the ecg in clinical practice: making the diagnosis at a glance prepared and presented by dr lukoji...
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The ECG in clinical practice: making the diagnosis at a glance
Prepared and presented by Dr LukojiSpecialist Physician
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DEFINITION:
• Graphic recording of the electrical activity (potential) of the heart on a standard paper grid.
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CONDUCTION SYSTEM (FLIP CHART)• Sinus node (initiate the electrical impulse): 60-
80/minutes: fires the impulse to the atria• AV node (CS in RA): only electrical connection
between atria and ventricles: transmit the impulse from the atria to the ventricle: slows down the impulse (filter and regulator)
• Bundle of His: made out of 2 branches: LBB and RBB
• Purkinje network: within the ventricle
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CONDUCTION SYSTEM
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How ECG is generated:
• Impulse depolarizes successively the atria then the ventricles follow by repolarization for each .
• Depolarization and repolarization are then recorder graphically as an ECG in form of a curve by means of electrodes attached to the patient’s body surface at conventional spots.
• Depolarization and repolarization generate waves on the tracing.
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ECG curve
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Deconstructing the ECG curve:
• P wave: atrial depolarization• QRS complex: ventricular depolarization (varies)• T wave: ventricular repolarization• Isoelectric line• Calibration signal (rectang=10mm=1mv)• ECG generally prints at a speed of 25mm/sec• Leads: standards (I,II,III), augmented (aVF, aVL, aVR)
&precordial (V1 to V6) • Leads#electrodes
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Electrodes placement
• Proper placement is key to accurate tracing hence accurate diagnosis.
• Ensure proper skin preparation• Ensure patient is calm (explain)• Connect electrodes at appropriate spots
(chest electrodes!)
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The precordial leads: correct placement
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ECG stepwise analysis• Check calibration• Check paper speed• Check patient identity• If needed have a caliper and lens• I take a minimum of 5 minutes to analyze each
ECG (you do not need to hurry, details are key for accurate diagnosis)
• Get senior colleague opinion if doubt (overdiagnosis or underdiagnosis)
• Automated interpretation from ECG machine is often misleading: beware!!!
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What to look for: general impression and rhythm analysis
• What is the rhythm: NSR or not?• What is the heart rate?• P wave duration• Intervals measurement: P, PR, QRS, QT• QRS axis• QRS duration• QRS amplitude: low voltage, sokolow, RSS• QRS infarction signs• Rotation and transition zone• ST and T segment• T-U wave
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Sinus rythm1• P positive in lead I and II• Every P wave is followed by QRS complex• PR interval is constant• QRS interval is constant• 2. Heart rate: 300/large square between R-R interval
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P wave duration
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Prolong P wave: P mitrale
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Right atrial hypertrophy: P pulmonale
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PR interval
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Prolonged PR
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Short PR duration (pre-excitation syndrome)
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Short PR duration
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Prolong QRS duration
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how prolonged QRS occurs
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Bundle branch block
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Bundle branch block
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Clockwise rotation
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Counterclockwise rotation
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Illustration of LVH
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ST depression and T inversion
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T wave inversion
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ST SEGMENT AND ACS
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