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In the diagram normal range - 30 to +90.

Left axis deviation superior and leftward

-30 to -90

Right axis deviation inferior and rightward

+90 to +150

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PR Interval

beginning of P to beginning of QRS

Normal: 0.12 - 0.20s

Short PR: < 0.12s QRS Duration

duration of QRS complex

Normal: 0.06 - 0.12s

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QT Interval

beginning of QRS to end of T wave

Normal: heart rate dependent (correctedQT =QTc = measured QT % sq-root RRin seconds; upper limit for QTc = 0.44 sec)

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How to read an ECG

Standardisation

Rate

RhythmAxis

Chamber enlargement & hypertrophy

Arrythmias & conduction delays Ischaemia / infarction

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Case scenario 1

26 year old man

Run over by a truck

Managed in local hospital

Brought to casualty 24 hours later

head injuries and extensive crush injury tolower limbs

GCS 10/15

BP: 90/60 HR:46/min

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Admitted in ICU and stabilised

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ECG

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S.creat: 4.5 mg%

S. K: 7.1 mEq/l

CPK: 36,000

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Course

Pharmacological measures to decrease

pottassium

Dialysis

Surgery

Patient did well and was discharged 2

weeks later

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ECG

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Take home message

Consider potassium derangements in any

arrythmia in the ICU

Focus on treating the underlying

dyselectrolytemia promptly

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Case scenario 2

20 year old primigravida from Chittoor Fever, jaundice and altered sensorium for

5 days

GCS: 12/15

Blood smear positive for plasmodium

falciparum

Parasitic index 10%

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Started on Quinine infusion

On day 2, Sudden hypotension

BP:80 sys HR: 200/min

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ECG

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Polymorphous ventricular tachycardia -Torsade depointes.

wide QRS complexes with multiple morphologies

changing R - R intervals

the axis twists about the isoelectric line

recognise this pattern - number of reversible causes heart block

hypokalaemia or hypomagnesaemia

drugs e.g. tricyclic antidepressant overdose congenital long QT syndromes

other causes of long QT (e.g. IHD

http://www.ecglibrary.com/l_qt.htmlhttp://www.ecglibrary.com/l_qt.html

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DC cardioversion

Causes

Treatment

hemodynamically stable andunstable

Monitor QT interval while on quinine!

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The QT interval duration is greater than

50% of the RR interval, a good indication

that it is prolonged in this patient. Although

there are many causes for the long QT,patients with this are at risk for malignant

ventricular arrhythmias, syncope, and

sudden death.

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QT

Normal upto 0.45

Stop quinine if 0.60

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Quinine discontinued, changed to

artemether

QT interval normalised

Delivered fresh stillborn

Gradual recovery

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Take home message

Monitor QT interval while on quinine!

Consider iatrogenic causes of arrythmias

- drugs- inotropes

- central lines

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Case scenario 3

72 year old man

Diabetic with urosepsis

Emphysematous pyelonephritis-postnephrectomy

Being ventilated in ICU

On inotropic support-noradrenaline5ug/min: BP- 110/60mm Hg

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On day 3, sudden hypotension

Cold clammy extremities

BP: 60 sys HR: 140/min CVP:25cms

Chest: bilateral crackles

CVS: muffled

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ECG

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Serial ECGs and Cardiac enzymes

Thrombolysis/ UFheparin/ LMWH

Differentials

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Trop I :12

Thrombolysis contraindicated

Progressive hypotension on increasinginotropes

Expired

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Take home message

Consider myocardial ischemia in every

case of sudden hypotension

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Case scenario 4

55yr old man

Sudden onset progressive BOE for 2

days.

Sudden worsening of breathlessness

today

No chest pain, fever, cough

No DM, HTN, Smoke

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Examination

Obese

No pallor, edema

BP: 110/70mmHg HR:110/min JVP: elevated 3cms

Resp : clear

CVS: S3, sharp S2Abd: NAD

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Sudden hypoxia and

hypotension

BP: not recordable

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Admitted to MICU

Thrombolysed with STK

Improvement over 24 hours

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Case scenario-5

A 30 year old lady diagnosed to have

ruptured empyema gall bladder with

peritonitis underwent cholecystectomy. On

the first post operative dayhigh gradefever followed by hypotension started on

ionotropes . A day later blood culture

heavy growth of pseudomonas

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O/E:

BP: 90/40mmHg. HR- 160/minute

Interpret her ECG

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Takotsubo cardiomyopathy

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Takotsubo cardiomyopathy

ICU cardiomyopathy

Seen in critically ill patients

Mimics myocardial ischemia No specific treatment

Reverts as patient improves

No residual complications

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Case scenario-6

50 year old man known alcoholic

presented with a history of acute abdomen

He was diagnosed to have pancreatitis

He had a similar episode 6 months ago

and a syncopial attack was admitted in the

ICU and discharged a week later

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Diagnosis

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Brugada syndrome

Congenital channelopathy

Seen in asians

Prone for sudden onset of ventricular

tachycardia/cardiac arrest

ICD only treatment

Precipitated by alcohol, prothiadine

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Case scenario-7

25 year old man with a history of corrosive

acid poisoning presented a day later with a

history of chest pain and fever

O/E: He was febrile BP100/60 PR

140/minute

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Case scenario-8

60 year old man with CA stomachunderwent a total gastrectomy. Three dayslater became breathless, was febrile and

had multiple ventricular ectopicsassosiated with hemodynamic instability.

Subsequently he was intubated.

Common causes ruled out .He was startedon an amiodarone infusion and he settled

24 hours later

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Take home message

All anti arrythmics are proarrythmics too

All patients on amiodarone infusion once

stabilised slowly overlap with oral route &

taper infusion

Amiodarone half life -prolonged

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Interesting ECGs

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Thank you