chest pain T↓ Chest pain Relieved Feb-24 Dr.Mohammed SeNaN-MsRC 12  The message The final decision must be made by total evaluation of the ECG and all the clinical findings. Feb-24 Dr.Mohammed SeNaN-MsRC 12  Thanks for attention Feb-24 Dr.Mohammed SeNaN-MsRC 12 96  Thank You. Feb-24 Dr.Mohammed SeNaN-MsRC 12