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Yeah. OK. So good evening everyone. And thank you for joining us today on this series on Basics of acute medicine. Today, we'll be focusing on ecg interpretation. But before we start, I would like to introduce myself. Um My name is Salwa Fuan, a member of Medpar International and I will be your host today um For those who don't know about us. Um Medi Plus International is a nonprofit organization which aims to help bridge the gap between medical professionals and medical students around the world as well as creating opportunities to strengthen the relationship between the general public and the medical professionals. In this way, we hope we hope to provide a flow of up to date medical education for all. Please make sure to ask any take advantage of the chat options below. And if you have any questions you would like to ask, um you can write it that and we hope to make this a very interactive um a webinar for everyone and it should be beneficial for everyone. So today we have um Alex with us um and he will be walking us through the webinar and we're very happy that you could join us today. Alex. I'm happy to be here. So, um you could actually start the presentation now. Um, if you feel comfortable II can hear you well, so that's good. And I'll be here if I like that does it, you can still see it. Yeah, I can see everything basic of stuff that, ok, so I'm Alex. I'm a foundation year one doctor in South London. And this is gonna be a part of a four part series basically on acute medicine. Um looking at ECG S and interpreting them in different scenarios. Um The first session we're gonna do is just the basic of the G. There's also another doctor with me Lauren. She's just having some wifi trouble and if she can still join when she can and she will be able to get in the chat and if there's any questions, um just so you have any questions I should, we just chat the same time. Um And so first of all, we thought we'd start with just saying how to do an E CG. And so you will know how to do this but just a pressure. And so those patients test, there are 1010 lead on paper, six on the test. Um I've done them in order of what, how you place them. So B1 is the fourth space on the right edge. B2, the fourth and cross space in the left than right B four is next the fifth and space in the mid line and B3 is, I'm halfway between B2 and B four and then B5 is left and hi line at the same level of B 4 B6 left mid Axillary line. I was saying, hold on to that 34135. Sorry, I've seen someone saying you can't hear me what I'm saying. Yeah. Um um I have no idea but like your microphone is a bit, it's bleaching, it's having like sounds um I have no clue. Maybe you could put it off and put it on again and try and see how it sounds. I thought you had or something like that. Sorry guys, for the inconvenience. We hope that she can fix it very soon. Um So I would just inform you guys about the feedback forms. Um It would be sent, the link would be sent immediately after the webinar and you could fill out the um the questionnaire and you should be able to receive a form or a certificate for medal directly and I'll send that for you guys um at the end of the web. Now. Thank you also for being patient. Um We're having a bit of technical difficulties at the moment, but we hope to get this on the way. Ok? Alex is gonna be back with us soon. She's trying to figure out how to fix the problem and we shall continue. Ok? I'm gonna ask you to say something so we could see if it, it worked. Hello? I, that's a bit of a lag but I can distinctly hear you a bit better. Ok. Can you hear me? Ok? But you can hear me now, right? Yeah, I can hear you. Ok. There's a little bit of a lag but I don't know. Ok. Um, um, if everyone can give like an opinion it, can you hear her well, because I can hear her but, but I don't, OK. I think I could hear you. Well, I don't know for the audience if they could hear you a little bit better since facility. Um Yeah, I feel like you should just try and speak so we can see like and judge the voice. Ok? You hear? OK. OK. So we can go ahead. I think that's, that's fine. I'm sorry for the technical difficulties guys. Ok. Powder as well. But let me know if you can in. Perfect, I could hear you. Yeah, perfect. I was just running through. Oh sorry. Was someone saying something? Uh no, I was just giving my approval that I could hear you perfectly well. So there's no problem. Yeah. Ok. OK. So OK. Um So you probably read through the chest leads by now anyway. Um but those are the positions for chess leads and then the limb leads. Um There's red on the right arm, yellow on the left arm, green on the left leg and black on the right leg. Um There's different ways to remember that the allergies ride your green bike. So I can remember the colors on the um And this is just a quick diagram to show the test on the test. Um So this is just a quick recap of the blood flow through the heart um which it all makes sense and then looking at the EKG. Um So it goes to the right atrium tricuspid valve into the right ventricle to the lungs, through the pulmonary valve, into the left atrium, after the lung, through the mitral valve into the left ventricle and through the aortic valve for the rest of the body. Um So the contraction of the cardiac muscle is systole and the relaxation is diastole. Obviously, the systole and diastole. I said a lot in cardiology, for example, with BP and you've got your diastolic and systolic test. And there's also two heart sounds. When you listen, the first heart sound is the start of systole. So that's the closure of the micro intest C valve. And the second is the end of systole. So the closure of aortic and pulmonary valves, the electrical flow is obviously important for the ECG as that's what the ECG is measuring. So the electrical flow goes from the sinoatrial node which causes the contraction of the atria down to the ATRIO ventricular node. And here there's a little pause to allow the ventricle to fill up before then the contraction of the ventricles. The ventricle contraction happens from the electrical activity going down the bundle of his um through the ventricle myocardium. And then it also spreads through the pini fibers and this is just the diagon of the heart. So that was a really whistle stop. So, uh everything about the heart. Um So components of the ECG, this is obviously a little snapshot of an act. Um A diagram that's labeled quite clearly. Um The P wave to start with is the ACL depolarization. That's the electrical activity figured by the S or A no, the pr interval comes next and that's from the start of the P wave to the start of the P wave. So the PR S complex and um that's, there's a delay obviously from the P wave to the Q wave caused by the ABM and the QR S is the depolarization of the ventricles. And then the T wave is the ventricle repolarization. And so the QT interval includes everything with the ventricles. So the PR S and the, and the um these are the leads. Um and how they're made up, obviously, we've told you where we put all of the ECG electrodes on the body. But on the ECG paper itself, you'll see, for example, lead one lead, two, lead three and ADR DF and ADL, the other one is obviously one. OK. So we've got that Einhaus triangle on the left of the screen which showed lead 12 and three. So from the leads on the limbs and lead, one is between right arm and left arm. And there's a way to remember which leads made and which ones by counting the numbers of L. So right arm to left arm has 1 L in the left. So it lead one left, right arm to left leg has two LS from left and legs. Ok? And then left arm, the left leg has three LS. So, um, more complicated, but halfway talk about how you can see. Um So A is made by um the right arm and left side which is the R in. Um And then it's from the right arm to halfway between the left arm and left leg. So halfway through um these ADL is the same but using the left arm, but then halfway between the right arm and right and left leg and the D is from the foot electrode, the left leg to halfway between right arm and left arm. You'll notice, obviously, there's only one on the leg. So the foot electrode and that's because the right leg has a black electrode which is, is basically to minimize the noise from the ECG, it gets like a background focus. Um So this is just a bit about the size and timings. Um So the size conventionally of an E CG is one millivolt is 10 m millimeters of reflection. So one big square is not 0.5 millivolts, the size of the deflexion is equivalent to the muscle mass. And so that's relevant when you're thinking about like hypertrophy of the heart. Um And therefore the reflexions would be better. Um The timing and the patient is, is usually 25 naet a second. So one small square is 40 milliseconds or naught point naught four seconds. And I think we here because people, some people say milliseconds, people say in seconds, just choose one and stick with it. So you don't get confused. Um If you arrest certain amount of time, it takes the depolarization of the ventricles. And I've just put a little example there, for example, if the left bundle is locked, so it's not working properly, then it has to, the left side of the heart has to work, wait for the right bundle to activate it. And that will make mean a longer time and therefore wider to other. So the P wave that comes first um is normally positive in all of the um leads of that for AD R sometimes it's biphasic let a bunch of detail. Um As long as it's more positive than negative and all et behavior um duration, it's usually smaller than three small squares. So less than 100 and 20 milliseconds, uh height is usually less than naught 0.2000 mits with 2.5 mo um just problems with the P wave. Um We also have more sessions on the problems but just to give a little bit of a picture in this one. They're a bit complicated with P waves, but usually it's atrial fibrillation or sinus. So, atrial fibrillation is when you don't see a few days. So the pr interval uh so it should be between 100 and 20 milliseconds and a few 100 milliseconds. So 3 to 5 small square yeah, interval changes could be from a prolonged delay between the nodes um and that's due to heart block. So there's obviously the different types of heart block. Again, we'll go in a different session. Um The short pr intervals may be due to plate citation syndrome such as Wolf Parkinson's white, which you never heard of before and they're often due to access pass away the TRS complex. Um So the first deflection is a key wave and that's when it goes, it's like downwards. So it's me before you get the higher. The always and this is not always obvious in an A CG and it can be quite small. And the problem of the flexor is the, the big up stroke, which is the R and the most negative straight after that is the total pr duration should be between 70 100 and 20 milliseconds. So about 2 to 3 small square um narrow complex, the QR S is quite um particular when you're looking for scient pathology. So if it's a bit a bit too wide or it's too narrow, so narrow complex could be in atrial flutter or fibrillation or sinus tachycardia. Um Broad complex can be in the bundle block hyperkalemia from the tachycardia or fibrillation or Wolf Parkinson's life. Again, we'll be one second in a second age is pretty um everywhere says a little bit different here. The D MD says anything over 2.5 millivolts is pretty big. So over five big square, but other places. So it's important to note that an increased voltage can be seen in very slim athletic people or elderly people. And it's just because the con um so it could look abnormal but it might be normal for the patient. The PT interval is the beginning of the key wave to the end of the two waves. This represents a, the reason of depolarization and repolarization of the ventricles. So it's a little bit different between women and men. For women, it's less than 460 milliseconds and for men, it is less than 440 milliseconds. And again, different places say about different things here. This is talking to the American Heart Association. Um and there's also different formulas um to calculate the three, but it's usually corrected for heart rate. The CC is corrected for heart rate as a faster heart rate is made. And that's why is it called the G PCA P. But the Q CC of more than 500 milliseconds is an increased risk of going into tachycardia, for example, tachycardia. And that can be the last that is a drug hyperkalemia, hypomagnesia, sorry, left slide, all of the numbers and stuff. And then I got um so two ways and this is upright in all like R and B1. The amplitude is less than five millimeters. So one square in the leg and less than 10 millimeters in the. So it is less than two square. Lots of key words and abnormalities is a general show in a different sessions, day point. Finally, it's not, I really not heard about it, but it's just where the end and the set up. So a normal day point is about the tic line is the line that running through really deep and you can come back to it. Um This can be elevated over the first group of normality injury. You can also have a gay w which probably reflect a day, have a family. But so these are example the day point and, and um by a this is a normal day point. So this would be a normal and suggest injury to the heart. OK? So when we're standing, I need to do a systematic approach. So component pr interval, pr interval and then a what? So we work out the heart rate by looking at the top corner of you because that will help the heart rate. So it prevent it from a but often in exam, they won't give you that and they want you to work it out yourself. And sometimes for example, in an irregular heart rate that might not be accurate. So there's three different methods. Um So not that, ii think most of me and my friends use is the bottom one. So it's count the number of power on the step and five because it's more, slightly less. Um So that's just count all the way across the bottom of the step of the, you count all the, the and then you can it. And one of the other methods is to count the number of Rs within three seconds. And that's 15 large squares and the time that number by 20. And then the third one is to count the number of small square between two adjacent hour, two hours next to each other and divide 15,000 by that number. However, if this is an irregular heart rate, you'll see just looking at one hour RR interval. So between two different heart rates and that's not going to be um so rhythm and there's lots of ways to check that and the ski. So that's the c a little at the bottom. It would usually be at the bottom of the paper and it's 32. This is a big one of basically the heartbeat and this is, this is what you use to check the rhythm. And so you can do multiple ways of this. The most common way if you use a piece of paper, mark a little dot Where you are it on a piece of paper and then move it up and down to see if the dots still matter. However, you can also count the RR interval um as you can count, the number are try, try a few different to make sure that it's not a regular. Um And then the conclusion, obviously it's just regular or irregular. Actually, there's lots and lots of complicated diagrams with degrees around the heart, et cetera. But the simplest techniques that I know and the, the most I've ever needed to know has been this one here. So you look at lead one and you look at lead and if both of them are positive and the PR s and then if both of them point more up than down, then they're both positive and we can do two comes up and that means it's normal. If these one is positive and these aVF is negative, then you've got one from up, one from down and they're leaving each other. So they're not pointing to each other and that would be less and lead, lead, one is negative and DF is positive, then it comes to point together. So they're reaching for each other. That would be right after. And if both are negative, that's two down and that's, and that's all I need to say. But I've also um the diagram as well. So it says we want an af like we're saying positive and negative. QR and there's that information about what that would mean and what degrees that would mean. And then there's obviously with what if you want to look at the degrees. So here's just an example of a normal axis. So you can try and work out they doing the phone technique. So leave one, the pr s is more positive and leave ad the PR s is more positive. A two comes up. Um And then there's also a less active example. So hopefully, you also agree with me that the Pr s in league one is, oh sorry, I think this is the wrong. How labeled that wrong? Because S is positive lead one is negative. So that would be right after reaching. So I live about one long. I um so sinus rhythm, it's good to know what you're looking for. So what how to say when an is normal, especially when you start work, we'll have to look at S and interpret them and a lot of the time are normal. And if you haven't found something wrong with it, it can be quite unnerving to find something with sinus rhythm. So you have to get comfortable with sinus rhythm. Um So this is when the heart rate is between 60 to 100 BPM. Some places, for example, the new score will say if it less than like 90 beats a minute, around 60 to 90 60 minutes um is the rhythm is regular. Um If each key wave is followed by a CRS. Um Obviously, if the P wave is present that we need um the P if the P wave is positive um and in lead to and negative in lead a but usually PWA will be positive all throughout the as and the PPR interval is consistent from one heartbeat to the next. And this is just an example of a sinus rhythm. So if you wanted to have a look at it, so our, our system was rate rhythm, active or all the components of P wave um P RSST P wave. Um And if you just wanted to kind apply what you just said, um It's important to just practice everything obviously on the slide. I know it's a bit of a got to um practice all of those points you talk about on the slide and practice looking at CT if the next few sessions will go through abnormalities and E CT. Um So it'd be really help to know what normal because that what's normal. I don't know if anyone's got any questions. II think I saw Lauren joined um as well as I don't know, been answering questions. Yeah. Um I don't think there are any questions at the moment. Um Mostly about whether uh the slides will be shared. Um And I mentioned we can share it once you fill out the feedback form um which we can, we can give you and all send out the, the slides. Absolutely. Yeah. OK. Um We'll put the feedback form and the link on. I'm not sure if you can see that, but I can do that. If not. Uh We'll do that. Yeah. So, so it was a bit quick and quick this time. Obviously, we're just looking at the basics of the EKG. So I see when we get the with that, then we'll get you a normal unless it makes happen. Hopefully we'll get able to see you guys there. Um Thank you, um Alex um Lauren, I see you sent in the feedback document and thank you also for joining us. Um Is that going to be um something else added or? Oh, no, sorry. That was, that was it for today. We were just going through like a normal act. Look if you have normal in the leg. Ok. That was great. Um Thank you guys so much for um being here and being able to come uh on here and like join us today and I apologize for the um network technical problems we had at the start and I hope you guys would be able to join us again on our next um series. So just keep out, keep watch for like the next poster and when we post something next and make sure to fill in the the form so that you can get your certificates in time. Thank you, Alex. Thank you. Oh, thank you. Bye. Ok. If anyone has questions Lauren um is still here. Um We can answer a few questions before we wrap it up and call it a night. Yes, hina. Um It would automatically be sent to you. Ok. Ok. I don't think anyone has any questions. So um I would like end the meeting here. Thank you again, loin for joining us. Um Thank you everyone for um making the time to be here until the next um series. Yes, the next session is on A CS. So, um I hope you see that and it will be more applicable. Amazing, amazing. We look forward to that, so I'll see you guys again next time. All right. So.