ECG Interpretation for Finals

Ali White (FY2, respiratory) and Lucie Shipley (FY1, vascular surgery)

Objectives
Physiology Basics of ECG Interpretation The Normal ECG Cardiac Arrest Rhythms Peri arrest rhythms Block and Bradycardia Tachyarrhythmias narrow and broad Myocardial Infarction and Ischaemia Tips for the exam and beyond

Physiology
Myocardium is polarised Depolarisation begins at the Sino Atrial Node Depolarisation of the atrium AV Node -> Bundle of His -> Bundle Branches -> Ventricular Depolarisation

ECG interpretation
Patient Details Voltage and Paper Speed

1. Is there any electrical activity? 2. What is the QRS rate? 3. What is the Rhythm? Is the QRS regular? Is each QRS preceeded by a Pwave? 4. What is the cardiac axis? 5. What are the PR, QRS, QT intervals? 6. Are there any Q-waves, or ST/T-wave abnormalities? 7. Compare findings with an old ECG (very useful!)

Is there any electical activity?

1.) ABCDE!!! (is patient in cardiac arrest/asytole) 2.) Check ECG machine is working and leads attached

What is the QRS Rate

Normal Rate 60 -100 <60 Bradycardia, >100 Tachycardia Standard paper speed 25 mms-1 Method 1 ( NUMBER OF CARDIAC CYCLES IN 6 Secs -30 large cycles) x 10 8 (AND A HALF) CYCLES = 80

Method 2 300 / NUMBER OF SQUARES BETWEEN QRS 3 (AND A BIT)= 100

Is the QRS rhythm regular?

Mark on a strip of paper If irregular: Totally irregular? Basic regular rhythm with intermittent irregularity? Is there a reccurent cyclical variation in the R-R intervals
Totally irregular with normal QRS morphology likely AF Irregular extrasystoles ventricular / atrial ectopics Narrow/ wide QRS

Axis

Left Axis Deviation

Left Axis Deviation: <-30. positive in I, negative in II + III. L = Leaving

Right Axis Deviation

Right Axis Deviation <90 degrees: Negative I, Positive II and III R = reaching towards

Causes of deviation
Causes of left axis deviation: left ventricular hypertrophy left anterior fascicular block obesity cardiomyopathy primum atrial septal defect
Causes of right axis deviation: right ventricular hypertrophy left posterior fascicular block thin body habitus chronic lung disease secundum atrial septal defect

PR intervals
Normal PR interval 120-200ms (3-5 small squares) PR < 0.12 - think Wolff Parkinson White First Degree Heart Block Second Degree Heart Block Complete Heart Block

First Degree Heart Block

PR interval, from start of P to start of QRS complex >200ms Still a P wave for every QRS complex Constant relationship between P and QRS Most Stable- often does not require treatment.

Second degree Heart Block

= Not every P wave has a following QRS MOBITZ TYPE 1 (Wenkebach) Gradually increasing P R interval prior to dropped QRS interval Usually signifies AV nodal block, often aysmptomatic

MOBITZ TYPE 2 (Hay) Constant P-R interval with intermittant 2/3:1 failure of conduction Predisposes to Complete heart block and Asystole Pathology usually distal to AVN = bundle branch disease

Third Degree Heart Block

AV dissociation, intrinsic ventricular rate Ventricular Rate dependant on location of block AV Node/ Proximal Bundle of His Rate 40-50 Narrow QRS Distal His/Purkinje Fibres / Ventricular Myocardium Rate <40 Unstable, peri-arrest Rhythm Usually QRS >0.12

What is the QRS

Q wave- normal <2 small squares Normal QRS <0.12s (3 small squares) QRS <0.12 seconds = SAN, Atria, AVN, Proximal Bundle of His Narrow Complex QRS >0.12 sec 1. Distal from ventricular myocardium 2. Proximal with Aberrant Conduction eg. Bundle branch block LVH S in V1 + R in V5/6 35 mm ( 7 large squares)

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QTrates. intervals QT lincreases with slower heart

Quantification of QT interval needs correction for rate : QTc Normal QTc = less than 0.42s (ten and a bit small squares). QTc = (measured QT interval)/ (cycle length-2) May require permenant pacing Multiple causes Genetic (Romano Ward, , Jervell and Lange Nielsen syndromes IHD Electrolyte abnormality (K Ca, Mg) Hypothermia Drugs Structural (mitral valve prolapse, dilated cardiomyopathy). Predisposes to Torsades des Pointes palpitations, collapse, sudden death

ST Segment
End of the QRS segment is the J-point From J-point to start of T-wave is ST Segment

ST Segment
Elevation = STEMI:
1 mm ST elevation in two or more adjacent limb leads 2 mm ST elevation in two or more adjacent chest leads new left bundle branch block

Leads
II, III, aVF = inferior leads V1-V2 = septal leads V1-V6 = anterior leads I, aVL, V6 = lateral leads Nb posterior MI may see reciprocal Septal ST depression

Scenario 1
John, 50 Known Hypertensive and smoker 3 hours of Crushing Central Chest pain
How will you manage him?

Initial Management
A Present B RR 32, SaO2 93% on RA, Chest Clear,
Good A/E C- BP 156/98, HR 75 (regular) CRT <2secs, D GCS 15, E Capillary glucose 11.9 (DEFG) ECG 12 Lead + Monitoring, Cannula, Bloods, MONAL, senior help, further management (PCI/thrombolysis)

ECG

MONA
MORPHINE Titrate IV 2-5mg + Metoclopramide 10mg IV Oxygen Aim Sats above 94% Nitrates sublingual Aspirin 300mg

Clopidogrel 300mg B-blocker Labetolol/Metoprolol usually IV first if BP ok Assess for PCI / Thrombolysis Twelve hour Troponin I (prognostic vs diagnostic)

Arrhythmias
Interpret the ECG in the context of clinical condition Always assess using ABCDE approach Treatment depends on presence of adverse clinical features Electrical treatment works faster than Chemical

Adverse Features
1. SHOCK-BP<90, cold, clammy, sweaty, confusion, GCS 2. SYNCOPE 3. HEART FAILURE- pulmonary oedema, JVP, low BP
GET SENIOR SUPPORT EARLY- MAY REQUIRE CCU ADMISSION!

Post- MI management
Lifestyle advice Aspirin 75mg OD (Life) Clopidogrel 75mg OD (1 year) B-blocker Statin ACE-I

AV Nodal Re-entrant Tachycardia

AV node surrounded by non conductive tissue. One tract from Atrium to AV node Accessory pathway + Atrial Ectopic = self sustaining rapid depolarisation loop. HR > 130 Normal Resting ECG

Atrioventricular Re-entrant Tachycardia

Accessory pathway between Atria and Ventricles (WPW-bundle of Kent) Abnormal Resting ECG PR interval <0.12s, Slurred Delta Wave into QRS

Scenario
James 17, No PMH Attending A&E:chest pain palpitations, shortness of breath On arrival: Pulse 200 BP 130/80 CRT 2 secs GCS 15

Management
A Present B RR 28, SaO2 99% on 15l, ABG awaited
C as previous, Cannula, Bloods, ECG D GCS 15, E Capillary glucose 5.9

ECG

Management Continued
Vagal Manouvre
Carotis Sinus Massage, Valsalva (Diving Reflex)

Adenosine reveals underlying pathology BLEEP CARDIOLOGY REG

Risk of sudden Cardiac Death Definitive treatment Radiofrequency ablation

ALS Bradycardia Algorhythm

Cardiac Arrest Rhythms

1. 2. 3. 4. Asystole Pulseless Electrical Activity Ventricular Tachycardia Ventricular Fibrillation