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1 ECG INTERPRETATION: the basics Damrong Sukitpunyaroj MD Damrong Sukitpunyaroj, MD Perfect Heart Institue, Piyavate Hospital
2 Overview Conduction Pathways Systematic Interpretation Common abnormalities in Critical Care Supraventricular arrhythmias Ventricular arrhythmias
3 Conduction Pathways
4 Conduction Pathways P wave = atrial depolarisation. PR Interval = impulse from atria to ventricles. QRS complex = ventricular depolarisation. ST segment = isoelectric - part of repolarisation. T wave = usually same direction as QRS - ventricular repolarisation. QT Interval = This interval spans the onset of depolarisation to the completion of repolarization of the ventricles.
5 Interpretation
6 Interpretation 1. Rate = Number of P s (atrial) R s (ventricular) per minute (6 second [30 squares] X 10 = minute rate). P rate: 8 x 10 = 80 R rate: 8 x 10 = Rhythm = Regular or irregular. Map P-P and R-R intervals.
![minute (6 second [30 squares] X 10 = minute rate).](/docs-images/44/19470198/images/page_6.jpg "P rate: 8 x 10 = 80 R rate: 8 x 10 = 80 2.")
7 Interpretation 3. P wave = present, 1 per QRS, shape, duration, voltage. 4. P-R interval = length ( sec = <1 big square), isoelectric.
8 Interpretation 5. QRS = duration ( ), voltage, q or Q waves 6. ST Segment = shape, isoelectric with PR segment
9 Interpretation 7. T wave = shape, direction 8. QT interval = length (R-R/2 or QTc <0.40 sec)
10 Abnormalities: Supraventricular arrhythmias Atrial Fibrillation Atrial Flutter Supraventricular Tachycardia (SVT) Abnormalities: Ventricular arrhythmias Premature Ventricular Complexes (PVCs) Ventricular tachycardia (VT)
11 Conduction Pathways Supraventricular Narrow QRS complex V t i Ventricular Wide QRS complex
12 Abnormalities: atrial fibrillation Rhythm: Irregular Rate: A: ; V: varies P: poorly defined P-R: N/A QRS: narrow complex S-T: normal T: normal Q-T: normal
13 Abnormalities: atrial flutter Rhythm: Regular / Irregular Rate: A: ; V: <300 (2:1, 3:1 or sometimes 4:1) P: Saw toothed appearance P-R: N/A QRS: narrow complex S-T: normal T: normal Q-T: normal
14 Abnormalities: supraventricular tachycardia (SVT) Rhythm: Regular Rate: >100 P: not visible P-R: not defined QRS: narrow complex S-T: depression (sometimes) T: normal Q-T: prolonged (sometimes)
15 Abnormalities: premature ventricular complexes
16 Examples
17 Examples
18 ECG INTERPRETATION: 12 Lead
19 Overview Lead Placement Axis Common abnormalities in Critical Care Heart block Bundle branch blocks Life threatening arrhythmias
20 Lead Placement V1 = 4th ICS right sternum V2 = 4th ICS left sternum V3 = midway between V2 and V4 V4 = 5th ICS midclavicular V5 = between V4 and V6 anterior auxiliary line V6 = midauxillary line lateral to V4 and V5
21 Lead Placement Electrical activity towards = Electrical activity away =
22 Lead Placement
23 Axis The direction of an ECG waveform in the frontal plane measured in degrees Represents the flow of the majority of electrical activity Normally the QRS complex is measured
24 Each lead has its own axis Axis
25 Lead Placement Standard Leads (bipolar) I - lateral wall II - inferior wall III - inferior wall Augmented leads (unipolar) avr - no mans land avl - lateral wall avf - inferior wall Chest Leads (unipolar) V1 - septal wall V2 - septal wall V3 - anterior wall V4 - anterior wall V5 - lateral wall V6 - lateral wall
26 Lead Placement No-mans land, inferior, lateral, anterior, septal,
27 Abnormalities: bundle branch blocks QRS widened, greater than 0.12 secs Change in axis Difficult to interpret ECG Right or Left Normal P wave Followed by a T wave
28 Abnormalities: right bundle branch blocks Indicates conduction problems in the right side of the heart May be normal in healthy people R wave in V1, ie two R waves in V1 Q wave in V6 Lead V1 cats ears
29 Abnormalities: left bundle branch blocks Always indicates heart disease, usually of the left side of the heart Hard to interpret an ECG with LBBB Lead V1 Q wave and an S wave Lead V6 an R wave followed by another R wave Lead V6 Rabbit ears
30 SA block (exit block) 1 st degree AV block 2 nd degree AV block Wenckeback (type I) Mobitz (type II) 3 rd degree AV block Abnormalities: heart block
31 Abnormalities: heart block SA block
32 Abnormalities: heart block 1 st degree AV
33 Wenkeback k Abnormalities: heart block 2 nd degree AV Mobitz
34 Abnormalities: heart block 3 rd degree AV
35 Abnormalities: life threatening arrhythmias Ventricular Tachycardia Ventricular Fibrillation Asystole
36 Abnormalities: life threatening arrhythmias - VT
37 Abnormalities: life threatening arrhythmias - VF
38 Abnormalities: life threatening arrhythmias Asystole
39 Examples
40 Examples
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