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ALL YOU NEED TO KNOW ABOUT ECGs AND CXRs MRama Aubeeluckeen KindNaranpervised by: Dr Revati Who are we? ● Penultimate / final year medical students at UCL ● Covering general medicine topics and specialty topics ● Want you guys to become the best F1s you can be and teach with this as a key focal point! ● Teaching every Thursday on MedAllat 18:00 to anyone in their clinical years of medicine ● Follow us on MedAll to get notifications and reminders for our upcoming eventshttps://app.medall.org/c/teaching-things ECGs Mohammed BinyameenWhat we will aim to cover: What I am aiming to cover in the ECG section of this session: - How to set up an ECG practically - Electrodes and leads in a 12 lead ECG - How the electrical changes in the heart can be mapped on an ECG - Systematic approach to interpret ECGs - Common/Important ECG findings What we WILL NOT be going through: - Different cardiology conditions and their respective pathophysiologyBasic physiology of the heart Conduction within the heart: Sino-Atrial Node (SAN) Atria Atrio-Ventricular Node (AVN) + Annulus Fibrosus Bundle of His Left + Right bundle branch Purkinje fibres VentriclesElectrodes and Leads 3 lead vs 12 lead ECG RL = Earth Exact placements on next slideElectrodes and Leads Limb electrodes: Chest electrodes: - Right arm - V1: 4th ICS on right margin of - Left arm sternum - Right leg (Earth) - V2: 4th ICS left margin of the - Left leg sternum - V3: Midway between V2 and V4 - V4: 5th ICS, mid- clavicular line - V5: 5th ICS, anterior axillary line - V6: 5th ICS, mid-axillary lineLimb Leads RA LA RA LA LL LL Lead 1 = RA to LA Lead 2 = RA to LL Lead 3 = LA to LLChest Leads Unipolar leads Can imagine -ve electrode in middle of heart and +ve on skin surface Give a detailed picture of different parts of the ventricle wallAugmented Limb Leads aVF = to LL aVL = to LA aVR = to RA Although these are unipolar, you can think of the -ve electrode being in the centre of the heart. Also the final letter of the lead name indicates the +ve electrode (F=Feet, L=LA, R=RA)How an ECG relates to the cardiac cycle (in lead 2)How an ECG relates to the cardiac cycle (in lead 2)How an ECG relates to the cardiac cycle (in lead 2)How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +ve How an ECG relates to the cardiac cycle (in lead 2) RA -ve LL +veNormal values to learn P wave = Less than 0.12s QRS complex = Less than 0.12s PR interval = Less than 0.2s QT interval = Less than 0.44s (Less than 0.46s in women)Putting it all together Blood supply of the heart LAD - Supplies RV, LV + ⅔ of the IVS LCx - Supplies the LA + LV RCA - Supplies the RA, SAN, AVN + Posterior ⅓ of IVSLeads and their territories LAD - Anterior RCA or LCx - Inferior LCx or diagonal of LAD - LateralAxis and Axis deviation How to calculate axis: Look at Lead 1 and aVF: - Normal axis = QRS deflection +ve in L1 and aVF - LAD = if QRS +ve in L1 and -ve in aVF - RAD = QRS +ve in aVF and -ve in L1 - If both leads negative, axis indeterminateHow to interpret an ECG In an OSCE, ALWAYS remember to: - Check the name and DOB of the patient - The date and time the ECG was done - Ask for any previous ECGs to compare to If you spot any abnormalities, specify if it is in certain leads or widespread Might not always be able to comment on individual componentsImportant ECG patternsTachyarrhythmias - HR > 100 WPW can be narrow or broad complexAbsent P waves Irregularly irregular Narrow QRS complex Atrial fibrillationSawtooth P wave pattern P wave to QRS ratio can vary (can also be variable) Narrow QRS complex Atria fire at 300bpm Atrial flutterDelta wave - Slurred upstroke Bundle of Kent Broad QRS complex? Wolff Parkinson WhiteNo P waves (how to differentiate with sinus tachycardia) Narrow QRS complex Supraventricular tachycardiaBradyarrhythmias - HR < 60PR interval around 300ms Athletes, drugs (b, c, d), Inc. vagal tone First degree heart block - Def PR int. >200msWenckebach phenomenon If asymptomatic, no pacing required Second degree heart block - Mobitz 1Regular pattern of non conducted P waves Requires pacing (even if asymptomatic) - High risk of progression to 3rd degree Second degree heart block - Mobitz 2P wave and QRS complex completely asynchronous Third degree heart blockHeart damage/ischaemiaST elevation seen mainly in leads V2 to V4 (also seen in V1 and V6) Anterior STEMILeads and their territories LAD - Anterior RCA or LCx - Inferior LCx or diagonal of LAD - LateralWidespread ST depression (seen in leads 1 to 3, and V3 to V6) Non-transmural ischaemia - Non specific changes such as t wave inversion or ST depression NSTEMIThink WiLLiaM: LBBB shows W in V1 and M in V6 New LBBB is ALWAYS pathological LBBBThink WiLLiaM: LBBB shows W in V1 and M in V6 New LBBB is ALWAYS pathological LBBBThink MaRRoW: RBBB shows an M shape in V1 and a W shape in V6 Can indicate pathology but can also be normal in older people RBBBRandom patterns to know 2 1 3 4Random patterns to know 2 1 3 Hypokalaemia 4 T wave inversion U waves Sine wave patternRandom patterns to know 2 1 3 Hyperkalaemia Tall peaked T waves 4 T wave inversion U waves Sine wave patternRandom patterns to know 2 1 3 Hyperkalaemia Tall peaked T waves Hypokalaemia 4 Pericarditis T wave inversion PR depression U waves Global saddle shaped ST elevation Sine wave patternRandom patterns to know 2 1 3 Hyperkalaemia Tall peaked T waves Hypokalaemia 4 Pericarditis T wave inversion PR depression U waves Global saddle shaped ST elevation Sine wave pattern Hypothermia Long PR + Long QT J wavesResources that I found useful for ECGs Links: https://litfl.com/ https://geekymedics.com/understanding-an-ecg/Chest X-rays Rama AubeeluckRapid fire spot diagnoses !Spot diagnosis 1 1. TB 2. Lung cancer 3. Asthma 4. Normal CXR 5. Alpha 1 antitrypsin deficiencyOptions: 1. TB 2. Lung cancer 3. Asthma 4. Normal CXR 5. Alpha 1 antitrypsin deficiencySpot diagnosis 2 1. Interstitial lung disease 2. COPD 3. Normal CXR 4. Pneumothorax 5. AsthmaOptions: 1. Interstitial lung disease 2. COPD 3. Normal CXR 4. Pneumothorax 5. AsthmaSpot diagnosis 3 1. Interstitial lung disease 2. Pneumonia 3. Alpha 1 antitrypsin 4. Lung metastasis (cancer) 5. Normal CXROptions: 1. Interstitial lung disease 2. Pneumonia 3. Alpha 1 antitrypsin 4. Lung metastasis (cancer) 5. Normal CXRSpot diagnosis 4 1. Pneumothorax 2. Atelectasis 3. Pleural effusion 4. Sarcoidosis 5. Normal CXROptions: 1. Pneumothorax 2. Atelectasis 3. Pleural effusion 4. Sarcoidoisis 5. Normal CXRSpot diagnosis 5 1. Interstitial lung disease 2. Pneumonia 3. Alpha 1 antitrypsin 4. Lung metastasis (cancer 5. Normal CXROptions: 1. Interstitial lung disease 2. Pneumonia 3. Alpha 1 antitrypsin 4. Lung metastasis (cancer 5. Normal CXRChest X -rays… easy or not? ● Some things are easy to spot diagnose - common things are common ! ● Multiple pathologies can be present e.g. pleural effusion is commonly secondary to cancer, most COPD patients smoke so are at risk of cancer ● Common CPSA station and something you will be asked to do routinely on wards for your placement and as an F1 doctor ● helpfulsult, having a set structure of going through CXR bit by bit is veryWhy do a CXR? ● Symptoms: what is the pt complaining about ● Any another reasonsee on examination?Why do a CXR? ● Signs: unexplained cough, fever, haemoptysis, ● Symptoms: essentially any abnormal chest finding from IPPA: tracheal deviation, impaired chest expansion, added sounds on auscultation, abnormal percussion note and / or vocal resonses ● Any another reasons: post pneumonia, fitness to fly, assessing the position of NG tube, chest drain etc.CXR interpretation - Dr . RIPE ABCDE Dr. RIPE: assesses CXR quality ABCDE: assesses CXR for any pathologies You want to spend much more time on ABCDE! When beginning your practice, Dr. RIPE might take some time, but this should become a quick process once you are fluent (<30 seconds)Dr . RIPE ABCDE First step (D - details) 2.. Mention you would compare to previous CXR if availableOB, Hospital number) 3. State any spot diagnoses that immediately stick out to youDr . RIPE ABCDE Rotation - does the x-ray hit the patient straight on or at an angle? ● processespects of the 2 clavicles should be equidistant from the spinous ● Spine should also be vertically orientated as well (in this case it is not perfect but that is fine)^ Good CXR!Dr . RIPE ABCDE Inspiration - how good is the patient’s inspiratory effort? ● You should be able to see 5-6 anterior ribs, or at least 7 posterior ribs, the lateral edges of each ridge as well as the costophrenic angle ● Hyperinflated if >10 posterior ribs visible, or >6 anterior ribs ● Are the costophrenic angles included in the film?^ COPD: hyperinflationDr . RIPE ABCDE Position ● Is the x-ray in a posterior-anterior (PA) or anterior posterior (AP) view? ● PA: posterior ribs visible, flatter, scapula out of view -more common method of CXR ● AP: more vertical ribs- anterior ribs, also scapula in the middle of the lung field, heart looks a little bit gigger Penetration Are the vertebral bodies visible behind the heart?Which is PA and which is AP?Left side (PA) ● Scapula not visible ● Ribs are flatter (posterior ribs) ● Heart is smaller Right side ● Scapula visible ● Ribs slightly more diagonally oriented ● Heart is bigger (why!?) Both CXR have good penetrationYou cannot comment on heart size if a CXR is AP!Dr . RIPE ABCDE Exposure ● Is all of the patient there? ● Pretty much common sense with this oneDr . RIPE ABCDE Airway ● Is the trachea central? If deviated, this suggests it is being pushed or pulled by something… ● Pulling: collapsed lobe or lung ● Pushing: pleural effusion and pneumothorax ● Carina and bronchi - can you see them? ●Dr . RIPE ABCDE Hilar region (these are lung roots with all the vasculature) ● Left hilum should be higher than right hilum Is there any lymphadenopathy? (i.e. are the areas more visible than they should be) Unilateral or bilateral asymmetrical lymphadenopathy ● Tuberculosis (“primary TB”) ● Lymphomaic or primary hilar tumor (bronchogenic carcinoma) ● Sarcoidosis Bilateral symmetrical lymphadenopathy ● Sarcoidosis—the prime diagnosisCollapsed lung: ● Trachea PULLED to the side of the collapse (right side in this case) ● Lung / lobe collapses -> decrease in volume, creates a relative negative pressure on the affected side of the thoracic cavity. ● To balance the pressure difference in thoracic cavity, the trachea is pulled to the collapsed side Pleural effusion ● Excess fluid physically pushes the trachea awayDr . RIPE ABCDE Breathing ● “Zones” describe the lung regions: apical, upper, middle and lower ● Do NOT say lobe ● Lack of lung markings: suspect pneumothorax!for like systematically ● Note any consolidation, areas of blackness (air), no lung markings (pneumothorax) and appearances of heart failure ● Ensure the lung markings extendcompletely to the edge of the lung field - you should not be able to see the pleural borders Comment as you go - verbalise what you see, but stay succinct (don’t bore the examiner…)Dr . RIPE ABCDE Opacification or consolidation? Be careful with what you say! ● Opacification: General term for reduced transparency of lung tissue on imaging (broad and non-specific). Could be due to pleural effusion, pulmonary edema, consolidation, atelectasis, or mass lesions ● Consolidation: A specific type of opacification caused by alveolar filling with fluid, cells, or other material (most commonly seen inpneumonia)Consolidation Opacity MassDr . RIPE ABCDE Cardiovascular ● Heart size, must be PA to comment on this ● Cardiothoracic ratio >0.5 indicates cardiomegaly ● Are the heart borders (LV and RA) able to be seen clearly? ● Borders ca become difficult to distinguish from the lung fields due to pathologies which increase the opacity of overlying lung tissue eg. consolidationNormal CXR: ● Right atrium and left atrium easily seen ● Heart takes up less than 50% space or the thoraxWhat are some causes of cardiomegaly?What are some causes of cardiomegaly? ● Heart failure ● Cardiomyopathy (HOCM, DCM) ● Congenital heart disease ● Pulmonary hypertension ● Hypertension ● Valvular heart diseaseDr . RIPE ABCDE Diaphragm ● Remember the right should should usually be a little higher due to the liver Costophrenic angles ● Where the diaphragm meets the ribs at the bottom of the image ● Should be well defined and acute ● If this angle is lost, this is costophrenic blunting - a sign that fluid has settled in this space, or hyperinflation like in emphysema ● Collapsed / expanded lung will push / pull the diaphragm with itNormal Blunted…. causes?Normal Blunted…. Causes? ● Pleural effusion ● Atelectasis ● Pleural thickening (e.g. asbestos exposureGas UNDER the diaphragm! This is called pneumoperitoneum - not a good sign More of a surgery topic… Causes ● Perforation (peptic ulcer, bowel, appendix et.c) ● Deliberately done in some surgeries Surgical emergency - i.e. needs operatingDr . RIPE ABCDE Everything else! ● Damage to bony structures: rib fractures, lytic lesions ● Breast shadows ● Foreign bodies: pacemakers, ECG leads, piercings, shirt buttons “There are no abnormalities with regards to bony structures or soft tissues” Practice! Patient details Name: Leandro Trossard MRN: 56781234 DOB: 13/01/1972 History: ● Known smoker (20 pack years)Example summary: This is a chest X-ray for Leandro Trossard, MRN 56781234, date of birth 13th January 1972. The image quality is good with no signs of rotation, adequate inspiration is adequate (I can count 9+ posterior ribs. Penetration is appropriate as I can see the vertebral bodies through the heart shadow. Moving on to the airways, the trachea is midline with no signs of deviation. In terms of breathing, both lung fields are hyperinflated, which is evident from the increased anterior-posterior diameter and the flattened diaphragms. There’s no evidence of focal opacification or pneumothorax. For the circulation, the cardiothoracic ratio appears normal and under 50%, and there’s no sign of cardiomegaly. The hilar vessels look prominent but are not congested. The diaphragms are flattened bilaterally which supports the hyperinflation seen with COPD. There's no subdiaphragmatic free air to suggest any acute abdominal pathology. Finally, there are no obvious abnormalities in the soft tissues, bones, or other structures like the ribs and spine. In summary, this X-ray shows hyperinflation and flattened diaphragms, findings consistent with chronic obstructive pulmonary disease (COPD).CXR - occurrence in exams AKT / Multiple choice ● Likely to receive at least 1 in your question set CPSA / OSCE / Practical exams ● Interpret an x-ray (5 minute station) ● Examination (resp, A2E) + interpret ● Interpret and speak to a patient (breaking bad news, counselling etc.)CT gives you a better look ● Often the gold standard ● Not covered today but conditions you need to be aware of are: ● Bronchiectasis ● Intersitial lung disease ● Lung cancer ● Rib fractures Condition Findings on CXR Lung abscess ● Cavity with air-fluid level: Thick-walled cavity with fluid inside. ● Surrounding consolidation: Due to infection Pulmonary oedema ● Bilateral perihilar opacities: Bat-wing pattern. ● Kerley B lines: Horizontal lines in the lower zones (interstitial oedema). ● Cardiomegaly: If associated with heart failure. ● Pleural effusions: if severe Lung cancer ● Solitary pulmonary nodule: Often irregular or spiculated. ● Mass: Larger and more centrally located. ● Atelectasis: Collapse of part of the lung. ● Unilateral Hilar enlargement: Due to lymph node involvement Pleural effusion ● Blunting of costophrenic angle: Fluid accumulation. ● Meniscus sign: Curved upper border of fluid. ● Complete opacification: If the effusion is large enough to fill the hemithorax Kartagener’s syndrome ● Bronchiectasis: Tram-track or signet ring signs. ● Situs inversus: Heart and other organs reversed on chest X-ray Heart failure ● Cardiomegaly: Enlarged heart shadow. ● Pulmonary oedema: Bilateral perihilar opacities. ● Kerley B lines: From interstitial oedema. ● Pleural effusions: Often bilateral. Condition Findings on CXR Bronchiectasis ● Tram-track sign: Parallel line opacities due to thickened bronchial walls. ● Signet ring sign: Enlarged bronchi compared to adjacent pulmonary artery. ● Dilated airways: Visible extending to lung periphery. Pneumothorax / ● Absence of lung markings: In the affected area. ● Visible pleural line: Separating the collapsed lung from chest wall. Tension pneumothorax ● Tracheal deviation (in tension pneumothorax): Away from the affected side. ● Mediastinal shift: Away from the affected side (in tension pneumothorax). ● Pleural plaques: Calcified, especially in the lower zones. Asbestos ● Diffuse interstitial fibrosis: Primarily affecting lower lobes. COPD ● Hyperinflated lungs: Flattened diaphragm, increased lung volumes. ● Pulmonary bullae : Cavities of ruptured air Idiopathic pulmonary ● Reticular opacities: Thickened interlobular septa. fibrosis Pneumonia ● Lobar consolidation: Homogeneous opacity (classic lobar pneumonia). ● Air bronchograms: Air-filled bronchi visible against the consolidated lung. ● Patchy infiltrates: In bronchopneumonia Tuberculosis ● Apical consolidation: Infiltrates or cavitations in upper lobes - TB normally reactivates in the upper lobes ● Bilaterla hilar enlargement ● Cavitation: Well-defined hollow spaces in advanced disease. ● Miliary pattern: Diffuse small nodules throughout the lung fields - common in immunosuppressed patientsResources that I found useful for CXRs https://www.radiologymas terclass.co.uk/ https://radiopaedia.org/ THANKS FOR WATCHING! Please fill out the feedback form on Medall and see you next week!