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ELECTROCARDIOGRAPHY
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Lecture outline
Part one
Information provided by ECG
Cardiac conduction system: anatomyand physiology
(Normal) ECG interpretation
Part two
Abnormal ECG
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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 electricalactivity recorded from electrodes on thebody surface
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Information provided by ECG:what do you think?
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SA node AV node
Bundle His
Cardiac conduction
system
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Impulse Transmission
SA Node
Internodal branch AV Node Hiss Bundle Purkinje Fiber
Contraction
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the sequentialactivation
(depolarization) of the right andleft atria
right and left ventricular depolarization (normally theventricles are activated simultaneously)
ventricular repolarization
One complex of ECG waveform
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Leads position
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Limb leads
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Chest lead
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Chest lead
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Chest lead
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ECG interpretation?
1. Calibration2. Rhythm3. Rate4. QRS axis
5. P morphology6. PR interval7. QRS duration8. QRS morphology9. Abnormal Q wave10. R wave progression
11. ST segment morphology12. QT interval13. T morphology14. U morphology15. Others: LVH, LV strain, BBB,16. Conclusion: normal/abnormal
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Paper speed and normal
value
One small box: 0.04 sOne large box: 0.2 s
PR Interval: 0,12- 0,20QRS duration: 0,04- 0,12
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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.
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Rate calculationpaper 25 mm/s
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Sinus Rhythm
Sinus Rhythm
Rhythm: Regular
Rate: 60 100P wave: Normal in configuration; precede eachQRS
PR: Normal (0. 12 0.20 s)
QRS: Normal (
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QRS Axis (N: - 30 s/d + 110)
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P wave
Wave of atrial depolarization
Normal characteristic:
1. Smooth and rounded
2. 3 mm tall
3. Upright in leads I, II avF
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PR interval
Including P wave until the beginning
of QRS complex
Normal duration is 0.12-0.2 seconds
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QRS complex
Wave of ventricular depolarization
5-20 mm tall
Duration 0.06-0.10 seconds
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QRS morphology
qRs RsR
rS
QR Q/QS RsR rSr
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ST segment
Begins at J point
Between ventricular depolarization andventricular repolarization
Generally isoelectric
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T wave
Ventricular repolarization, followed by
ventricular relaxation
Positive in lead : I, II, V3-V6
Negative in lead avR
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Interpret this ECG..
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And this..
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Abnormal ECG
Myocardial ischemia/infarct
Hyperthrophy
Hyperkalemia
Arrhythmia
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ACUTE CORONARY SYNDROME
No ST Elevation ST Elevation
Unstable Angina
NSTEMI
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Acute myocardial
infarction
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STEMI Non STEMI
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Mid LAD occlusion
after the first septal
perforator (arrow)ECG : large anterior MI
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Occlusion of diagonal
branch ( arrow)
ST elevation in I and aVL
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ECG demonstrates large anterior infarction
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Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6
with precordial ST depression
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Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
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Peaking T
Shortening QT interval
Widening P wave,
QRS complex
Prolongation PR interval
HIPERKALEMIA
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PPM
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How to identify arrhythmias ?
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QRS complex
Regular / irregular ?
QRS complex
Normal-looking QRS complex?
Wide / narrow ?
P wave ?
Relationship between P and QRS ?
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NORMAL SINUS RHYTHM
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PSVT :
-due to re-entry mechanism
-narrow QRS complex-regular-retrograde atrial depolarization-P wave ?
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PSVT
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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
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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
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Junctional rhythm:-AV junction can function as a pace maker
(40-60 x/min).-due to the failure of sinus node to initiatetime impulse or conduction problem.-normal-looking QRS.-retrograde P wave.-P wave may preceede, coincide with, or
follow the QRS
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VES
SR
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SR SR SR SRSR SR
VES VES
Sinus rhythmwithMultifocal VES
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Sinus rhythm with VES couplet
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Sinus Rhythm with VES, R on T
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Ventricular Tachycardia
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Torsade de Pointes
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Ventricular Fibrillation
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Prolonged PR interval
1st degree AV block
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Missing QRSMissing QRS
2nd degree AV block, type 1
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2nd degree AV block, type 2
Missing QRS
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P PP P P P P
QRS QRS QRS
Total AV Block /3rd degree AV block
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