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Making sense of the ECG

Making sense of the ECG. By Dr Saqib Mahmud MRCP(UK) MRCP(London) MRCGP. Systematic approach to ECG. Rate – normal, tachycardia or bradycardia Rhythm – sinus or irregular P waves present (II & V1 best leads to assess) PR interval

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Making sense of the ECG

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  1. Making sense of the ECG By Dr Saqib Mahmud MRCP(UK) MRCP(London) MRCGP

  2. Systematic approach to ECG • Rate – normal, tachycardia or bradycardia • Rhythm – sinus or irregular • P waves present (II & V1 best leads to assess) • PR interval • QRS complexes & axis- widened QRS, Q waves, buddle branch block, voltage criteria for LVH • ST segments – isoelectric, depression or elevation • T waves – N, peaked or inverted

  3. Clinical correlation of ECG • What was the indication? • age • Symptoms-CP, palpitations, sob, syncope, dizziness • Haemodynamically stable? • Clinical signs- HF, poor peripheral perfusion • Pre-morbid Hx-HTN, IHD, DM, CKD • Medications- b-blockers, diltiazem etc • Consider repeating for interval change • Compare with previous ECG if available

  4. Criteria / recap • LVH – sum of S in V1 & R in V5 or V6 >35 • RBBB – tall R in V1, QRS >0.12sec, R’sR pattern • LBBB - QS-V1,V2, QRS>0.12 • Axis - Axis leads-I&III or I&aVF,Normal axis-“double thumbs up’’(I&III+),RAD I –ve, III +ve, LAD I +ve, III –ve • Inferior leads-------------II, III, aVF • Antero-septal leads------V1,V2,V3&V4 • Antero-lateral leads------I,aVL,V5,V6 • Heart rate calculation-(rhythm regular) count the no of large squares b/w 2 consecutive QRS & divide into 300.HR=300/? • Irregular – count no QRS in 30 large squares X 10

  5. Normal RBBB LBBB

  6. axis Thumbs up! Normal axis

  7. RAD LAD

  8. Bradycardia - HR<60bpm(causes) • Sinus bradycardia • Sick sinus syndrome • 2nd or 3rd degree/CHB • Escape rhythms- form of safety net to maintain heart beat if impulse generation fails or blocked • Negatively chronotropic drugs – beta-blockers(don’t forget eye drops!), Ca antagonist; diltiazem, verapamil, digoxin

  9. Symptomatic bradycardia can present with • Dizziness • Syncope • Recurrent falls in elderly • Fatigue • Breathlessness • CP • Palpitations • O/E-look for hypotension, signs of HF & poor perfusion • Relevant Investigations – U&Es , TFTs

  10. Tachycardia-HR>100bpm • Narrow complex (<3 small squares) • Broad complex (>3 small squares) • Narrow complex tachycardias always supraventricular in origin • Narrow complex tachycardias: • Sinus tachycardia • Atrial fibrillation • Atrial flutter • AV nodal re-entrant tachycardia

  11. Broad complex tachycardia • Occurs if normal electrical impulses are abnormally or aberrantly conducted to the ventricles causing delay in ventricular activation & widening of QRS complex • VT • Torsades de pointes • Accelerated idioventricular rhythm • SVT with aberrant conduction

  12. VT

  13. Tosade de pointes

  14. SVT with aberrant conduction

  15. Assessment of tachycardia • Tachycardia causing hemodynamic disturbance requires urgent Rx • Evidence of hemodynamic disturbance; • Hypotension • Cardiac failure • Poor peripheral perfusion • Investigations • FBC • U&Es • TFTs • BNP

  16. Possible causes • Hypothermia • Hypothyroidism • B-blockade • Raised ICP • Obstructive jaundice • Uraemia • Increased vagal tone • Ischemia • Structural SA node disease • Thyrotoxicosis • Any cause of adrenergic stimulation including pain • Hypovolaemia • Anaemia • Pregnancy • Fever • Myocarditis • drugs;theophylines,salbutamol, vasodilator antihypertensives Sinus bradycardia Sinus tachycardia

  17. Heart rhythm & dysrhythmias • Is it regular or irregular? • Regular rhythms • Sinus rhythm- P waves precedes every QRS complex with consistent PR interval • Nodal or junctional rhythm- no P wave preceding QRS complex but narrow regular complexes • Atrial flutter-saw tooth appearance, rapid & regular with a rate about 150bpm(2:1 block) • SVT, AVNRT-if high rate 150-220bpm

  18. Junctional or nodal rhythm

  19. AVNRT

  20. Irregular rhythms • Sinus arrhythmia-P wave precedes QRS with constant PR interval but irregular

  21. Atrial fibrillation- no P waves preceding each QRS with an irregular rate

  22. 2nd degree HB(Mobitz type 1/ wenckebach’s)- progressive lengthening of PR interval ending with a dropped beat followed by short PR interval

  23. 2nd degree HB/Mobitz type 2-P waves followed by QRS, fixed PR interval with occasional non-conducted or dropped beat

  24. 3rd degree/ CHB

  25. ST segment elevation

  26. Ventricular ectopic-QRS broad & bizarre,>3 small squares, T opposite to QRS

  27. Tented t waves

  28. VF

  29. The end Thank you

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