The document discusses the basics of electrocardiography (ECG) including calculating heart rate, identifying cardiac rhythms and axes, analyzing P waves, PR intervals, QRS complexes, and ST segments. It provides an overview of common ECG leads and techniques for invasive and epicardial monitoring. The standardized approach for ECG interpretation is outlined step-by-step.
The document discusses the basics of electrocardiography (ECG) including calculating heart rate, identifying cardiac rhythms and axes, analyzing P waves, PR intervals, QRS complexes, and ST segments. It provides an overview of common ECG leads and techniques for invasive and epicardial monitoring. The standardized approach for ECG interpretation is outlined step-by-step.
The document discusses the basics of electrocardiography (ECG) including calculating heart rate, identifying cardiac rhythms and axes, analyzing P waves, PR intervals, QRS complexes, and ST segments. It provides an overview of common ECG leads and techniques for invasive and epicardial monitoring. The standardized approach for ECG interpretation is outlined step-by-step.
The document discusses the basics of electrocardiography (ECG) including calculating heart rate, identifying cardiac rhythms and axes, analyzing P waves, PR intervals, QRS complexes, and ST segments. It provides an overview of common ECG leads and techniques for invasive and epicardial monitoring. The standardized approach for ECG interpretation is outlined step-by-step.
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ECG IN ANAESTHESIA PRACTICE – I
Basics of ECG (Part-A):- Dr. Naveen Mathew
Diagnosis of Common Rate and Rhythm Disorders
(Part-B) :- Dr. Pragya
Moderator:- Dr. Mahendra Kumar
Dr. Zainab Ahmed BASICS OF ECG
BONJOUR Calculate the heart rate :
A. 120 B.90-100 C.150-160 D.60-70
Identify the AXIS :
A. RAD B. LAD -60 º C. EXTREME AXIS D. NORMAL AXIS/ PHYSIOLOGICAL LAD -30º IDENTIFY THE AXIS !!! Young, black, athletic asymptomatic, male, clinically normal
CLOSEST DIAGNOSIS:
A.POST MI B. ACUTE PERICARDITIS C. EARLY REPOLARISATION SYNDROME D. HYPERKALEMIA ECG Introduction
• The Electrocardiogram is a representation of the electrical events of the
cardiac cycle
• Each event has a distinctive waveform
• The study of waveform can lead to greater insight into a patient’s cardiac pathophysiology HISTORICAL MILESTONES IN ECG
• 1887 : Augustus Desire Waller, recorded electric current
preceding cardiac contraction AD Waller • 1895 : William Einthoven - invented ECG and won nobel prize in medicine - 1924
• 1932 : Wolferth CC and Wood CC, introduced chest leads
• 1942 : Goldberger E, introduced unipolar limb leads
Einthoven Each 1 mV gives a 10 mm deflection
Standard paper speed : 25 mm/sec
1 mv(10 mm high) Each small square 1 x 1 mm = 40msec = 0.04 sec
Each large square 5 x 5 mm =
200msec = 0.2 sec 1 small box = 0.04 s Each minute = 60 sec = 1500 small boxes = 300 large boxes 1 large box = 0.2 s ECG LEADS
LIMB LEADS Precordial chest leads • Lead V1 : Over the fourth intercostal space, just to
the right of sternal border.
• Lead V2 : Over the fourth intercostal space, just to
the left of sternal border.
• Lead V3 : Over a point midway between V2 and V4
• Lead V4 : Over the fifth intercostal space in the
midclavicular line.
• Lead V5 : Over the anterior axillary line, at the same
level as lead V4.
• Lead V6 : Over the midaxillary line, at the same
level as leads V4 and V5.
Right sided chest leads
• V1R : 4th intercostal space to left of sternum.
• V2R : 4th intercostal space to right of sternum.
• V4R : 5th intercostal space in midclavicular line, and so on.
• Acute inferior wall myocardial infarction (to diagnose right
ventricular infarction).
• ST elevation in V4R has a sensitivity of 88%, specificity of
78% and diagnostic accuracy of 83% in the diagnosis of RV MI 3 ELECTRODE SYSTEM Three electrodes are placed :
• (RA)right arm and left arm (LA) are placed on
right and left infraclavicular fossa respectively
• Left leg (LL) electrode is placed on left lower rib
cartilage
• Most commonly used in operation theatre and ICU
• Anterior wall myocardial ischaemia is not suitably
monitored by this system. 5 ELECTRODE SYSTEM
Out of total five electrodes, one is placed
on each limb and one on the chest wall. (Usually V5 position ) advantages a)Seven leads can be monitored b) All except posterior wall ischemia can be monitored c) Up to 95% of ischemic events can be diagnosed d) Useful in differentiating atrial vs. ventricular dysrhythmias Invasive and Epicardial leads Oesophageal leads : Incoporated in oesophageal stethoscope
• help in diagnosis of atrial dysrhythmias in 100% of cases compared to 54% for lead II
• detecting posterior wall ischaemia.
Endotracheal ECG : through endotracheal tube, useful in paediatric patients for atrial dysrhythmia detection.
Intracardiac ECG : through pulmonary catheter help in recording of intracavitary ECG
• diagnosis of atrial, ventricular and atrioventricular dysrhythmias and conduction blocks
Epicardial leads : Cardiac surgeons before sternal closure place epicardial leads in the form of pacing wires. They help in atrial and ventricular pacing. LEADS Corresponding region of the heart
Lead I and AVL Left side of the heart
(Lateral)
aVF, Lead II and Lead Inferior wall of the
III heart
V1 and V2 Septal area
V2, V3 and V4 Anterior surface of the
heart
V5 and V6 Apical surface
Mirror image changes Posterior surface
in leads V1 – V4 ECG Interpretation Standardized sequence of steps to analyze the ECG are: • RATE • Rhythm • Axis • P wave • PR interval • QRS complex • ST segment • T wave • QT interval • Conclusion HEART RATE
When rhythm is regular:
• Divide 1500 by the number of small squares between one R-R interval or
• Divide 300 by number of large squares between one R-R interval.
1500/17 =88/min
300/3.4 = 88/min HEART RATE
When rhythm is irregular:
• Count the number of QRS complex in 3 sec (15 large squares) and x by 20 Or • Count the number of QRS complex in 6 sec (30 large squares) and x by 10
9 QRS complex in 6 sec
HR = 9 x 10 = 90/ min ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • RHYTHM • Axis • P wave • PR interval • QRS complex • ST segment • T wave • QT interval • Conclusion RHYTHM • The rhythm refers to the part of the heart which controls the activation sequence. • A cardiac rhythm originating from the SA node is called sinus rhythm. • Normal Sinus Rhythm : 1. The rhythm is regular 2. The rate ranges between 60-100/min 3. P wave precedes every QRS complexes in ratio 1:1 4. P wave is upright, PR interval is normal and QRS is normal Rhythm abnormalities- Irregular rhythm, ectopics, atrial, junctional and ventricular rhythm ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm • Axis • P WAVE • PR interval • QRS complex • ST segment • T wave • QT interval • Conclusion P wave
Lead II : pyramidal and rounded apex
no notching or peaking height < 2.5 mm Lead V1 : biphasic P wave width < 2.5 mm (duration between 0.06 to 0.08 second) LA enlargement :
• Lead II - P width > 2.5 mm notched/bifid ‘P’ • Lead V1
MITRALE Area of –ve phase of P wave ↑ (LA)
Morris Index = depth (mm) x width
(sec) of –ve phase >0.04 mm sec RA enlargement :
• Lead II : P wave height > 2.5 mm • Lead V1 :
‘P’ PULMONALE +ve deflection of P wave > 1.5mm in amplitude Area of +ve deflection > 0.06 mm sec ( height in mm x depth in sec) ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm • Axis • P wave • PR INTERVAL • QRS complex • ST segment • T wave • QT interval • Conclusion PR interval
• PR interval is measured from the beginning of the
P wave to the beginning of the QRS complex
• Represents the time taken by the electrical impulse
to travel from the sinus node through the AV node to bundle of His
• Duration : 0.12 to 0.2 s (3-5mm)
Prolonged PR interval >0.2 sec • First degree AV node Block
• Drugs: Beta blocker, Digoxin
• Dyselectrolemia : ↑K+ >7.5 meq/L
• AV node inflammation : Acute Rheumatic
fever , diphtheria
• AV node infiltration : Amyloidosis,
Hemochromatosis **ATHLETIC, **increased vagal tone, vagomimetic drugs Short PR Interval
• Lown ganong levine syndrome
Atrial impulse joins bundle of his via. James pathway
• Wolf Parkinson white syndrome
Atrial impulse bypass AV node and depolarize Ventricle directly via. Bundle of KENT.
**Vagolytic drugs WOLF PARKINSON WHITE SYNDROME
Short PR interval, Delta wave, Wide QRS complex
LOWN GANONG LEVINE SYNDROME
Short PR interval, No Delta wave Normal QRS complex ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm Axis • P wave • PR interval • QRS COMPLEX • ST segment • T wave • QT interval • Conclusion QRS Complex
• Represents ventricular depolarization
• Normal width : 0.08–0.12s (2-3mm)
• In V1, S wave is greater than the R wave and R wave amplitude does not exceed 4 mm
• In V5 or V6, the height of R wave is less than 25mm , S wave < 7mm
• V5 or V6 may show Q wave (but < 1mm across , < 2mm depth)
• Normal R wave progression
PROGRESSION OF R WAVE NORMAL R WAVE PROGRESSION NON PROGRESSION OF R WAVE
Chronic lung disease, Old anteroseptal infarction ,
RV * R wave in V1 > 4 mm * S wave in V6 >7 mm. H * R in V1 + S in V6 more than 10 mm • S wave in V1 + R wave in V5 or V6 > 35mm (Sokolow) LVH • R wave in V5 or V6 >25mm (Framingham) RBBB LBBB
rSR’ Deep and Deep S Broad and
slurred S wave clumsy R wave wave The Cardiac Axis
QRS axis Range in degrees
Normal axis – 30° to +90°
Left axis deviation – 30° to –90°
Right axis deviation + 90° to +180°
Indeterminate axis – 90° to –180°
Determination of axis Method 1 : Isoelectric method • Find the lead with smallest or equiphasic deflection. • The cardiac axis lies at right angles to that equiphasic lead . • Determine the lead at right angles to the first lead. • See the net deflection in the perpendicular lead. Determination of Axis- Quadrant method Main QRS deflection QRS axis quadrant
Lead I aVF
+ve +ve 0 to +90°
Normal +ve –ve 0 to –90° **LAD –ve +ve +90 to +180° RAD –ve –ve –90 to –180° Northwest RAD
Right ventricular hypertrophy, Left posterior hemiblock,lateral wall infarction Physiological LAD deviation/Normal Axis
OBESITY,pregnant female,Ascites LAD
Obese stocky built, Ostium primum ASD,Left ventricular hypertrophy
Left anterior hemiblock,Inferior wall infarction Q Wave : Septal depolarization
Physiological Q waves : I,avL,V5,V6
Pathological Q waves
• More than or equal to 0.04 sec in duration
• More than one-fourth of R wave amplitude
• Seen in necrosis of heart muscle or previous
myocardial infarction, Severe reversible myocardial ischemia as in severe angina, hypoxia, hypothermia or hypoglycemia. ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm • Axis • P wave • PR interval • QRS complex • ST SEGMENT • T wave • QT interval • Conclusion ST SEGMENT
• It is the time at which the entire ventricle is depolarized and roughly corresponds to the plateau phase of the ventricular action potential
• The portion of the isoelectric line between the termination of the S wave (J point) and the onset of the T wave is called the S-T segment.
• ST-T segment depression (>1mm from the baseline) : coronary ischemia,
hypokalemia, ventricular hypertrophy, digitalis(reverse tick sign), • ST SEGMENT ELEVATION (>1mm from the baseline):
Acute MI :
convex upward, in specific leads
Artery involved:- • V1,V2, V3, V4- LAD Artery • V5, V6, L1, avL- LCX Artery • II, III, avF- RCA
Acute pericarditis :
concave upward, Almost all leads
J point • The J point is the junction between the termination of the QRS complex and the beginning of the ST segment.
EARLY REPOLARIZATION SYNDROME : • Young, athletic, black male, asymptomatic • The clinical evaluation is entirely normal • tall R waves in leads V4 to V6 • concave-upward ST segment elevation • initial slur on ST segment; the J wave • tall and upright symmetrical T waves ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm • Axis • P wave • PR interval • QRS complex • ST segment • T WAVE • QT interval • Conclusion T WAVE • The T wave is produced by the rapid phase of ventricular repolarization and follows the QRS complex
• Asymmetric and slightly rounded without sharps
• It is upright in most leads (except aVR, LIII, V1)
• It does not exceed 5 mm in height in the limb leads
and 10 mm in precordial leads T wave significance • Tall T wave Hyperkalemia (>6 meq/l) Acute MI
Symmetrical Symmetrical Broad base Narrow base Blunt apex Pointed apex
• Giant inverted T Wave : HOCM
Flat T wave or inverted T waves : Hypokalemia, Subendocardial ischemia, strain pattern of LVH or RVH, hypocalcemia, ECG Interpretation Standardized sequence of steps to analyze the ECG are: • Rate • Rhythm • Axis • P wave • PR interval • QRS complex • ST segment • T wave • QT INTERVAL • Conclusion QT INTERVAL • Measured from the beginning of the QRS complex to the end of the T wave.
• Represents the time for both ventricular depolarization and repolarization (ventricular action potential).
• DEPENDS ON HEART RATE :
HR ↑= QT short. HR ↓= QT long
• The corrected interval (QTc) can be calculated using
Bazett’s formula: QTc = QT ÷√(R–R interval in sec)
• NORMAL VALUES : 0.35-0.43 sec
Long QT interval : Q-Tc interval > 0.43 sec Long QT interval
Prone for TORSADES DE POINTES ventricular fibrillation
• An introduction to electrocardiography, 7th Edition, Leo Schamroth
• The ECG Made Easy, 8th edition, John R. Hampton • ECG Made Easy, 4th edition, Atul Luthra • Harrison’s principles of Internal Medicine-18th edition MERCI BEAUCOUP ANSWERS Calculate the heart rate :
A. 120 B.90-100 C.150-160 D.60-70
Identify the AXIS : A. RAD B. LAD -60 º C. EXTREME AXIS D. NORMAL AXIS/ PHYSIOLOGICAL LAD -30º IDENTIFY THE AXIS !!! Young, black, athletic asymptomatic, male, clinically normal
CLOSEST DIAGNOSIS:
A.POST MI B. ACUTE PERICARDITIS C. EARLY REPOLARISATION SYNDROME D. HYPERKALEMIA
