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Hello. Um Hi guys. Welcome back to 101. We're gonna do ECG interpretation today and it's a very important topic is, um, either people get scared when you see an ECG or it will most likely come up. If not in your oy, it will definitely come in your life 100%. Um So, yeah, um I, so cat will be there to do the Q and A on the chart and I'll be there to teach you today. Um, just, just gonna see if I can share my screen. Yeah, like Rsma said, you will absolutely 1000% be interpreting ECG S and just while R is doing that. Um Sorry, I lose my voice a little bit. That's why I sound a bit like a, a husky man. Um But yeah, when in this setting they will, they'll give you ecgs that will be relatively, I don't wanna say straightforward, but they'll be kind of obvious there won't be like any ambiguity like, oh, is that af is that first? Uh it'll be quite obvious? So go with your, go with your gut as well. Um I'm looking at it in the clinical context to say if someone's come in, they've collapsed. Um And they give you an ECG you think? OK, what, what could cause a collapse came in there in heart block? Maybe they're having a very, very, very fast heart rate. So kind of just clock on to that uh the context. Um Can you, can you see my powerpoint slide? No, we can just see uh the metal uh screen, right? Oh And Roan's come along lovely. So you were sharing something Rsma but it wasn't the powerpoint. You were sharing the metal screen. So it's obviously working, which is good. It's just the wrong screen that we were seeing. Is it working now? Uh We can't see anything. All right. One sec sorry guys, we will get there if in the meantime, you have any questions, just pop them in the chat now. Um And while Risus sorting that out, I can try to have a crack at them. Yeah. ECG is saying that I am as a student, I just found, found so baffling. Um And to be honest to a degree you still still do. Um But the more you look at, I know it's, it's a bit of a cliche. The more you look at the easier it gets. It really is. No. Lacrima. Um No. Mm It was working earlier. We we could see your screen. I just think you must, you must have been sh showing the wrong tab. Really? Wait, I think I know why. In fact that sounds promising. Is it working now? Oh, sorry. No, no. Have you tried a different um platform like chrome or safari? Because that's what happened to me last time. Sorry guys. Um I promise you it will be worth it. Same thing happened to me on my teach underwear as well. Kind of gives a better time for people to come through anyway. So it's all good. OK, I'm gonna leave. I'll come back. Ok. Yeah, sorry about this guys. Um We'll just try and sort this out. What, what, what, what's the issue? Struggling to share a screen. So she's just what she said now is she just popped off and she had to come back in, I presume on a different platform. So rather than Chrome safari or vice versa. Um because that's what happened to me in my psychiatry teaching. And so I'm sure it will be, I'm sure it will work. We'll get there. Ok. That's fine. Yes, this will be recorded. Nicola. Yeah. If any questions please put in the chat and we can answer. It doesn't need to be about ecgs. It could be about anything for, for everyone who's been emailing about different slides going up. I'll, I'll make sure that all of the um teaching sessions that have already happened, all the um presentations and all the videos are uploaded. So all of it will be available, so it'll be up to date. Um There, there's been a couple of issues with uploading them sometimes. So I'll make sure that that's all up to date for you. Thank you. Has at least put it in the shared drive because I can technically share this. Uh She didn't mention that. Um So I'm not too sure is an answer. But last time when I presented the same thing happened, I wasn't able to share until I oh hang on. We've got some movement. Yeah. Um I had to leave and come back when I came back on different platform work. Hey, are you? OK. Hi. Um Is it working now? No, sorry. No, RMA Ro and ask if you put it on the, on the shared drive. Yeah, I can do it. Mhm Thank you for your patience guys. Like as we said, it'll be worth it. Good bye with us. If this comes up in the ski, you'll be glad you, you uh stay tuned in. Yes. Mhm Risa. What? Um internet O oa. So again, we can see your meal but we can't see your slides and now. Excellent. There you go. And now is it on presentation? Yes, excellent. We're good to go. Thank you for your patience. Everyone. We haven't lost anyone along the way. We've actually gained more people now. So that's awesome. So over to you, right? Um Catherine, I might have to ask you to read out the answers. Um Hopefully this would be an interactive session. Um But I am aware that we don't have much time to go over like E CG in full detail. Uh But there should be a comprehensive guide. Um I promise you you should be able to answer any, read any E CG to a certain degree if it comes up, even if you don't know what the diagnosis is. Um I am RSMA one of the F ones in A&E at the moment. So you do have the right person for the ECG S. Um Yeah, so any questions you can always um email us at the 101 email or I put my email as well at the end of at the on the last slide. Um Right. Um Yeah, I did write Wiggly Line and Scary Electrical Line. Yeah. Um and I'm aware of the orthopedics joke um about those random squiggly lines as ECG, but hopefully you'll be an expert by the end of the session. Um And yeah, we'll be covering through how to read ECG how to structure it and then how to clearly present it um in an A um and feel free to be as interactive as you can because um more we interact them more, you'll remember at the end of the session. Um So starting off um just quick basic overview um ECG or in the US, they say A EKG um literally all we're looking for is um the electrical conductivity of the heart and as you are, as you might be aware um back to preclinical years, um sa node down through the atria, down through the ventricles purkinje fibers down here. Um And that is technically what we're measuring and if there's anything wrong with structurally abnormal with the heart, then you would be able to detect it. Um And as you might be aware one sec, um I don't know if you can see my pen. Oh, can you give it a bit of a wiggle Arima? Oh Yeah, we can see it right. So, yeah, you have the P. QR S and T wave as the main basic concept, you'll know a lot more by the end, right? So starting starting off um one thing I didn't actually mention and it might be very useful is P wave, any P wave activity is actually associated with the atria the first bit and then QR S goes down to the ventricle. So if you have any problems with P wave, absent P wave, then you know that there is a problem with the Atria um such as absent P wave and atrial fibrillation. It makes sense because P waves link to atrial activity. Um Give me a second. Yeah. Uh And then QR S for ventricles and then TTV would be um literally resting of the heart. Um Yeah, just moving on. Um Let's have a quick start. So if you are shy enough, feel free to grab a piece of paper and write down anything you want but if not, um I would highly appreciate you message on the chat and rather than cat can reach out to me, but um any comments in on this ECG to start with or if anyone is brave enough, do you, does anyone wanna present it guys? This is an absolutely safe space to um to do it. So, no problem at all if you don't want to, that's absolutely fine. But it is a really, really, really good opportunity to practice, um, with us here helping you along the way because it could well be that you're asked to interpret G if you get it wrong, that is absolutely fine because that's what we're here for. Um, so if you don't want to, that's totally fine. But if you do, then we are more than happy to give you feedback and help you any responses. Cat afraid not. No, no one yet. Ok. That's fine. Um, ok, we'll come back to this ECG then. Um, but I do wonder if you've got a, we've got a response. Oh, hello. Got two responses actually. So we've got someone saying, is it normal and says, sorry, I'm not good at ECG S. Don't need to apologize. That is a very good, um, observation and someone else, but it's a 12 lead ECG to start. Excellent, good thing to say. It's 12 lead ECG. That's very good. It's not an X ray. Yeah. Well, no, actually, if you don't know anything in saying what you know, so you will actually believe it or not, you will get an appointment for and someone else here, we are all the answers coming through. Now, as someone's got check patient's name and details when it was taken and mention the voltage and speed. Excellent. That's exactly what to do. Ok. 25 for 10 for voltage. We've got brilliant good answers. Thank you everybody, right. I'm gonna ask you guys to take a picture of this slide. Um If, if, whilst we're going through the structure, I'm happy for you to look at this ECG and then see what you would say in an actual OSC. This is a normal ECG uh well done to the one who's abnormal. And yeah, there is more of a structuring. That's the main thing. So caging suicide. OK. Moving on, right? Basic structure to start. Um So start with introduction. Yeah, it's a 12 lead ECG check the patient name, date of birth, um ECG, date and time and calibration speech. Um One thing, number of people who actually fail an ki station because they don't do the introduction. But I'm emphasizing this so much with any ki station. You have anything you're interpreting, be it x-ray, be it ECG, be it a blood test, be it glucose measurement. Always check the patient name and date of birth. Um And when it's taken, right? Uh Bonus question, does anyone know know cheating? No looking at any ecgs does anyone know the calibration speed that's normal for an ECG. I think someone's beat you to it. Someone already answered said 25 for speed and 10 for voltage. Brilliant, brilliant uh thing I should. Yeah. Uh 25 millimeter per 2nd and 10 millimeter per volt milli voltage. So all done good. Um We've done the introduction. Next comes the rate. So what's the normal rate? Guys? Got 60 to 100. Yeah, well done. So 60 to 100. Anything more than 100 tachycardia, anything less than 60 bradycardia if you can in an ay try and use the jardin uh rather than saying high heart rate, just say tachycardia, I will give you a bit a bit of a boost only for data interpretation, not in front of patients. Um Right. And how would you calculate the rate? There are two ways? Firstly, I would I normally just scan the number of large squares and then do 300 divided by that. So in this example, you've got 1234, so 300 by four that would give you 75 if that makes sense. And I I'm taking copyright from Kiki Max um Method two, especially if it's irregular, you won't be able to do this because um sometimes you might have four square square, sometimes you might have three squares. So sometimes not really possible. If that's the case you need to do, you can do just count the number of complexes. So what I mean by that is QR S or PQ RSD, one complex um count how many there are in the lead strip and then a few times it by six, it should give you the average um pulse or heart rate, um then comes rhythm uh with rhythm. Very interestingly. Um confusing medical jardiance. Um You have 22 things that you can have regular or irregular and that is normally based in either the trend or the morphology. I'll explain that in a second. If it's regular rhythm, it's just regular. And then if it's irregular, you can have regularly irregular and then irregularly irregular. I know uh weird names but um I'll go through this. Um But let's give you a chance actually. Does anyone wanna describe the rhythm for me? So I don't want you to say what the diagnosis is. Just describe it. Anyone? We've got someone that says irregularly irregular. Oh, I think you were saying irregularly irregular. Yeah. So what I would, what I normally do is I look at the, so the trend. So that's where I would go is it count the number of boxes? If it's not the same, then you know, it's irregular at that point. See this one has three and then this one has five that's irregular. Um Now you need to figure out if it's regularly, regular, regularly, irregular, you just need to look for the normal PQ RS, the normal shape. Sorry, that's not the actual shape, but if you look, you don't really have P waves um properly and it's a bit, it doesn't really look like a normal P uh PQ RST complex. So I would then say it's irregularly irregular if that makes sense. Right. What's the diagnosis? Yeah. Yeah. Yeah. So that would be atrial fibrillation if you have absent P wave and irregularly irregular atrial fibrillation. Um Right. How about this? Someone to describe the rhythm and then bonus point for uh diagnosis. So we got someone saying regularly irregular. Mhm Then we got someone else saying irregularly regular and then we got someone saying atrial flutter. So what else saying regular flutter, atrial flutter? OK. Regularly, regular 3 to 1 atrial flutter. OK. Well, then, so you put the normal trend thing at the end. So yeah, wait, I'll explain it. So it's actually regular rhythm. So you can see how it's like the same number of boxes in between. So that's regular and then you just need to now figure out the morphology. So it's irregular, regularly irregular. Now, if that makes sense. Um Yeah. Um I have atrial flutter, well done and this um just for the sake of time um irregular agreed cause. Um No, sorry, not irregular. It's technically irregular in a way if you look. Yeah, 1234, five. OK. It's irregular, you've got four, you've got five. But the main issue here is that you only have like random bits where it's different. So there are three in here but everything else is normally like four or five kind of thing. And this back to a big beat. This is the other, other common pattern that comes up in an EK um where you have one beat that's off and then everything else is normal. Um Right. So we've done introduction rate rhythm. Next comes axis. So easy way to remember. Axis is just the way the heart kinda like orientates in a way. So you can go right or you can go. Oh, so you can go right. And if you think gravity, that's why I made the animation. If you think of of gravity, the reason why it could get pulled is possibly because you have a lot of OK, lost my pen, you have a lot of weight in here like so then it kind of gets pulled to the right if that makes sense, I mean left in those cases. So that what I'm trying to explain is the left, left ventricular hypertrophy where you have um a lot of muscle in the left ventricle which would then pull the heart to the left. So that's the reason for a left axis deviation. So something similar right axis deviation where the heart just pull to the right if that makes sense, right? ECG. Easy way to figure it out is if you look at the first two leads in an ECG, I'll show you I'll show you the full ECG or you guys all have a picture at the bit from the beginning slide, I'm assuming, um, the first lead and the second lead, um, all you have to do is just look at it. If it's both pointing up, that's normal. If they are, one is pointing up and one is pointing down, it's kind of like the arrows are leaving L for left axis deviation and then this is going reaching kind of way. So R for reaching returning R for right axis deviation, I hope that helps. Um What I wanna do is I'm sorry to cut in. There's a really good youtube video actually, which explains that I'm gonna find that and pop it in the chat. I think you explained it brilliantly but I just, this video um was a visual as well. So I'll just, I'll pop that in the chat now while you carry on. All right. Um Thanks K um Right. Moving on. Uh So this is what I mean, full ECG picture. So the first two leads, you can see how one is going up. One is going down anyone on the chart. What access deviation is it or is it normal anyone? Yeah, we've got people saying left. Yeah, good cause it's leaving. Well done. And then how about this? Hm. Tricky one. Uh We got a couple of people saying left and a couple of people saying right, one person saying normal, we got. Right. Right. Right. That's a good mix. Right? Looks like it's right. People are saying, right. OK. If you look at this, so we're very sure that this is done. Right. Let me know if there's any um, objection to this, that's definitely left. Uh That's definitely down. I'm assuming people are confused with this bit, whether it's pointing up or down. If you don't know, feel free to look at lead three as well, actually, and it's going up. So then it's right axis because it's reaching the other thing to remember, you can never have one lead one going down in any other way, cause normal would be up and left would be up as well. That's left. So if lead one points down, then most likely it's gonna be a right axis stimulation, right? And that's again. So we've now gone through rate, rhyth introduction, rate, rhythm and axis right now coming to the big chunk of ECG, all we need to do. Just simplifying this as much as possible. You just need to follow the pattern. Literally, you go through P, then you go through Q RST and then you, we'll talk about that. That's all, that's the easiest way. And if you can follow that, I think ECG should be fairly easy to present. Um So that's what you said. You start with peeing, right? What can go wrong with the S possibly just check if it's there or not, if it's not there we talked about it before atrial fibrillation. Possibly if it's, if it is there, if the P waves are pre present, um mm you could then have shape problems or morphology problems. So, so for example, I'm gonna throw you guys into the deep end, but can anyone find out what the issue is here? And I kind of give it a hint with red markings or do you think that's normal? We got a question which I don't know if you want to go back to it later. Um It's about the rate and the irregularly irregular. Uh Do you want to go back to that later or do you want to carry on with this question? We'll go through questions later on. OK. So people are saying big, sorry, big slash tall P waves. Mhm uh Yeah, yeah, good. So if you can see it's tall PVI and the way you actually differentiate it from being actually being a tall is um if it's more than 2.5 small square. So this is where the, yeah, 2.5. So that's tall. Um So well done. And does anyone know the fancy term for a tall P? OK, I'm just gonna say it. So uh yeah, we got someone saying Pulmonale, it's meant to be P Pulmonale. I don't know why that. Oh Yeah, P Pulmonale um height. Did you say s asking 2.52 0.5? Right? And the reason why you normally have that is because of right uh enlarged right atrium. So remember how I said the atrium problem would be PV. And if you have a big atrium, if you think about it, you have a big PVI as easy as that. Yeah. Um I am gonna let you guys think about the causes for why you have um enlarged right atrium. Um You can pop it on the chart and we can go through it at the end or if anyone's popping it on the chart, then I'm happy to go through it. Now, we'll go through that later on, right. Um I'm glad the answer is but um oh, I'm glad the answer. So this is caused by mitral stenosis actually, this be this B wave. Um And that's actually caused by left atrial enlargement. Does anyone know what the term is? Yeah. Pitra. Yeah. And that's actually why it's called vitral stenosis pi metra. There you go. So these are the two common uh morphology issues with P vs um or you can have E CG with no PV. So that's the three things to look out for in PV, in an AK. Um Next moving on pr interval. So I don't know if you saw that, but either way pr interval, um normal is 120 to 200 milliseconds. So that's roughly around 3 to 5 small square. Um If it's more than that, well, if it's less than that, um we don't really uh um it could be like structural or uh yeah, most people don't really have smaller pr interval. Um More concerning would be if you have a large prolonged pr interval because um if you think about it, remember what I said, the QR S complex is the ventricle area and p for the atrial area. If you have sa small pr interval, it just means they're kind of close together. I don't know, like smaller hard or the conduction system is a bit concise. That's not an issue. Problem is when it's further or yeah, or you have delayed pr interval. So yeah, if you have anything more than 200 millisecond or 0.2 seconds, then you have prolonged pr interval. Um I'm just gonna whiz through this um because of time. Um But yeah, if you look here now, so that's our normal sinus rhythm. So normal ecg that should be roughly 3 to 5. Yeah, three, it is three square. So 3 to 5 squares if you have prolonged pr interval. Uh and it's same throughout, then that tends to normally go for go under first degree heart block, which means that you have all PS called conducting. It just adds come along. No. Second degree heart block is the one where you have um increasing prolongation. So the first one might be fine and then it keeps getting longer and longer and longer until one of the beat would be dropped. Yeah. So look at that that's small, bit longer and long. And then you've got that drop, there's no QR there. So that's second degree or is also called L back, back uh heart block. Um second and then you can have a second degree type two where you have a constant pr uh pr interval. Um but that's to do with the QR S at the, at this point. So um it's more when you have P when you have a ratio between the, the P and the QR S and then, but it's not 1 to 1. So for example, you'll have one PV and then you, you'll have two P waves and then one QR S two P waves and then one QR s. So that's type two second degree heart block, but the pr interval should be OK with that. And then 3rd, 3rd degree heart block, we're now definitely not talking about pr intervals at all. It's just you have complete disruption of the conduction. So you have random QR s random T wave. Um Just I'll explain that. Um Sorry, I am whizzing through, I'll go through it clearly if you guys need at the end of the session. Um moving back to E CG and how to present. So we've talked about introduction rate R axis started off with the wave, then we talked about the PR interval and now we have not the QA but more QR S complex. So a couple of things, there is one you can look at the size of it so you can look, see if it's narrow or broad. And how I remember this easy way is n narrow if it's narrow, N for normal and then we broad bad. So it's worse if it's broad QR s and then narrow completely fine. Don't worry about it. Um So this used to confuse me. I'm really sorry to cut in riser narrow is normal. Like riser said, it's not that it's pathological. So it should be called, it should be called normal or broad, but they call it narrow complex, but that doesn't mean it's abnormally narrow. It just means it's normal. So as said, normal is narrow, narrow is normal. Sorry riser. Um And then you got, yeah, and then just the measurement cut off that you might wanna know is 0.12 seconds. So that's roughly around three small squares. So you should be having three, not more than three small squares in here, right? The next thing you can check is the morphology. So for example, um if you have we, if you specifically for V one and VV six, that's where you normally see it. Sometimes you can see the QR s that looks like that, it kinda looks like, well, where is the Q? Where is the R? What is the R? It looks weird. Um And yeah, the way to interpret that is if you see this m like looking structure in V six. And then possible. W like very good W in V one and then it, we use the AB acronym William. So W LM LL four left bundle branch block and then you can have it reversed where V one could have VW. There you go. And that. Oh no, we sorry. My bad V one can have M and then over here V six can have the W bit if you can see that. And that's marrow R. So in marrow, I don't know if that makes sense but whizzing through, I'll come back, right? Cause is for bundle bundle branch blocks. So if you just think about it, um something for you to remember basically, uh if you do wanna show off in an ey, um you can just be like, oh based on the history I've taken and based on the ecg this what I think, but if you don't know that's completely fine as well. Uh the right bundle branch block tends to be like pe or um ischemic disease or cardiomyopathy. All of those can cause right bundle branch block and left can be caused by um again, cardiomyopathy can cause both actually less can be caused by aortic stenosis or hypertension or high high potassium. Just things to remember um the slides will be uploaded so you can have a look at this again, right? What do you think about this so far? So far with everything you've learned? What do you think about this. How would you describe it? IEC uh oh yeah, we've just got someone saying irregularly irregular and then someone else says VF technically, it is irregularly irregular. But when we say irregularly irregular, we might as well be saying af and that doesn't particularly like a quick, quick point. We're, we're, we've just talked about um QR s. So why don't we start with QR S? What do you think about the QR S? So technically sorry, just to, but it again, so technically, you're not wrong when we say irregularly irregular because it is, but when you say regularly irregular people will just think you're saying af um and that doesn't look like af so, but it's a good point. Good point. So yeah, we've got broad complex tachy VF, regular broad complex tachy VF broad complex tachy. Yeah. Good. So just keep in mind what we, how we learn the words to use for describing. So the QR S in this, you would describe it as broad cause clearly if you look it's 1234, we said three small square, nothing more than that. So it is definitely broad and it's irregular. There are no pings and it's different shades is weird. Yeah, so this is uh regular broad QR S complex. Um Right. And remember how many say you is to do with ventricles. So, hence, this would actually be called ventricular and fibrillation. I remember it as like one of you said, how you said it's irregularly irregular, which technically is af I think of it as if it's ventricular problem which you know, it is cause QR S is broad. Remove the A and the AF and, but as we so ventricular fibrillation. Yeah, that's how I remember I making life easy. Um uh Yeah, well done moving on. Um So we will now talk about introduction rate, rhythm axis P waves, pr interval, QR QR S complex. Now, the second last thing, I guess the ST segment med school favorite um which would come to ST elevation or depression and you just need to make sure that yeah, ST elevation would be semi. So ST elevation uh myocardial infarction, just make sure in an OSC or a clinical setting, you also look, look at troponin levels. Um and depression would be when you have either, well, you have the T wave starting low or inverted or it goes down. So I think of it as this looks happy, well as the elevation, not really happy but up and then this is down to ST depression. Um just make sure um because a lot including me myself um back in the day, um I do know that people get confused if something starts like that, that will not be the elevation. You just need to make sure where this line starts and whether that matches with the baseline. I don't know if that makes sense. I'll show it to you in when we have a proper ECG. Um But you just, what I'm saying is you just need to make sure that this start of the ST segment is way about the pr um whatever uh pr interval, for example. Um And not just about how you take off of the ST segment. Um Right, the one other things, let's suppose you got the ST elevation figured out ST depression figured out. The next thing you do definitely need to say is where is it happening? And so there are two ways to remember this. You can either memorize it. So all of these lateral leads are for in uh sorry, all the lateral leads are for L AD No, no, sorry, not lad, sorry, left um circumflex artery and then this is the right circumflex artery and then this is the biggest one, lad. Um The other. Yeah, you just need to remember that actually, the way the other way I remember which leads are, which is um I saw this on a youtube video actually. Um I'll share it later but I normally just draw this looks like an L and then this is the septum. So that's the middle and then you've got a bit of uh A as when to come like that. Um And then the one here would be inferior um because it's on the bottom end of ACG uh trace and it's for the right circumflex because it's on the right side. And sorry, if I'm confused you. Is anyone confused? I think you're good, Roma. Ok. Just let me know if there are any questions and we can actually sit down and talk through it properly at the end as well. Right. Um, we're done with ST ST segment final bit. Uh, oh, before that, actually, what is this? Anyone has any idea what, what's going on now? It's very curve and it is a bonus question, by the way. So I'll be very impressed if you know it, not expecting you to know it anyone. Oh, we've got some very clever um reverse tick sign. Yeah, well done. So I realize I brought the answer on the slide as well actually. So reverse takes, reverse take sign um is actually an indication of uh digox digoxin toxicity possibly. Um But they'll definitely be on digoxin if you see that sign. Um And it's called the digitalis effect actually. Um So just look out for this, right? Moving on final bit T waves. Um Oh Yep, yep, final bit T waves. Um I have gotten my animations wrong but let's start with inverted T waves. So yeah, you can have emergen T weeks and possible reasons for that could be anything pretty much like pe M I digoxin can also cause uh inverted TV. It just means you will need to actually investigate further. Um But this is not a normal presentation, it is normal in three leads. However, anyone wanted anyone know what what lead has normal, um, TB in version. If you don't know, I'll uh yeah, I'm, I won't be offended if you want to look at the initial slide we had, we've got someone said AVR V one. So we've got two so far. AVR and V one. Yeah, there is one more. Yeah. A R and V one is the correct, um, most definite answer and sometimes you can also have it in lead three. So, yeah. Um if you see that, don't panic, if you see an emergency wave in any of these three, do not panic, it is normal. Um But if you forget it, you can tell the examiner that you see an inverted TV. Um As I said, it's, it's not about what, you know, it's about how you present. Um So don't worry if you don't know, just present structurally and confidently. Right. How about this? What is that anyone? We've got two tented T waves. Well done at all. Tented T wave. Exactly. And what does that suggest? And you need to know this someone else has written hyperkalemia? Yeah, well done. So T 10 T waves they come up if the patient is hyperkalemic, uh that's something you need to look out for cause um you know, it's uh emergency situation at that point. Um Yeah. Right. So, yeah, I just bought the slide again just to show you that. Um oh yeah, you can have inverted T wave on lead three R and we want, yeah, well, we, we want the whole thing is inverted. So that would technically be as be inverted. But yeah, I hope that makes sense. Moving on. Final bit, final, final bit QT interval. Um QT interval tends to be related to like uh cardiomyopathy possibly. Um But the main thing to look out for is um if the T wave is way off, like more than halfway between the uh two complexes like RR RR interval and anyone wanna guess what any of the causes are, right? All on. So, so the I've just listed these, the yeah, and the Psychotics amiodarone um uh T CS for like um for psychiatric conditions, macrotes, hyperkalemia, hyp magnesia, magnesemia, hypercalcemia. It can all cause QT enteral uh prolongation as well. So again, it means you need to think through what's going on and might need further blood test or medication review, moving on. Um Yeah, I guess we're done. But oh, what's this now? Um what's this? So you got PQ RST? That's an extra wave. So yeah, alphabet. Next one from T is U. So that is called AU wave. Does anyone know what that represents? You've got someone saying hypokalemia? Yeah, well done. So I think of it as tall, tended T waves as hyperkalemia and then if you have an extra wave at after that, it tends to be for hypokalemia. So low potassium. Um Yeah, that's something to look out for as well. And before I say we're done, what is this? Now? Can anyone find the abnormality? So we're just moving on to the interactive sec session section now? So anyone, it's a bit of a hard one. OK. Some of the basics. W what can you not see in this? We've got something flattened P wave and long QP. Yeah. Good. W right. That was a tricky one. Do you see this bit of bump here? So that is actually called AJ wave. Um And I promise you, this is the last one I'm not making uh letters up now. Um It's called AJ wave. Um It, it's actually the point between the QR S and the ST segment and you, if you, sometimes you can have AJ wave like actually comes up and that's actually also called Osborne Wave cause um it's a guy called Osborne who found out what the issue was. So, um Right. And this to save you time is very common in hypothermia. So the vision goes really cold. You might start seeing J wave. Very important uh um emergency situation at that point now. Um Yeah, so something to keep in mind and I think we're, yeah, so we're technically done now. So we've covered P QR s and yeah, do you see that be J point? So J and then TT we covered you. Does anyone have any questions so far? We have a couple of questions just to clarify. Really? So someone wrote earlier on, I think, II think hopefully I've clarified what, what the, what the issue was um said, sorry to go backwards in rate. Um isn't irregularly irregular to do with the rate being irregular and with no patterns to the irregularity and regularly irregular to do with it being irregular. But in a pattern, for example, five squares, four squares, three squares back to 543, et cetera rather than to do with the morphology of the QR S complex itself. Oh Yeah. Um So, so I think there was mention of it. Um So it was presented, it sounded like we should look at the morphology of the QR S complex to see if it is normal or not. So I think there's a little bit of misunderstanding there about what we, what we meant by that. OK. So all, I mean by morphology is um if it's so if it's sinus, you know, the sinus as in PQ RST, no issue, then you know that that is that bit is fine. So I'm all I'm saying is not really morphology. There are two things to look at. Basically one is, does the actual complex look weird or, and the second bit is the whole trend bit. So is it like, yeah, 54321 or something like that? So over here is this the reason why this is regularly irregular is because you've got regular as in it's 555 that's regular and the, the pattern or the shape or more f not more fogy per se but the actual complexes. Weird. Sorry, that's not, I know that's not the jargon to use. And I'm asking that is not the normal sinus rhythm. So, yeah, that what I would say, it's not sinus because you haven't got QR STP Q RST that's very regular and very kind of predictable. The, the way I describe it is it's irregular because um but you can kind of predict it. Um Yeah, Grace. So sorry, one of the students are saying, wouldn't this just be regular? Um Yeah, II think it's difficult to say if you, if you felt the pulse, it would, it would be relatively regular. So it would be regular pulse. But the in on an ECG it would be considered irregular, regularly, irregular um rhythm. So we're now talking ECG and pulse pulse would be regular because you're only looking, looking at that five per beat kind of thing, not five per beat, but 55555 kind of thing. Does that make sense? Um I was uh we're not done yet actually, sorry. Um I just wanted to say, oh yeah. Um Yeah, I just wanted to conclude basically that, yeah, you go through intra rhythm axis, you go through the PQ RSD, you and others um structure and then also at the end of the ECG interpretation, make sure you actually conclude it don't just, and then like, oh there's AU wave and then that's it just say in conclusion this ecg pre um suggest um hypothermia due to the J waves or um, something we bought. Yeah, just make sure you always conclude whatever you present in a nosy. Um And the final bit was I was actually gonna give a question so you guys can practice on. Um, but if, uh what time is it? Yeah, what we'll do is I'll uh one of us will put the feedback form on the um chat. If you guys wanna practice, stay back. If you wanna leave, you can do the feedback form and then leave. Um And if you have questions, I'll answer them now. But this is the question II think it might be worth doing a little bit of clarity about um eight. because I think uh I think you're right. I think it probably would be considered regular um because like you say the, the heart rate would be regular. Um It's, it's irregular in that it's not one P wave to one QR s, it's like three P waves to one QR s in that sense, it's not regular, 1 to 1. Um But it's regular in that it's, I can understand if that makes sense. Yeah. Yeah, I agree with K sorry for the confusion. So yeah, so basically it's gonna be regular with the whole uh morphology. You don't really have to say what it is. But if it's flutter, it's gonna be very obvious cause you have those fluttery patterns with AP wave. So you can just say if, if you, if you're sure you can just say atrial flutter. Um But yeah, I'm just saying the way to approach an EG would be just look at the um look at the, look at whether it's sinus or not and then look at whether um it follows a 555 pattern kind of thing. The other thing to be aware of with atrial is that it tends to be a set number. It tends to be 100 and 50 or 300. It, it's, or 75 it's, it's very um predictable and that the rate is usually those set numbers whereas AF can go up to like, I mean, it can go up to like 304 100 that, um I've never seen that. But, um, the other way of looking at it, to be honest is probably more um helpful is to see a flat if you see sort of pattern, sort of pattern makes you think atrial flutter. Yeah. Yeah. Sort of pattern of tooth pattern is, is synonymous with atrial flutter as irregularly irregular means af sort of pattern means a flutter. We've got another question here is, um, could you please go over the L SA shape you made on the main ECG? Sorry. Um Could you go go the L the S and the A? Oh, yeah. Yeah. I'll do that. Um, can, uh, have you brought the feedback for me? Uh, no, I haven't, I don't know how to in all. I just one second, I'll do that. How would you done it? I think it just today. Yeah, I think we just did it. Yeah. Yeah. Ok. Uh Right. Uh, ok. I hope I'm not co uh complicating this bit but it's just the way the youtube channel described it. I, that has stuck in my head quite a bit. So um let me see, you can still see my slides, right. Hello. Yeah. Yeah. So um you basically how they described it is you can, it's here here and here, which technically looks like an L an L for lateral lead and oh ignore, ignore this, but you don't normally have VV eight and V nine. Yeah, just this bit. So that's the L and over here. Uh Let me change colors. OK. So over here you've got, you can draw an S so that's covering these two. And that's the septum lead. So those leads um kinda target the septum of the heart. And over here you can draw one big a um Basically what I'm saying is um this bad, this bad, this bit and this bit technically would go under anterior A for anterior so sunlight. Um And yeah, the other bit, you can think this one you can think of the right um right side of the sheet or the inferior side. Um Or you can, I think they kinda drew a shoe like I in here. Um which kinda looks like eye for inferior. I don't know if that, that's complicated it. But if you remem this is how I remember cause I can draw an LA and then I and an s and it just means lateral lead, anterior septal lead and inferior lead. I don't know if that makes sense. Should I explain that properly? Oh, that's fine. M I can, I can send you the youtube link in a bit. Any other questions? G uh someone asked about the um P um male, how you describe the P wave? And II answered and said, I think bifid is the way I would describe it. And then I went um and I've shared the link to life on the fast lane which confirm what they call it bifid. So I was very pleased myself that I actually got it right. So, yeah, anything else? No, I think um that's fine. If anyone wants to have a practice, feel free to have a go at this. Um I've taken the ECG from life in the fast la fast line website and they've got plenty. So sorry as well. I'm gonna be just because people are put in, in the chat about um the clarification. Um So one student that I, sorry, I presume you're a student um as I said, very accurate. Uh F four doctor, sorry, Um Yeah, so I said to a student actually, this, this uh person's an F four doctor in cardiology. So um you should be teaching us some Grace. So, yeah, um Grace was saying that uh regular, irregular and irregularly irregular is all to do with rate and rhythm, not with the morphology. I think maybe when they use, when the, when the term morphology was used, um maybe it wasn't in the sense that we usually use it. It wasn't in the sense of what the QR S looks like. Um It was, it was like you say, it's exactly like you say, rate of rhythm. So um Yeah, thank you, Grace. Yeah. Thank you. Any other questions? Nope, no questions. All good. Um Anyone brave enough to come and uh actually describe it or into practice ECG and I'm happy to take you to the stage. Is that it? No, we, we've got, we've got someone um so weight 75 regular rhythm, normal access evidence of J wave um hyperthermia from being unconscious outside. Oh That's a very thorough one. Brilliant, brilliant. Well, then um yeah, so check the patient's name and date of birth and time the ECG was taken. That was the only thing you missed out. Um Yeah, and then rate good rhythm, regular and uh P wave present um narrow. Um That's fine J wave. I, if you haven't seen it, it's here there. Not good that but so James present um possibly because they were lying outside. Yeah. Um, yeah. Um. Right. And I think that's pretty much it. Thank you. And that's my emai email. If anyone wants to, um, ask me any questions, I hope that helped. And I haven't confused you guys much. We've got one more question. Um, number one, is that just poor conduction? Which one? I mean, Lim lead one. Yeah. Oh. yeah, I think it's probably. Yeah. Yeah. Yeah. Yeah. Where can we get the powerpoint? There's only one of things. Yeah, exactly. And so we will put the slides up on metal and then you'll have access to the powerpoint on the recording then and there is no silly questions. Please do apologize. Um All the questions have been brilliant and keep us learning. So thank you so much. Thanks for coming. Thank you guys. I've shared the email address as well um on the chart. So feel free to email us if you have any questions. Oh, Di di na and for an adult. Well, staff for you. Bye everyone. Thank you. Bye. Thank you. Uh welcome. Send any emails that you want to answer any questions.