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Q U B C A R D I O S O C ECG INTERPRETATION Bianca Botezatu email: bbotezatu01@qub.ac.uk CONTENT S TA N DA R D 1 2 L E A D E C G TAC H Y / B R A DY I N T E R P R E TAT I O N A N D S H O C K A B L E R H Y T M S R E P O R T I N G R H Y T H M R E L E VA N T C L I N I CA L S C E N A R I O S ELECTRICAL ACTIVITY Deflections – positive (above the isoelectric line) when the depolarization wave is moving toward the electrode. Negative is away 12 LEAD ECG P wave : depolarization of atria QRS complex: ventricular depolarization T wave : ventricular repolarization U wave : delayed repolarization, low K/Ca, brady, MV prolapse PR interval: < 200 ms 5 Large squares = 1 second QRS duration < 120 ms (<3 ssq) 1 large square = 200ms or 0.2 seconds QT interval: 390-450 ms (< 12 ssq) Small square 40ms REPORT AN ECG 1. Date and time of ECG 2. Name and DOB of patient 3. Electrical activity: present/absent (check leads placement) 4. Rate and rhythm 5. Are there P waves and do they correlate to QRS? + PR interval 6. QRS complex: broad/narrow + QT segment 7. Axis 8. ST/T waves RHYTHM Usually can see if the rhythm is regular or irregular by looking at the bottom lead on the ECG (normally lead II) Paper test: put a piece of paper under the ECG strip and mark 3 consecutive QRS complexes. Move the paper along the line and see if complexes match 3 Methods: • Divide 1500 by the small squares between 2 R waves • Divide 300 by the number of large squares between 2 R 300/3.2 = 93.75, approx 94 bpm • Count 30 large squares and count the number of QRS complexes within this interval. Then multiply by 10. - > irregular rhythm 8 QRS -> 8x 10= 80 bpm HEART RATECalculate the HR: 300/4.2 = 71.42 --> 71 bpm 7 x 10 = 70 bpm 300/2.2= 136.36 --> 136 bpm 13 x 10 = 130 bpm72 yo is admitted to A&E following an episode of SOB with palpitations. She has been feeling very tired for the past 3 days. O/E you notice that her HR is 125 bpm and when you check her pulse it is irregularly irregular. You decide to do an ECG to confirm the diagnosis: First line of management is: a) Amiodarone b)Flecainide c) Bisoprolol d) Digoxin72 yo is admitted to A&E following an episode of SOB with palpitations. She has been feeling very tired for the past 3 days. O/E you notice that her HR is 125 bpm and when you check her pulse it is irregularly irregular. You decide to do an ECG to confirm the diagnosis: First line of management is: a) Amiodarone b)Flecainide c) Bisoprolol d) Digoxin P wave: present or absent? P wave is present -> Is it followed by a QRS complex? Yes -> check PR interval PR prolongation: > 200ms (> 1 large sq) 1st Degree Heart Block: prolonged PR interval 2nd Degree Mobitz 1/Wenckebach: progressive prolongation of PR interval until a complex is dropped 2nd Degree Mobitz 2: -normal complex followed by a non-conductive P wave. Usually some pattern -> 2:1 or 3:1 3rd degree/Complete heart block: no correlation between P waves and QRS complex A 63 yo female presents to the GP with SOB and palpitations. She was admitted to the cardiac unit 3 weeks ago after suffering an anterior MI, but has since recovered and was discharged. She is afraid this might be another MI, so you perform an ECG: The definitive management of this diagnosis is: a) Adenosine b) Atropine c) Permanent Pacemaker d) Flecainide A 63 yo female presents to the GP with SOB and palpitations. She was admitted to the cardiac unit 3 weeks ago after suffering an anterior MI, but has since recovered and was discharged. She is afraid this might be another MI, so you perform an ECG: The definitive management of this diagnosis is: a) Adenosine b) Atropine c) Permanent Pacemaker d) FlecainideECG of a patient with a dual chamber pacemaker QRS complex Bradycardia: usually wide QRS (> 120 ms or 3 ssq) SVT • Tachycardia – narrow complex: comes from atria/above the AV node • Tachycardia – broad VT complex: originates below the AV node VFQRS > 120 ms (3 small squares) MaRroW WiLliaM RBBB LBBB42 yo male is complaining of dizziness and palpitations which started a couple of hours ago and have not stopped. He has a hx of schizophrenia managed with haloperidol and has recently been prescribed citalopram for his depression. This is his ECG: The first line of management for this condition is: a) Adenosine b) Calcium gluconate c) Magnesium Sulphate d) Cardioversion42 yo male is complaining of dizziness and palpitations which started a couple of hours ago and have not stopped. He has a hx of schizophrenia managed with haloperidol and has recently been prescribed citalopram for his depression. This is his ECG: The first line of management for this condition is: a) Adenosine b) Calcium gluconate c) Magnesium Sulphate d) Cardioversionpolymorphic VT TDPA 67 yo male with a history of hypertension complains of SOB and general lethargy for the past couple of months. His BP is 172/98, HR 78 and sats 99%. He admits that he has skipped his BP medication and the GP decides to do an ECG: Diagnosis: a) STEMI b) Atrial flutter c) Hyperkalaemia d) Left ventricular hypertrophyA 67 yo male with a history of hypertension complains of SOB and general lethargy for the past couple of months. His BP is 172/98, HR 78 and sats 99%. He admits that he has skipped his BP medication and the GP decides to do an ECG: Diagnosis: a) STEMI b) Atrial flutter c) Hyperkalaemia d) Left Ventricular Hypertrophy Axis deviation Extreme Deviation - I neg, II neg , aVf neg STEMI, NSTEMI, ACS, PERICARDITIS59 yo man with a hx of hypertension comes to A&E complaining of central chest pain and dizziness for the past 2h. O/E his HR is 81 bpm, BP 200/90, his JVP is not raised, heart sounds are normal and lungs are clear. His troponins are normal. His ECG: Diagnosis: a) Unstable angina b) Aortic dissection c) STEMI d) NSTEMI59 yo man with a hx of hypertension comes to A&E complaining of central chest pain and dizziness for the past 2h. O/E his HR is 81 bpm, BP 200/90, his JVP is not raised, heart sounds are normal and lungs are clear. His troponins are normal. His ECG: Diagnosis: a) Unstable angina b) Aortic dissection c) STEMI d) NSTEMIA 27 yo patient arrived to A&E with ongoing chest pain, SOB and palpitations. The pain started 2 days ago and has gotten progressively worse, excerbated when he lies down. It radiates to his shoulders. He has no past medical hx of note and no family hx of cardiac problems. On auscultation, you can hear a friction rub a) STEMI b) PE c) Hyperkalaemia d) PericarditisA 27 yo patient arrived to A&E with ongoing chest pain, SOB and palpitations. The pain started 2 days ago and has gotten progressively worse, excerbated when he lies down. It radiates to his shoulders. He has no past medical hx of note and no family hx of cardiac problems. On auscultation, you can hear a friction rub a) STEMI b) PE c) Hyperkalaemia d) PericarditisA 76 yo man with a Hx of heart failure is admitted to hospital complaining of palpitations and SOB. His BP is 168/95 and HR 50 bpm. The rest of the obs are normal and sats are 98%. On examination, his lungs are clear with no additional heart sounds. a) Hypocalcaemia b) Atrial fibrillation c) Hypokalaemia d) HyperkalaemiaA 76 yo man with a Hx of heart failure is admitted to hospital complaining of palpitations and SOB. His BP is 168/95 and HR 50 bpm. The rest of the obs are normal and sats are 98%. On examination, his lungs are clear with no additional heart sounds. a) Hypocalcaemia b) Atrial fibrillation c) Hypokalaemia d) Hyperkalaemia63 yo female is assessed in A&E for sudden onset SOB and right pleuritic chest pain. O/E chest is clear and normal heart sounds. Her RR is 24, O2 sats are 95%, BP 129/74, and temperature is 36.2. You observe that she has an external fixture of a humerus fracture on her right arm and she has also complained of a painful and swollen left leg. The ECG trace: What is the classic ECG sign of this diagnosis that appears in this ECG?: a) RBBB b) Right axis deviation c) S1Q3T3 d) Sinus tachycardia63 yo female is assessed in A&E for sudden onset SOB and right pleuritic chest pain. O/E chest is clear and normal heart sounds. Her RR is 24, O2 sats are 95%, BP 129/74, and temperature is 36.2. You observe that she has an external fixture of a humerus fracture on her right arm and she has also complained of a painful and swollen left leg. The ECG trace: What is the classic ECG sign of this diagnosis that appears in this ECG?: a) RBBB b) Right axis deviation c) S1Q3T3: deep S wave in lead I, deep Q wave in III and inverted T wave in III d) Sinus tachycardiaTHANK YOU!