ecg 101 with answers
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ECG 101
ECG 101
Inferior posterior STEMILikely RV infarct
Avoid GTN and morphineMay need a fluid load
The eyes may be the window to the soul
But the ECG is the window to the heart, lungs, toxicology, electrolytes, body temperature and sometimes even the brain
Pattern recognition
An ECG is put under your nose
Immediately
InterpretTime
Name stamp
Covers nurse/HCA’s arseMakes you read it
We know who to educate if it’s wrong
Be systematic
One system
Patient’s name
Presenting complaint
ECG machine RR interval big squares: 300, 150, 100, 75, 60, 50
total number of complexes across the page x 6
Rate
ECG machine RR interval big squares: 300, 150, 100, 75, 60, 50
total number of complexes across the page x 6
Rate
SVT
Rhythm
RhythmAtrial flutter with 2:1 block
Atrial flutter with 2:1 block
Same patient after treatment for sepsis
AAtrial flutter with variable block
Frontal axis
Frontal axis
Sinus tachycardia with R atrial abnormality (P pulmonary) and extreme R axis deviation
Why else do we care about axis?
CQC
Why else do we care about axis?
CQC
Incomplete Trifasicular block:RBBB, LAD and 1˚HB
Incomplete trifascilar blockRBBB, LAD and 1˚HB
1 myocyte away from complete heart blockDon’t send this post syncope patient home
Then proceed through the complexes
p waves
p waves
P mitrale: mitral stenosis
PR interval
PR interval
1˚HBLown-Ganong-Levine syndrome
with short PR interval
Mobitz type 2 2˚HB
PR depression II, V5, V6,PR elevation aVR
Saddle shaped ST elevation II, v5, V6Inverted saddle shaped ST elevation aVR
= pericarditits
QRS complex
QRS complexWide complex tachy, probably VT
LBBB
RBBB
QRS complex
QRS complex
Hyperkalaemia
Sodium channel blockadeeg tricyclic overdose
QRS complex
QRS complexSevere hyperkalaemia
Killer Qs
Pathological Qs
> 40 ms (1 mm) wide > 2 mm deep > 25% of depth of QRS complex Seen in leads V1-3
Killer Qs
Pathological Qs
> 40 ms (1 mm) wide > 2 mm deep > 25% of depth of QRS complex Seen in leads V1-3
Q waves 2˚ to MIMay still be thrombolysable
HOCM
ST segment
ST segment
LBBB
LVHBrugada
ST segment
R
ST segment
R
Right ventricular infarct
Posterior STEMI
ST segment
ST segment
Inferior-posterior-high lateral STEMI
ST segment
ST segment
Paced rhythm with Sgarbossa+ve anterior ST depression and
> 5mm ST elevation in III
LBBB
Original Sgarbossa Criteria
Concordant ST-segment elevation ≥ 1 mm in any lead (5 points) Concordant ST-segment depression ≥ 1 mm in lead V1 – V3 (3 points)
Discordant ST-segment elevation ≥ 5 mm in any lead (2 points)
ST segment
ST segment
Critical left main coronary occlusion or extensive triple vessel disease
avoid clopidogrel
T waves
T waves
Hyperactue Ts in ischaemia
Wellens’ Type A
Wellen’s type B
Repeat ECGs
13 minutes later, pain free:
Repeat ECGs
Same patient 13 minutes later, pain free:
Biphasic T in V2T wave inversion aVL
Deep anterior T wave inversionWellen’s syndrome (type B)
Don’t put a Wellen’s patient on a treadmillthey tend to drop dead
T waves
T wavesAnterior and inferior TWIRight heart strain
PE
Lateral T wave inversion due to LVH
Lateral T wave inversion due to LBBB
T waves
T wavesAnterior and lateral T wave inversion
HOCM
Flattened T wavesIschaemia
T waves
T wavesLateral and high lateral
T wave inversion due to ischaemia
T wave inversion due to subarachnoid haemorrhage
(rare)Hyperkalaemia
QTc
Long QT syndrome (genetic)
Drugs incl amiodarone, digoxin, macrolides, antipsychotics, tricyclics, SSRIs, loratidine
HypothermiaHyperCaHypoK, hypoMag
Myocardial ischaemiaICH
+ others
> 440ms in men or > 460ms in women
QTc
Long QT syndrome (genetic)
Drugs incl amiodarone, digoxin, macrolides, antipsychotics, tricyclics, SSRIs, loratidine
HypothermiaHyperCaHypoK, hypoMag
Myocardial ischaemiaICH
+ others
> 440ms in men or > 460ms in women
Prolonged QT
Prolonged QTleading to
Torsades de pointes
Just to reinforce …
Just to reinforce …
Anterior-septal marked ST depression(reciprocal ST elevation)
and prominent S R waves (reciprocal Qs)
=probable posterior STEMI
Posterior STEMI
Posterior STEMI
Confirm by moving V4-6 to the posterior chest
Methodical readRecord your interpretationTimeName stampFurther actions esp repeat ECGs q10min x 3 for CP
eg Trodat Printy 4910 http://www.selfinkingstamps.co.nz/shop/trodat-4910-26x9mm/
$20 delivered
References and images
Most facts checked with and images obtained from
Life in The Fast Lanehttp://lifeinthefastlane.com/
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