basic ekg
DESCRIPTION
Basic EKGTRANSCRIPT
-
Kittikarn Thongsonkreeb
-
Electrical cells: Pacemaker cell Fiber tract
Mechanical cells : Myocardium
-
Sinoatrial node (SA node): Primary pacemaker (rate 60-100/min)Atrioventricular junction: Escape pacemaker (AV node, bundle of His rate 40-60/min)Purkinje system: Escape pacemaker (rate < 40/min)
-
saline , gel
-
Isoelectric line : Upright/positive : Inverted/negative :
-
12 leadsBipolar limb leads 3 leads : I ,II, IIIUnipolar limb lead 3 leads : aVR,aVL,aVFPrecordial chest leads 6 leads : V1-V6!!! LeadIII aVRII aVLI aVF
-
Right armLeft armRight leg (ground electrode)Left leg
-
V1 : right 4th ICS sternumV2 : left 4th ICS sternumV3 : V2 V4V4 : left 5th ICS , Midclavicular lineV5 : left 5th ICS , Anterior axillary lineV6 : left 5th ICS , Middle axillary line
-
stylus 25 mm/secVoltage 10 mm (2 ) = 1 mV 1 = 0.20 1 = 0.04
-
P wave : atrial depolarizationPR interval : P wave QRS complex (atrial depolarization ventricle depolarization)PR segment : AV nodeQRS complex : ventricular depolarizationT wave : ventricular repolarizationU wave : repolarization of Purkinje system
-
ComponentsNormal limit (!!!)P waveAtrial depolarization x = 2 x 2.5 RA, LA , ectopyPR delay AV/BB/muscle etc.3-5 Heart block Q x = 1x2 , else patho QOLD MIQRSVentricular depolarization 5 2.5 -: LVH, RVH, : Ventricular rhythm, BBB, HyperKSTPhase 2 ventricular depoisoelectricNSTEMI, STEMI, Pericarditis, LVH strain, Dig intoxTPhase 3 Ventricular repolarization< 2/3 R R-: Hyper/hypoKInvert: ischemia, infarctQT ventricle8-11 Hyper/hypoCal, Dig intox, antiarrhythmicURepolarization of Purkinje system normal post exerciseHyperCal, HyperThyroid, HypoK
-
Rate: 300/, 1500/, regular Rhythm:sinus? OR non-sinus (atrial?, Junctional (AV)?, Ventricular?)AxisP: 2 x 2.5 RA, LA PR: >5 AV blockQRS: RVH, LVH, BBBST:depress, elevate MI, pericarditisT: peak T, invert T MI, hyper KU: HyperCal, HyperThyroid, HypoK
-
: 300/, 1500/: 300 150 100 75 60 50 45 40 35 30
-
Sinus tachycardia: rate > 100Sinus bradycardia: rate < 60Normal sinus rhythmP II, III, aVF, aVRSame p contour in the same leadOne p for every QRSPR < 5 Regular rate 60-100Normal R progression
-
Regular rhythm with rate < 60 beat/min (45-59)Uniform P wavePR interval NOT PROLONGED MI , sick sinus syndromeHypothyroidismBeta blocker ******
-
Rate > 100 beat/min (101-160)1 P 1 QRS , MyocarditisPulmonary embolism********* + (SI, QIII, TIII)Increase cardiac output : fever, hyperthyroidism, anemia
-
Respiratory sinus arrhythmia SA node Nonrespiratory sinus arrhythmia SA node
-
SA node atrial depolarization AMISick sinus syndrome
-
Reentry focus in atria 250 Atrial rate 250-350 beat/minP wave : sawtooth pattern
-
Identify P wave QRS Irregularly Irregular
-
Aging: 10% > 70 15% > 90IschemiaAlcohol abuseHyperthyroidism
- Treatment Heart rate control (
-
Regularity : regularRate : 130-210P wave : QRS complex P wave P wave lead II ( AV)QRS : 3
-
QRS : 3 rhythm (Ventricular ectopy) rhythm EKG ( complete heart block, Ventricular tachycardia)
-
Ventricular irritability ventricular contraction
-
I, II, III Biphasic axis Lead biphasic ( I Bi aVF -ve axis = -90) Biphasic Lead Lead 15
-
Example I +ve II ve III ve aVR ve aVL +ve aVF -ve
-
!! limb lead Axis = 75 - 30x -15y Lead I = 105 + 30x +15y Lead I
X = Lead Y = Lead biphasic( lead I)
LeadAxisII+III+aVR-aVL-aVF+
-
Axis = -15
-
Axis = -165
-
Axis = +30
-
lead II Normal: 2x2.5 RA/LA enlargementRA : peak P 2.5 DDx: Cor pulmonale, congenital PS or tricuspid atresia, TR, TSLA : wide & notch biphasic P V1
DDx: MS ( 3 ), MR ( 4 ), LA myxoma
-
Criteria:p wave 3 negative p V1 1 Left atrial abnormality:1 of 2 CriteriaLeft atrial enlargement:2 of 2 Criteria
-
5 = Prolonged AV block 1st degree: PR prolong 5 2nd degree: - Mobitz I: PR prolong QRS 1 prolong - Mobitz II: PR QRS - 2:1 AV block: P-P-QRS (High grade)3rd degree: P QRS rate QRS Junctional () ventricular rhythm ()
-
PR = 6
-
Mobitz I: PR prolong QRS 1 prolong
-
Mobitz II: PR prolong QRS
-
2:1 AV block: P-P-QRS
-
P QRS rate QRS Junctional () ventricular rhythm ()
-
LVH, RVH, BBBNormal: 5 2.5 Normal R progression: R V1 V4-5S V1 V6Biphasic V3-4
V1: R S V3-4: BiphasicV5-6: Q S
-
Tall R in V1 DDx ???Rt. Block: RBBBClockwise: Clockwise rotation: Dextrocardia, Situs inversus: Posterior wall MI RV: RVH : WPWHypertrophic obstructive cardiomyopathyDuchenne muscular dystrophyMisplaced electrode
-
EKG sensitivity Gold standard = EchocardiogramVoltage criteriaNormalPressure loadVolume load AS, Coarc, HTN AR, MR, PDA, etc.
-
Criteria for RVH ( LV DDx LVH)1. R V1 (7 ) + S V6 (10.5 )2. Strain (ST depress V1-2) pressure load3. +/- Rt. axis deviationDDx:1. LA : MS, Myxoma 2. LA : COPD, Cor, PE, PAHT, PS
-
Criteria for LVH1. [max S in V1-2] + [max R in V5-6] >352. Strain (ST depress V4-6) pressure load3. +/- Lt. axis deviationDDx:1. Pressure load: AS, Coarc, HTN 2. Volume load: AR, MR, PDA
-
Incomplete vs Complete block Incomplete: QRS < 3 Complete: QRS > 3 M-pattern:rSR pattern: M rSR Lead Block
-
Can be normal variantM rSR () V1-3 + Slur S V6
-
Always ABNORMAL!!!M V5-6 + Slur S V1 DDX: Cardiomyopathy, Ischemia, Myocarditis, LVH, HTN
-
Complete block (QRS > 3 ) !!! M rSR LBBB, RBBB
-
Pathologic Q wave: > 1 > 2 lead 2 leads ST elevation: ST segment > 2 mm V1-2 > 1mm Lead 2 leads ST depression: > 0.5 mm Lead J point HorizontalDownsloping
-
More remnant R wave: better prognosis (Still have some good wall left)Persistent ST elevation: Possibly ventricular aneurysm
-
LCXRCA supply SA node 60% AV node 80% Right ventricle Posterior wall 75% Inferior wallLCX supply Posterior wall 25% Inferior wall lateral wall of LV SA node 40% AV node 10%LAD supply Septal wall of LV Anterior wall of LV Lateral wall of LV LBB, RBB
-
ST depression Lead lead ST elevation NSTEMI Lead
Inferior wall MI I, aVLAnterior wall MI II, III, aVF
Anterior wall MI Reciprocal proximal LAD stenosis Poor prognosis
-
ST Elevate inII, III, aVF:RCAOR LCX+ V1, V3R, V4R:proximal RCA+ V5, V6, I, aVL:LCX+ ST depress V2-4:inferoposterior MI+ dominant R in V1-2:inferoposterior MIV1-V4 (at least 2):LADV2-4:mid LADV1-6, I, aVL:proximal LAD (extensive wall MI)V5, V6, I, aVL:LCX: EKG single vessel
-
ST elevate in II, III, aVF 2 RCA, LCX RCA stenosis: RV infarct (V3R,4R) III Elevate IILCX stenosis: lateral infarct (V5-6, I, aVL) II Elevate III Inferior wall infarct ST depress V2-4 dominant R V1-2 Posterior wall infarct V7-9 Inferior wall V3R,4R V7-9
-
Acute inferoposterolateral STEMI, possibly LCX occlusion
-
Acute anteroseptal STEMI, possibly proximal LAD occlusion
-
Acute inferoposterior wall STEMI, possibly RCA occlusion
-
Acute extensive wall STEMI, possibly proximal LAD occlusion
-
Acute inferior wall STEMI, vessel??
-
Acute inferior wall STEMI c RV infarct, RCA occlusionV3RV4RV5RV6R
-
A 25 YOM presenting with sudden cardiac arrest, the EKG at ER shows
After CPR 5 min & Defibrillation, patient was recovered. The 12-lead EKG was obtained
-
Brugada syndrome: Mutation of Na channel
-
Reentry: 2 different conduction fibersMost common cause of tachyarrhythmiaAVNRT, Aflut, VTEctopy: abnormal automaticity of ectopic fociCause from abnormal tissue, e.g. post cardiac surgery, post MIAtrial tachycardia
-
NarrowWideRegular Sinus tachycardia Atrial flutter Atrial tachycardia PSVT (AVNRT, AVRT) VT SVT c BBB Antidromic AVRTIrregular P: AT/Aflut c varying block MAT P: AF AF c BBB/WPW Aflut/AT c varying block c BBB/WPW
-
Most common isSinus tachycardia
-
Rate > 100 beat/min (101-200)1 P 1 QRS , Increase cardiac output : fever, hyperthyroidism, anemiahypoxemiaHypovolemiaMyocarditisPulmonary embolism********* + (SI, QIII, TIII)
-
Macro reentry focus in atria 250 Atrial rate 250-350 beat/minP wave : sawtooth pattern 2:1 block (rate = 150)
AV node blocker slow rate flutter wave
-
Ectopic foci in atrium: rate SA node (150-250) ASD (Scar formation) Isoelectric p wave p wave lead II, III, aVF SVT P QRS
-
AV nodal reciprocating tachycardia (AVNRT) reentry circuit AV nodeAV reciprocating tachycardia(AVRT)Reentry circuit accessory pathway
-
Reentry circuit in AV node, Precedes with PAC 70% no retrograde PPseudo S in II, III, aVFPseudo R in V1
-
After adenosine injection
-
Congenital accessory pathway (Bundle of Kent)Orthodromic or antidromic AVRTUsually, p wave is seen inverted after QRS
-
Conduction through bundle of KentShort PR + delta wave + QRS Dominant R in V1-2 arrhythmia, syncope Wolff-Parkinson-White Syndrome
-
With P wave:Atrial tachycardia c varying blockAtrial flutter c varying blockMultifocal atrial tachycardiaWithout P wave:Atrial fibrillation
-
At least 3 morphologies of p waveVariable PR interval Chronic lung disease
-
1 2 3 2 4 2 5 1 4 2
-
Multiple micro-reentry circuit in atriumParoxysmal: heart failure, hypovolemia, sepsis, postoperativePermanent: structural atrial disease MS, HTN LAA-LAEP wave rate: 350-600 bpm in a character of Fibrillation waveQRS is usually irregular, except AF with 3rd deg. AV blockSlow, normo or rapid ventricular response
-
Identify P wave QRS Irregularly Irregular
-
VT is the MOST COMMONSVT with BBBAntidromic AVRT Criteria VT VT
-
PVC 3 Sustained VT (>30s): DefibrillateNon-sustained with hypotension: DefibrillateNon-sustained without hypotension: find the causeVentricular rate: 150-250/minAV dissociationFusion beatEscape beat
100% VT for sure
-
Monomorphic: single ectopic focusPolymorphic: multiple ectopic fociTorsade de pointes
-
Escape beatFusion beat
-
Polymorphic VT in long QTc (>0.45 sec)QRS axis
-
AF/Aflut with varying block withBBBWPW
-
1:1 AV conduction (bypass AV node) AV node blocker: adenosine, digoxin, diltiazem, verapamil
-
Regular rhythm with rate < 60 beat/min (45-59)Uniform P wavePR interval NOT PROLONGED MI , sick sinus syndromeHypothyroidismBeta blocker ******
-
SA node atrial depolarization AMISick sinus syndrome
-
PR 5 = Prolonged AV block 1st degree: PR prolong 5 2nd degree: - Mobitz I: PR prolong QRS 1 prolong - Mobitz II: PR QRS - 2:1 AV block: P-P-QRS (High grade)3rd degree: P QRS rate QRS Junctional () ventricular rhythm ()
-
PR = 6
-
Mobitz I: PR prolong QRS 1 prolong
-
Mobitz II: PR prolong QRS
-
2:1 AV block: P-P-QRS
-
P QRS rate QRS Junctional () ventricular rhythm ()
-
2:1 AV block
-
1st degree AV block, ST depression in V4-6, II, III, aVF, LVH with strain pattern
-
3rd degree AV block with complete RBBB
-
Hyper/hypokalemiaHyper/hypocalcemiaDigoxin intoxicationDextrocardiaMisplaced leads
-
Tall-peaked T: K = 5.5-6.0P wave : K = 6.5-7.5 Wide QRS: K = 7.5-8.0Sine wave: K > 8.0
Mx:10% Ca Gluconate 10ml in 10 minInsulin 5-10 U IV + 50% glucose 50 mlExcretory agent: diuretics, Kalimate
-
Flat T UST depressionT inversion
-
HyperCal: Short QTHypoCal: Long QT
-
block SVT with AV blockAF with AV blockAccelerated junctional rhythm (specific)Ventricular arrhythmiaMultifocal PVCs (Most common)VT, VFReversed check sign in ST segment
-
FeaturesRight axis deviationDominant R in V1, with declining heights in V2-6Positive p wave in aVRInverted p wave in I, aVL (DDx reversed limb electrode)
-
Positive P in aVR (RA involved)Inverted p in I, aVL: RA LAInverted p in II, III, aVF: RA LLAbsent II, or almost biphasic I: RA RL (unsure)Negative P in aVR (RA not involved)Inverted p in III only: LA LLAbsent III: LA RL (unsure)Nothing change: LL RL
-
*