Speedy ECG for medical student
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1. The document provides an overview of essential clinical ECG skills, including understanding what an ECG is, heart anatomy and electrophysiology, ECG waveform components, and how to interpret ECGs. 2. It reviews ECG basics like lead placements, normal sinus rhythm, abnormal rhythms, rates, axes, and chamber enlargements. 3. Guidelines are given for identifying ischemic patterns from ST segments, T waves, and Q waves that indicate myocardial ischemia, injury, and infarction.
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Speedy ECG for medical student
- 1. Essential Clinical skill “ จากพี่...สู่น้อง สู่มวลชน ” The last pre-clinic course อ.นพ.ปฏิญญา ยุทธชาวิทย์ ตรวจทาน : อ.พญ.ศุภวดีวงศ์นิจศีล ขอขอบคุณเพื่อนๆพี่ๆแพทย์ขอนแก่น รุ่นที่ 37 และ 38 ที่รักทุกคน คณะแพทยศาสตร์ มหาวิทยาลัยมหาสารคาม
- 2. SPEEDY ECG! MIXED! (BASICS AND USES) สอนและปรับปรุง โดย อ.นพ.ปฏิญญา ยุทธชาวิทย์ คณะแพทยศาสตร์ มหาวิทยาลัยมหาสารคาม สาหรับนักศึกษาแพทย์ชั้นปี 3
- 3. True education is what remains after one has forgotten what one has learned in school. -Albert Einstein
- 4. STEPS ! • Part I :To know ECG • What is ECG ? • Anatomy of heart and (electro)physiology • Anatomy of ECG • Part II :To use ECG • Leads placement positions • Read ECG like a pro (?) : Step by step • Ischemic pattern • Need-to-know ECGs
- 5. TO KNOW ECG… What is ECG ? Anatomy of heart and (electro)physiology Anatomy of ECG
- 6. WHAT IS ECG ? • An electrocardiogram (ECG / EKG) is an electrical recording of the heart and is used in the investigation of heart disease. • 1895 ;Willem Einthoven invented ECG. • A representation of electrical events in cardiac cycle. • Each events has a distinctive waveform. • Study ECG >> study shadow of heart. Look from different aspects.
- 9. CONDUCTION PATHWAY Depolarized at SA node Internodal pathway to AV node interatrial tract to Lt. atrium Bundle of His Left and right bundle branches Purkinje fiber to contractile cell (~0.05 m/sec) (~ 4 m/sec)
- 10. CONDUCTION PATHWAY Depolarized at SA node Internodal pathway to AV node interatrial tract to Lt. atrium Bundle of His right bundle branches Purkinje fiber to contractile cell Left bundle branches Purkinje f to contra Purkinje fiber to contractile cell Purkinje fiber to contractile cell Purkinje fiber to contractile ce Purkinje fiber to contractile cell Purkinje fibe to contractil Purkinje fibe to contracti Purkinje fiber to contractile cell Purkinje fiber to contractile cell Purkinje fiber to contractile cell
- 11. ELECTROPHYSIOLOGY 2Types of cardiac cells • Myocardial cell • Mechanical • Cab be electrical stimulated • Cannot generate electrical itself • Pacemaker cell : SA node,AV node • Generate electrical impulse spontaneously
- 23. ELECTROPHYSIOLOGY Depolarization, Repolarization +- Depolarization wave + - Depolarization wave Repolarization wave -+
- 26. ANATOMY OF ECG AND CORRELATION https://www.youtube.com/user/ECGTeacher
- 27. ANATOMY OF ECG …THE PAPER Basics • ECG paper has many squares • Big square = 5 small square • Each small square = 1 mm in width and height (1mm x 1 mm) • Rate of paper • 25 mm/sec • So 0.04 sec/1 mm (small square) • Or 0.2 sec/ 5 mm (large square) • Electrode and machine record • 1mV = 10 mm • So 0.1 mV/1 mm (small square)
- 28. ANATOMY OF ECG …ABOUT 12 LEADS Electrodes ≠ leads ; basic 10 electrodes make 12 leads 3 types of leads • Bipolar limb leads (frontal plane): • Lead I: RA (-) to LA (+) (Right Left, or lateral) • Lead II: RA (-) to LL (+) (Superior Inferior) • Lead III: LA (-) to LL (+) (Superior Inferior) • Augmented unipolar limb leads (frontal plane): • Lead aVR: RA (+) to [LA & LL] (-) (Rightward) • Lead aVL: LA (+) to [RA & LL] (-) (Leftward) • Lead aVF: LL (+) to [RA & LA] (-) (Inferior) • Unipolar (+) chest leads (horizontal plane): • Leads V1, V2, V3: (Posterior Anterior) • Leads V4, V5, V6:(Right Left, or lateral)
- 29. ANATOMY OF ECG …ABOUT 12 LEADS
- 30. ANATOMY OF ECG …ABOUT 12 LEADS
- 31. ANATOMY OF ECG …ABOUT 12 LEADS
- 33. NORMAL ECG COMPLEX PWave - depolarization of the atria - normal sinus rhythm: the P wave is upright in leads I, II, aVF,V4,V5, andV6 and inverted in aVR QRS Complex - ventricular depolarization V1,V2; Rt.Ventricle V3,V4; septum (R wave = S wave ; transition point”) If Rt.Ventricle enlargement;transition pointV4/V5 orV5/V6 V5,V6; Lt. ventricle
- 34. THE ‘PQRSTU’ QRS complex QWave. The first negative deflection of the QRS complex (not always present) pathologic:the Q wave should be > 25% of the QRS complex RWave: The first positive deflection S Wave :The negative deflection following the R wave
- 35. THE ‘PQRSTU’ • TWave - repolarization of the ventricles and follows the QRS complex - normal : upright in leads I, II,V3,V4,V5, andV6 and inverted in aVR … AndWhere’s atrial depolarization ???
- 36. THE ‘PQRSTU’ Intervals (PR, QRS, and QT intervals) measured in the limb leads (ดู lead II ง่าย) 1. PR interval = 0.12–0.20 s (3-5 ช่องเล็ก) 2.QRS duration < 0.12 s (เล็กกว่า 3 ช่องเล็ก) *** 3. QT interval increases with decreasing heart rate, usually < 0.44 s * QT interval (not exceed one half of the RR interval)
- 37. THE ‘PQRSTU’
- 40. TO USE ECG… Electrodes placement positions Read ECG like a pro (?) : Step by step Ischemic pattern Need-to-know ECGs
- 41. Price of ECG depends on how you read it. The more you know, the more you see. The more you see, the more you know!
- 43. ELECTRODES PLACEMENT POSITIONS Midclavicular line Midaxillary line V1: 4 intercostal space to right sternum, V2: 4 intercostal space to left sternum V3: halfway betweenV2-V4, V4: 5 intercostal space at the midclavicle Line V6: 5 intercostal space at the madaxillary Line, V5: halfway betweenV4-V6
- 44. READ ECG LIKE A PRO (?) • Rhythm • Rate • Axis • Chamber enlargement • Myocardial ischemia and infarction • Miscellaneous • Drug effect • Electrolyte imbalance
- 45. NORMAL SINUS RHYTHM Rhythm • ทุก QRS ตามหลัง P wave โดย QRS เป็น positive ใน II และเป็น negative ใน aVR • regular PR and RR interval • rate between 60 and 100 beats/min
- 46. ABNORMAL RHYTHM • Varying rhythm • Extra beats and skip • Heart block • Total irregularity • Basically regularity • Regular irregularity (Grouping beat) Rhythm
- 47. VARYING RHYTHM Normal Sinus Rhythm Atrial Fibrillation Rhythm A Fib Totally irregular Can’t identify/ fibrillated p wave
- 48. Sinus bradycardia Sinus tachycardia Rhythm Sinus tach Sinus rhythm Rate > 100 Other normal Sinus brad Sinus rhythm Rate < 60 Other normal
- 49. Sinus pause Atrial flutter Rhythm AF Saw tooth wave Atrial rate near 300 Sinus pause Sinus rhythm Sometime sinus fails to pace
- 50. Ventricular fibrillation Ventricular tachycardia Rhythm VT Fast ventricular rate 100-150 Wide QRS Advanced life support! (tachy) VF Severely unorganized CPR!! Wide QRS ; > 3 ช่องเล็ก (0.12 s)
- 51. Torsades de Pointes Supraventricular tachycardia Rhythm SVT Fast atrial and ventricular rate 100-250 narrow QRS Advanced life support! (tachy, adenosine) Torsades Twist around point PolymorphicVT Advanced life support! (tachy, MgSO4)
- 52. Premature ventricular beat Asystole Rhythm Asystole No electrical activity Check leads! CPR!! PVCs Ventricle >> extra beat Wide QRS Occasional irregular
- 53. Premature atrial contraction Atrial tachycardia Rhythm PACs Supraventricular origin Narrow QRS Occasional irregular Compensatory/ non- compensatory pause AF A Fib MAT ; multifocal atrial tach Pre-excitation syndrome +- accessory pathway (WPW) AVRT AVNRT ไว้รอเรียน ตอนโตกว่านี้ ก็ได้ครับ
- 54. Pulseless electrical activity Rhythm PEA Any ECGs That produce no pulse ExceptVT,VFNo pulse !!
- 55. HEART BLOCK First degree Second degree Third degree Rhythm PR interval ยาวกว่า 5 ช่องเล็ก (0.2s)
- 56. SECOND DEGREE Mobitz I Mobitz II Rhythm
- 57. RATE Rate • Rule of 300 • จงนับช่องระหว่าง RR ว่ามีกี่ช่องใหญ่ • แล้วนามาหาร 300 • Rate = 300/N = 1500/n N=จานวนช่องใหญ่ , n = จานวนช่องเล็ก
- 58. RATE Rate • ทาไมหล่ะ ? • กระดาษไหล 25 mm/sec • เท่ากับ 25x60=1500 mm/60 sec • 1500 ช่องเล็ก/นาที • 300 ช่องใหญ่/นาที • ดังนั้นถ้าความถี่ QRS 300 ครั้งต่อนาที (HR=300 bpm) จะเกิด QRS ทุก ตาแหน่ง 1 ช่องใหญ่พอดี ก็เทียบ บัญญัติไตรยางค์
- 59. RATE Rate
- 61. RATE Rate • กรณี QRS มาไม่สม่าเสมอ • ให้นับจานวน QRS ให้หมด ใน 10 วินาที (50 ช่องใหญ่) • นับใน lead II/lead ยาวสุดจะสะดวก • นับแล้ว x 6 = rate • ปกติ ECG record 10 sec อยู่แล้ว 33 x 6 = 198 bpm
- 62. AXIS Axis
- 64. AXIS MADE IT EASY! Axis
- 65. Axis
- 69. CHAMBER ENLARGEMENT AND HYPERTROPHY • Right atrium enlargement • Peak of P wave > 2.5 mm • Left atrium enlargement • Width of P wave > 0.12 seconds • Right ventricular hypertrophy • R/S wave ratio in leadV1 > 1 + RAD • Left ventricular hypertrophy • S in leadV1 + R wave in leadV5 orV6 > 35 mm Chamber enlargement
- 70. CHAMBER ENLARGEMENT AND HYPERTROPHY • Check P wave for atrial enlargement • Check R wave in leadV1 for RV hypertrophy (RAD) • Check S wave in leadV1 and R wave in lead V5, 6 for LV hypertrophy Chamber enlargement
- 72. ABNORMAL P WAVE RA enlargement (P pulmonale) LA enlargement (P mitralae) Biatrial enlargement Chamber enlargement
- 78. MYOCARDIAL ISCHEMIA, INJURY, AND INFARCTION • ST-T segments depression andT wave inversion • myocardial ischemia • ST -T elevation • myocardial injury • Q wave • myocardial infarction Ischemic pattern
- 79. CORONARY SUPPLY MYOCARDIUM Ischemic pattern
- 80. CORONARY DISEASE TRANSMURAL • ISCHEMIA : invert T • INJURY : ST elevate • INFARCTION : Q wave • RECIPROCAL CHANGE SUBENDOCARDIAL • ISCHEMIA: QT prolong , upright tallT • INJURY : ST depress • INFARCTION : symmetrical deep inverted T, ST depress • RECIPROCAL CHANGE Ischemic pattern
- 84. • Flattening • ST depress – Plain ST depress (Horizontal) – Non plain ST depress • Downslope pattern : dig intox • Reverse correct check mark : strain pattern ABNORMAL ST SEGMENT (ST DEPRESSION) Normal Flattening ST segment Horizontal ST depress Downsloping ST segment Ischemic pattern
- 85. ST DEPRESS IN ISCHEMIA Ischemic pattern
- 86. ST DEPRESS IN UNSTABLE ANGINA Ischemic pattern
- 87. NON-ISCHAEMIC ST DEPRESS Digoxin effect Strain from Hypertrophy Ischemic pattern
- 88. T WAVE IN ISCHEMIA Ischemic pattern
- 89. INVERTED T WAVE IN UA Ischemic pattern
- 90. BIPHASIC T WAVE IN UA Ischemic pattern
- 92. ABNORMAL ST SEGMENT (ST ELEVATION) • Elevate • convex upward • Injury • Aneurysm • concave upward • early repolarization • Pericarditis • Reciprocal strain in hypertrophy • nonspecific Ischemic pattern
- 93. ST ELEVATE IN LV ANEURYSM • QS pattern • ST elevated • T wave inversion Ischemic pattern
- 94. ST ELEVATE IN EARLY REPOLARIZATION • Common in M>FM • Common in black • Begins elevated J point and usually concave form, commonly associated with notching of the downstroke of the QRS complex and can reach 500 microvolte in amplitude Ischemic pattern
- 95. ST ELEVATION IN PERICARDITIS Ischemic pattern
- 96. ST ELEVATION HYPERTROPHY Ischemic pattern
- 97. ANATOMY OF ECG …ABOUT 12 LEADS Ischemic pattern
- 102. HEART BLOCK First degree Second degree Third degree Other
- 104. RBBB CRITERIA • Widening QRS > 0.12 sec • S in I • R’ inV1 • Repolarization abnormality Other
- 105. RBBB Right bundle branch block manifest by prominent S wave in leads I, aVl , and the left ventricular precordial leads and an rsR pattern in lead V1 . The left anterior fascicular block is indicated by the marked left-axis deviation in the frontal leads. Other
- 106. LBBB CRITERIA • Widening QRS > 0.12 sec • Notch R (M shape) inV5-6 • Negative QRS inV1-2 • Repolarization abnormality Other
- 107. Other LBBB
- 108. A FLUTTER Other
- 109. AF Other
- 110. VENTRICULAR TACHYCARDIA • Wide complex tachycardia.Atrioventricular dissociation confirms ventricular origin. Other
- 111. HYPERKALEMIA Other
- 112. HYPOKALEMIA Other
- 113. DIGITALIS EFFECT Other Salvador Dali sagging
- 114. CARDIAC TEMPONADE • Low voltage , electrical alternan Other
- 115. PERICARDITIS Other • ST elevate all lead (Concave elevation)
- 116. COR PULMONALE (E.G. PE) Other • Abnormal wave - S in lead I - Q กว้างกว่า 1.5ช่อง lead III - invertedT in lead III
- 117. BRUGADA SIGN Other • Coved ST segment elevation >2mm in >1 ofV1-V3 followed by a negativeT wave • Abnormal cardiac Na+ channel • Sudden death สัมพันธ์กับโรคไหลตาย
- 118. WOLFF-PARKINSON-WHITE Other • Delta wave ; slurring slow rise of initial portion of the QRS • Syndrome is a combination of the presence of a congenital accessory pathway and episodes of tachyarrhythmia. • Bundle of Kent
- 119. QUIZ TIME?! Let’s see what remains… ดูในเอกสาร Speedy ECG (exercise)
- 120. Thank you! A little bit hard today… >w<!!