Download - Ecg tutorial (2)
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DR. RAGHOBA
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• DR. RAGHOBA T. GAONKAR
• JUNIOR PHYSICIAN
• NORTH DISTRICT HOSPITAL – GOA
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SCOPE OF ECG DR. RAGHOBA
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1. ECG LEADS
2. NORMAL ECG
3. TACHY ARRYTHMIAS
4. BRADY ARRYTHMIAS
5. ISCHAEMIC HEART DISEASE
6. BUNDLE BRANCH BLOCK
7. ECTOPICS
8. CHAMBER ENLARGEMENT
9. POTASSIUM DISTURBANCES
10.MISCELLANIOUS
DR. RAGHOBA
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ORIENTATION OF THE 12 LEAD ECG
DR. RAGHOBA
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DR. RAGHOBA
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AXIS OF ECG
DR. RAGHOBA
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COMPONENTS OF NORMAL ECG COMPLEX DR. RAGHOBA
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NORMAL ECG VALUES
P waves : P amplitude < 2.5 mm and width < 2.5 mm. May see notched. Best seen in lead II
PR Interval: 0.12 - 0.20 sec i.e. max one big square
q-waves :are narrow (<0.04s duration) and small (<25% the amplitude of the R wave). They are
often seen in leads I and aVL when the QRS axis is to the left of +60°, and in leads II, III, aVF when
the QRS axis is to the right of +60°.
Septal q waves should not be confused with the pathologic Q waves of myocardial infarction.
QRS Duration: 0.06 - 0.10 sec i.e. around max three small squares
QT Interval (QTc ≤ 0.40 sec)
Bazett's Formula: QTc = (QT)/Sq Root RR (in seconds)
ST segment: is a misnomer, because a discrete ST segment distinct from the T wave is usually
absent. More often the ST-T wave is a smooth, continuous waveform beginning with the J-point
(end of QRS), slowly rising to the peak of the T and followed by a rapid descent to the isoelectric
baseline or the onset of the U wave. This gives rise to an asymmetrical T wave. In some normal
individuals, particularly women, the T wave is symmetrical and a distinct, horizontal ST segment
is present.
Normal ST segment elevation: this occurs in leads with large S waves (e.g., V1-3), with concavity
upwards; this is often called early repolarization
T wave :The normal T wave is usually in the same direction as the QRS except in the right precordial leads. In the normal ECG the T wave is always upright in leads I, II, V3-6, and always inverted in lead aVR.
DR. RAGHOBA
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QRS axis : The normal QRS axis range (+90° to -30° ); this implies that the QRS be mostly
positive (upright) in leads II and I
Precordial leads:
• Small r-waves begin in V1 or V2 and progress in size to V5.
• In reverse, the s-waves begin in V6 or V5 and progress in size to V2.
• Small "septal" q-waves may be seen in leads V5 and V6.
U Wave : amplitude is usually < 1/3 T wave amplitude in same lead. Direction is the same as T wave direction in that lead
Rate : 60 – 100 per min i.e. 3 -5 big squares
Correlate with old ECGs
Amplitude of complexes will be affected by thickness of chest wall
DR. RAGHOBA
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NORMAL
Sinus rhythm PR interval max 0ne square
R-R interval between 3-5 squares
QRS max 3 small squares
ST segment normal t waves upright except aVR Normal axis
DR. RAGHOBA
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DR. RAGHOBA
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SINUS TACHYCARDIA
Sinus rhythm R-R interval < 3 squares
DR. RAGHOBA
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SVT
Regular Narrow QRS complex Tachycardia No definite P waves
DR. RAGHOBA
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ATRIAL FIBRILLATION
Irregular Narrow QRS complex Tachycardia Irregular R-R interval
Baseline wavy No definite P waves
DR. RAGHOBA
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ATRIAL FLUTTER
Narrow QRS complex Tachycardia Irregular or regular R-R interval
Baseline saw toothed No definite P waves
DR. RAGHOBA
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MULTIFOCAL ATRIAL TACHYCARDIA (MAT)
Narrow QRS complex Tachycardia Irregular or regular R-R interval multifocal P' waves at least 3 different P wave morphologies in a given lead
Varying PR interval Commonly seen in COPD
DR. RAGHOBA
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VENTRICULAR TACHYCARDIA
Regular broad QRS complex Tachycardia No P & QRS relation
Capture & fusion beats may be seen
DR. RAGHOBA
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VENTRICULAR FIBRILLATION
Irregular broad QRS complex Tachycardia Chaotic rhythm
No definite P or QRS
DR. RAGHOBA
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TACHYCARDIA
NARROW/NORMAL QRS BROAD QRS
DR. RAGHOBA
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NARROW/NORMAL QRS TACHYCARDIA
DEFINITE P WAVES
REGULAR
PRESENT
ABSENT
SINUS TACHYCARDIA
SVT
MAT/PAT
DEFINITE P WAVES
IRREGULAR
PRESENT
ABSENT
BASELINE
IRREGULAR
SAW TOOTHED
ATRIAL FLUTTER
ATRIAL FIBRILLATION
DR. RAGHOBA
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BROAD QRS TACHYCARDIA
EACH QRS PRECEEDED BY P WAVE
NO P &QRS RELATION
SINUS RHYTHM WITH BROAD QRS
ALMOST REGULAR R-R
INTERVAL
IRREGULAR R-R
INTERVAL / CHAOTIC RYTHM
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
DR. RAGHOBA
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DR. RAGHOBA
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SINUS BRADYCARDIA
Sinus rhythm R-R distance > 5 squares
DR. RAGHOBA
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FIRST DEGREE HEART BLOCK
Sinus rhythm P-R interval > one square
DR. RAGHOBA
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2 nd DEGREE A-V BLOCK
Sinus rhythm Some P waves not followed by QRS complex
DR. RAGHOBA
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COMPLETE HEART BLOCK
bradycardia
No association between p and qrs i.e. pr interval is varying
Constant pp and rr interval
DR. RAGHOBA
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NODAL RHYTHM
Bradycardia No P waves
Regular narrow QRS
DR. RAGHOBA
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SICK SINUS SYNDROME
Sinus pauses i.e. Missed p waves Seen in elderly
DR. RAGHOBA
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BRADYCARDIA
P WAVES ABSENT P WAVES SEEN
DR. RAGHOBA
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P WAVES SEEN
MISSED QRS
PRESENT
ABSENT
P & QRS RELATION
ABSENT CONSTANT
COMPLETE HEART BLOCK
SINUS BRADYCARDIA
A V BLOCK
DR. RAGHOBA
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ABSENT P WAVES
SICK SINUS SYNDROME
NO SINUS PAUSES
INTERMITTENT SINUS PAUSE
NODAL RYTHM
DR. RAGHOBA
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DR. RAGHOBA
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ANTERIOR WALL MI
ST elevation in V1 - V6 Reciprocal ST depression in inferior leads
DR. RAGHOBA
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EVOVLED ANTERIOR WALL MI
T waves inverted
Q waves developed
DR. RAGHOBA
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INFERIOR & LATERAL WALL MI
ST elevation in II, III and Avf, V5 V6 Reciprocal ST depression in anterior leads
DR. RAGHOBA
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POSTERIOR WALL MI
ST depression in V1 V2
May have ST elevations in V5 V6 i.e. lateral leads
DR. RAGHOBA
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UNSTABLE ANGINA
Horizontal ST Depression Anginal symptoms
DR. RAGHOBA
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DR. RAGHOBA
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RIGHT BUNDLE BRANCH BLOCK
Broad QRS M pattern in right sided leads i.e. V1 V2 Reciprocal T inversion usually present in
right sided leads
DR. RAGHOBA
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LEFT BUNDLE BRANCH BLOCK
Broad QRS M pattern in left sided leads i.e. V5 V6
Reciprocal T inversion usually present in left sided leads
DR. RAGHOBA
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DR. RAGHOBA
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ECTOPICS
VPC APC
DR. RAGHOBA
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VPC
Early onset broad QRS No preceding P wave
Usually associated with T inversion Complete compensatory pause
DR. RAGHOBA
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APC
Early onset narrow QRS Deformed P wave
Incomplete compensatory pause No reciprocal T wave inversion
DR. RAGHOBA
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VENTRICULAR BIGEMINY
Alternating normal QRS and ventricular ectopic
DR. RAGHOBA
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DR. RAGHOBA
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LEFT VENTRICULAR HYPERTROPHY WITH STRAIN
LVH – S wave in V1 + R wave in V5 or 6 > 35 mm i.e. 7 squares R + S in any leads > 45 mm Downsloping ST depression in lateral leads V5,V6,I,AvL
DR. RAGHOBA
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ATRIAL ENLARGEMENT
P wave height > 2.5 small square P wave width >2.5 small square
DR. RAGHOBA
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P PULMONALE DR. RAGHOBA
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RIGHT VENTRICULAR HYPERTROPHY
R/S ratio < 1 May be associated with p pulmonale, RBBB Right axis deviation i.e. deep s in lead I
DR. RAGHOBA
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DR. RAGHOBA
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HYPOKALAEMIA
usual triad of: ST depression, low T waves or inversion, and large U waves
DR. RAGHOBA
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HYPERKALAEMIA
Tall peaked broad based t waves Suspect in kidney failure patients
DR. RAGHOBA
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DR. RAGHOBA
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DR. RAGHOBA
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WRONG LEAD PLACEMENT
Positive QRS in aVR Deep S wave and small R in lead I
DR. RAGHOBA
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EARLY REPOLARISATION DR. RAGHOBA
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DR. RAGHOBA
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COMMON NONSIGNIFICANT ABNORMALITIES
1. T inversion in V1-3 in females
2. Isolated T inversion or q wave in lead III
3. Minor conduction defects in limb leads
DR. RAGHOBA
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DR. RAGHOBA