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Noel R. Lamorena,MD,FPCP,FPCC,FPSCCM
Internal Medicine
Cardiology
Critical Care Specialist
Objective
to provide a thorough understanding of both
the fundamental principles of clinical
electrocardiography, and building upon these,
more advanced concepts of interpretation.
Myocardium
Responsible for
contraction of the heart
Endocardium
Lines the inside of the
myocardium
Covers the heart valves
Kinds of
Cardiac Cells
Where
Found
Primary
Function
Primary
Property
Myocardial cells
Myocardium
Contraction and
Relaxation
Contractility
Specialized cells
of the electrical
conduction
system
Electrical
conduction
system
Generation and
conduction of
electrical
impulses
Automaticity
Conductivity
SA Node
Atrial Muscle
AV Node
Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle
ELECTROCARDIOGRAM
ELECTROCARDIOGRAM
Impulse formation
Transmission of the impulse
Depolarization
Repolarization
12 LEAD ECG
Limb Leads
RA
LA
LL
RL
Red
Yellow
Green
Black
Right arm
Left arm
Left leg
Right
Chest Leads
V1
V2
V3
V4
V5
V6
Red
Yellow
Green
Brown
Black
Violet
12 LEAD ECG
ECG PAPER
TERMINOLOGY
Definition of Terms
Waveform
Movement away from the baseline
in either a positive or negative
direction
TERMINOLOGY
Definition of Terms
Segment
A line between wave forms
TERMINOLOGY
Definition of Terms
Interval
A waveform + segment
P wave
Generated by activation of the atria
PR segment
Represents the duration of atrioventricular (AV)
conduction
QRS complex
Produced by activation of both ventricles
ST-T wave
Reflects ventricular recovery
The P wave
Atrial activation
Height < 2 mm
Duration < 0.12 sec
P-R Interval
Intraatrial, internodal, His purkinje conduction
Duration 0.12 to 0.20 sec
The ST-segment
Isoelectric in normal subjects
The T wave
Ventricular relaxation
- Normally upright
The QT Interval
From beginning of QRS to end of T wave
Reflects the duration of depolarization and
repolarization
Bezett: Q-Tc Interval = Q-T/ R-R (NV=0.350.44sec)
ANALYZING ECG
I. Rate
II. Rhythm
III. Axis
IV. Hypertrophy
V. Ischemia and Infarction
VI. Miscellaneous
Mnemonic: RRAHIM
ANALYZING ECG
I. RATE
I. RATE
a) 3 Possibilities:
Bradycardia (<60 beats/minute)
Normal Rate (60-100 beats/minute)
Tachycardia (>100 beats/minute)
RATE
b)Rate Analysis
1. Mnemonic using # of big squares between RR intervals
300, 150, 100, 75, 60, 50, 40, 30
2. Formula
HR = 1500/# of small boxes between the R-R
interval
or
HR = 300/# of big boxes between the R-R
interval
I. Rate
1500/#Small squares (R-R Interval)
300/#Big squares (R-R Interval)
ANALYZING ECG
II. RHYTHM
II. Rhythm
Tips
- Identify the P wave
- Identify the relationship of P wave to the
QRS
- Check the PR interval
- Check QRS duration
- Check the R-R interval and P-P interval
Atrial Fribrillation
Rate
Rhythm
P waves
PR interval
QRS
Sawtooth appearance
R
Atrial Rhythms
Atrial Flutter
Rate
Rhythm
P waves
PR interval
QRS
Supraventricular Tachycardia
Atrial Rhythms
Supraventricular Tachycardia
Rate
Rhythm
P waves
PR interval
QRS
Atrial Rhythms
ELECTRICAL THERAPY Synchronized Countershock
Description and Purpose
Synchronized countershock reduces the potential for delivery of
energy during the vulnerable period of the T wave (relative
refractory period). A synchronizing circuit allows the delivery of
a countershock to be programmed. The machine searches
for the peak of the QRS complex (R wave deflection) and
delivers the shock a few milliseconds after the highest part of
the R wave.
Indications:
Supraventricular tachycardia
Atrial fibrillation
Atrial flutter
HEART BLOCKS
Atrioventricular Blocks
First Degree AV Block
Rate
Rhythm
P waves
PR interval
QRS
Atrioventricular Blocks
Second-Degree AV Block, Type I (Wenckebach)
Rate
Rhythm
P waves
PR interval
QRS
Absent QRS
Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate
Rhythm
P waves
PR interval
QRS
Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate
Rhythm
P waves
PR interval
QRS
QRS Width
RBBB vs LBBB
Rhythm Interpretation
2 Types of BBB
- complete if QRS is > 0.12sec
- incomplete if QRS is < 0.12sec
Rhythm Interpretation
Ventricular Arrhythmias
Ventricular Rhythms
Premature Ventricular Complexes (PVC)
Rate
Rhythm
P waves
PR interval
QRS
Ventricular Rhythms
Patterns of PVCs
1.
2.
3.
4.
5.
6.
7.
Isolated PVC
Multifocal PVC
PVC in Bigeminy
2
PVC in Quadrigeminy
4
3
1
2
4
1
PVC in Couplets
Ventricular Rhythms
Common Causes of PVCs
Normal variant
Anxiety
Exercise
Hypoxia
Digitalis toxicity
Acid-base imbalance
Myocardial ischemia
Electrolyte imbalance (hypokalemia, hypocalcemia,
hypercalcemia, hypomagnesemia)
Congestive heart failure
Increased sympathetic tone
Acute myocardial infarction
Stimulants (alcohol, caffeine, tobacco)
Drugs (sympathomimetics, cyclic antidepressants,
phenothiazines)
Ventricular Rhythms
Warning Dysrhythmias
Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate
Rhythm
P waves
PR interval
QRS
Torsade de pointes
Ventricular Rhythms
Torsades de Pointes (TdP)
Rate
Rhythm
P waves
PR interval
QRS
Ventricular Fibrillation
Ventricular Rhythms
Ventricular Fibrillation
Rate
Rhythm
P waves
PR interval
QRS
Ventricular Rhythms
Defibrillation (Unsynchronized Countershock)
Description and Purpose:
The purpose of defibrillation is to produce momentary asystole. The
shock attempts to completely depolarize the myocardium and
provide an opportunity for the natural pacemaker centers of the
heart to resume normal activity. Defibrillation is a random
delivery of energy there is no relation of the discharge of
energy to the cardiac cycle.
Indications:
Pulseless ventricular tachycardia
Ventricular fibrillation
Sustained Torsade de pointes
Idioventricular Rhythm
Ventricular Rhythms
Idioventricular (Ventricular Escape) Rhythm
Rate
Rhythm
P waves
PR interval
QRS
Asystole
Ventricular Rhythms
Asystole
Rate
Rhythm
P waves
PR interval
QRS
ANALYZING ECG
AXIS
Normal
0 (+90)
Left axis
0 (-90)
Right axis
(+90) (+180)
AVL
Extreme axis
AVR
(-90) (-180)
AVF
10
AVL
Lead I
AVR
10
AVF
AVF
Lead I
Normal axis
+
Left Axis Deviation +
Right Axis Deviation Indeterminate Axis -
Lead AVF
+
+
-
ANALYZING ECG
HYPERTROPHY
OR
CHAMBER
ENLARGEMENT
ANALYZING ECG
IV. Hypertrophy
6 Possibilities:
- No hypertrophy
- Left ventricular hypertrophy (LVH)
- Right ventricular hypertrophy (RVH)
- Left atrial enlargement (LAE)
- Right atrial enlargement (RAE)
- Combination of the above
Features:
Width of the P wave > 0.12
sec in lead II
Notched P wave
P terminal force is > 0.04
sec & >1mm tall
Lead V1 shows large
biphasic P wave with
wide terminal component
Leftward shift of P axis to
+45 and -30
Bi-atrial Enlargement
Features:
Tall and broad P wave in lead II, III or AVF
Large biphasic P wave in V1 with wide terminal
component
RVH
s
R
S
R
ANALYZING ECG
ISCHEMIA AND
INFARCTION
Atherosclerosis Timeline
Normal Anatomy
Foam
Cells
Fibrous
Plaque
Complicated
Lesion/
Rupture
Endothelial Dysfunction
From First
Decade
From Third
Decade
From Fourth
Decade
Localization
I, AVL
High lateral wall
AVL
AVR
AVF
V3,V4
Anterior wall
V5,V6
Lateral wall
V1-V3 or V4
Anteroseptal wall
V3 or V4-V6
Anterolateral wall
ST T WAVE CHANGES
ST elevation
-Myocardial infarction
ST depression
-Myocardial ischemia
T wave inversion (symmetrical)
-Myocardial ischemia
Q waves
-old myocardial infarction
ST T WAVE CHANGES
ST ELEVATION
ST T WAVE CHANGES
ST DEPRESSON
ST T WAVE CHANGES
T WAVE INVERSION
Q WAVE CHANGES
>0.04.
sec duration
OR
>25% of the height of associated
R wave
ANALYZING ECG
VI. Miscellaneous
ANALYZING ECG
Electrical Alternans
ANALYZING ECG
Practice Tracings
Supraventricular Tachycardia
Ventricular Tachycardia
Ventricular Fibrillation
Practice makes
perfect!
Thank You