Electrical System Overview Electrocardiograms Action Potentials 12-Lead Positioning Values To Memorize Calculating Rates
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1 Electrocardiograms Electrical System Overview James Lamberg 2/ 74 Action Potentials 12-Lead Positioning 3/ 74 4/ 74 Values To Memorize Inherent Rates SA: 60 to 100 AV: 40 to 60 Ventricles: 20 to 40 Normal PRI: 0.12 to to 5 small boxes Normal QRS: < 0.12 Less than 3 small boxes Normal QTc: 0.35 to 0.45 QT < 1/2 RR; QTc = QT / sqrt(rr) Calculating Rates Count R waves in 6 seconds x 10 R waves between 2 sets of 3s marks Large boxes between R waves / 300 Small boxes between R waves / / 74 6/ 74 1
2 Standard ECG Precordial Leads 7/ 74 8/ 74 Determining Axis & Rotation Axis: Leads I, II, III Axis: Look at Lead I and avf QRS complexes Positive: Normal Leaving : Left Reaching : Right Negative: Indeterminate Perpendicular to isoelectric lead Rotation: Look at V1 to V6 V1 or V2 isoelectric: Right V3 or V4 isoselectric: Normal V5 or V6 isoelectric: Left 9/ / 74 Determining Axis: An Example Normal Sinus Rhythm 11 / / 74 2
3 Sinus Bradycardia Sinus Tachycardia 13 / / 74 Sinus Arrhythmia Congestive Heart Failure Causes FAILURE Forgot medication Arrhythmia, Anemia Ischemia, Infarction, Infection Lifestyle (too much salt) Upregulation of cardiac output (pregnancy, hyperthyroidism) Renal failure Embolism (PE) 15 / / 74 First Degree Heart Block Second Degree Block Type I 17 / / 74 3
4 Second Degree Block Type II Third Degree Heart Block 19 / / 74 Premature Atrial Contraction Premature Junctional Contraction 21 / / 74 Premature Ventricular Contraction Atrial Fibrillation 23 / / 74 4
5 Atrial Fibrillation Causes Atrial Flutter THE ATRIAL FIBS Thyroid Hypothermia Embolism (PE) Alcohol ( holiday heart ) Trauma (cardiac contusion) Recent surgery (post-cabg) Ischemia Atrial enlargement Lone (idiopathic) Fever, anemia, high-output states Infarct Bad values (mitral stenosis) Stimulants (cocaine, theophylline, amphetamine, caffeine) 25 / / 74 Atrial Tachycardia Atrial Bigeminy & Trigeminy Bigeminy Trigeminy 27 / / 74 Supraventricular Tachycardia Junctional Escape Rhythm 29 / / 74 5
6 Junctional Tachycardia Ventricular Fibrillation 31 / / 74 Ventricular Tachycardia Torsade de Pointes 33 / / 74 Ventricular Bigeminy & Trigeminy Ventricular Asystole Bigeminy Trigeminy 35 / / 74 6
7 Bundle Branch Blocks The Turn Signal Rule Characteristic QRS pattern in lead I, V1, and V6 Turn-Signal Rule QRS >0.12 everywhere Look V1 QRS Find J point Draw a horizontal line Triangle pointing up indicates RBBB Triangle pointing down indicates LBBB 37 / / 74 William Marrow (V1-V6) Left Bundle Branch Block LBBB RBBB 39 / / 74 Right Bundle Branch Block Wolff-Parkinson-White Pre-excitation Bundle of Kent Delta wave Slurred QRS Lown-Ganong-Levine Bundle of James Short PR Interval < 0.12s 41 / / 74 7
8 Sick Sinus Syndrome Atrial Hypertrophy 43 / / 74 Atrial Hypertrophy Ventricular Hypertrophy P Pulmonale: Right (RAH) P Mitrale: Left (LAH) Right (RVH) Right axis deviation and rotation Tall QRS on right side leads (V1, V2, V3) Left (LVH) Left axis deviation and rotation Tall QRS on left (V4, V5, V6) 45 / / 74 Left Ventricular Hypertrophy Significant Q Waves 47 / / 74 8
9 Myocardial Infarction Significant Q wave = Necrosis ST elevation = Injury T wave inversion = Ischemia MI Location 49 / / 74 MI Location Anterior Leads 51 / / 74 Lateral Leads Inferior Leads 53 / / 74 9
10 Pericarditis Pericarditis Causes Diffuse ST Elevation PR Depression CARDIAC RIND Collagen vascular disease Aortic aneurysm Radiation Drugs (hydralazine) Infections Acute renal failure Cardiac infarction Rheumatic fever Injury Neoplasms Dressler l syndrome (MI or surgery) 55 / / 74 Non-STEMI versus STEMI STEMI Progression Non-STEMI STEMI 57 / / 74 STEMI Progression ST Segment Elevation ELEVATION Electrolytes Left bundle branch block Early repolarization Ventricular hypertrophy Aneurysm Treatment (pericardiocentesis) Injury (acute MI, contusion) Osborne waves (hypothermia) Nonocclusive vasospasm 59 / / 74 10
11 ST Segment Depression Abnormal T Waves DEPRESSED ST Drooping valve (mitral valve prolapse) Enlargement or LV with strain Potassium loss (hypokalemia) Reciprocal ST depression (inferior MI) Embolism (PE) Subendocardial ischemia Subendocardial infarct Encephalon hemorrhage Dilated cardiomyopathy Shock Toxicity of digitalis, quinidine Subarachnoid hemorrhage Cerebral hemorrhageh Cerebral thrombosis 61 / / 74 Electrolytes & Drugs Electrolytes & Drugs Hyperkalemia High K+ Peaked T Hypokalemia Low K+ Flat T, U Wave Hypercalcemia Short QT Hypocalcemia Long QT Dititalis Sloping ST Quinidine Long QT Notched P 63 / / 74 Brudada Syndrome Interpretation Example #1 Asian Males ST Elevation in V1, V2, V3 65 / / 74 11
12 Interpretation Example #2 Right Sided ECG 67 / / 74 Interpretation Example #3 Interpretation Example #4 69 / / 74 Interpretation Example #5 Interpretation Example #6 71 / / 74 12
13 Tools of the Trade Recommend Calipers Useful Magnifier Avoid Rulers Questions? 73 / / 74 13
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