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actually one. Yeah, it's a country. Yeah, okay, I'm just gonna follow on from columns shot there and on the defense. I'm gonna look, um, just at a couple of topics around the CDs in the day, um, apologize in advance if it's a little bit basic feet and get them usually of it. And so we're going to briefly around three funny CG physiology, Um, on cover a couple of topics which I think, um, always helped to get helpful to get a refresher on to a special we're gonna like, um, at the peak here as complex. So, um, understanding the facility, the C is helpful when we're seeing patients in the d e d. Because it helps really appreciate what you're looking at. What the pathophysiology is that still happening? So I am starting with your P wave complex. That's our representation of atrial depolarizations. So your impulse coming from the from the essay node? No. You get a brief eyes without tricks. Stage up between piano are whilst the impulses going through the IV note and then into your your s is representing intracuticular ization. And obviously that would be accepted. If it's a nation. Uh, branch blocks and hold on to that point on. Then your T wave is representative of your trigger repolorization. So, um, going to talk briefly about access on, give the basic any definition of access and what we can do for that? So access is it's what it says on the 10. So it's at the average direction of electrical activity was in the heart. So normal access is between maggot of 30 and 90 degrees, um, on down, and we're gonna touch a little bit on left on right access. I'm not really address extreme axis deviation too much because it's not something I know much about. Um, but, um, the basic guy to try and work out your access from your from your hcg Um, look at lead one on Look at lead, ABF, um and that will give you the answer most of the time. And so what you're looking is for your and your overall direction of of your complexes. So if later one I need a b f r both majority positive, then that's normal access. And if lead one is positive unleashed, a V F is negative. That's bizarre. Potential left axis deviation on deflated one is negative on bleed. ABF is positive amounts, right? Access. And just in terms of, um, elixir Ways toe make a little bit easier to remember that I generally go if if they're leaving each other, it's potentially left on if they're reaching toward each other. And it's right, um, And if both leader negative, please, you know, asked me what that is and okay, And so why do we care? Uh, literally, Um, where any d We're not cardiologists, but why is it potentially significant for us for cases in any and so right axis deviation? If your electrolyte event e is more toe the right, um, what reasons might cause that so and if you think of the idea of right ventricular hypertrophy, So if you have, um, increased growth of the muscle in the right side, your is gonna move towards this. So anything that causes right ventricular. But tree, which is usually coming from some chronic lung disease, is pulmonary hypertension or possible pee. Um, building to think about it is from a point of view of myocardial ischemia. So if you've had a lateral am I I either tissue has died on the lateral side of the heart. Your electrical activity is going to be away from the site of your infarction. Therefore, more towards the right. Obviously, the caveat with right access is that it can also just be a normal variant and young, slim adults or in Children. Um, looking at left access deviations. It was really the opposite. So anything that's gonna cause left ventricular hypertrophy your trip, the activity is gonna move closer towards the left side of the heart. Um, and similarly, with the idea of the inferior am I So if you're in fear of my from your right coronary artery has occurred and there's, um, tissue Unfortunate. The right side in your electrical activity is going to move to the left and also helps to remember that it can also be a mechanical, um, change causing a left axis deviation. So if you have any reason for, um, basically you die from moving up, it's gonna be potentially moving the heart to the left. So that gravity address, um, abdominal, It's ID's on. Also, sometimes just with the expiration. Um, so I'm gonna quickly move on to some e c g e s on. Have we got a little bit of of interaction. So first EKG, I just want to know if you can work right what we're looking at There's a few things in this easy, but, um, from the rules, do you think this is left right or normal access? Um, no, I can't actually see my eyes. Um, you might be chatting. I can't see. Um, Okay, So in the absence of my ability to use it Peter and see if anyone's chatting. Um What? We're looking out there so you can see lead one is negative and lead a V f is positive. So those are reaching toward each other, so that looks like a right axis deviation. We're gonna move on, Teo, another one here. So again, I don't know if there's anyone shopping, so yes, the lead one is, um probably positive. Care s on bleed ABF. It's negative. So they are leaving. They're going away from each other. That's a potential left axis deviation and gonna move on just quickly to cover a little bit on acute coronary syndrome. So obviously one of our, um, big topic. Same. So, um, acute corners in within the context of ACG. So Obviously, the big thing that we don't want to miss that we want to write for is ST Elevation and my eyes. Um, so some of the changes also that can come with it will also be pathological. Q. Wave formacion, although it's last times the wreck. And I will also talk a little bit about your non ST elevation and I changes the Westie depression and T wave inversion, and so specifically with within the context of, um, your ST elevation and my eyes just going to cover it up on the CT territories and what this means for an automated and again, why any D This is helpful for first, understand? So, um, your main constipation's of, um, I've fresh one would be your anterior or anterior septal ST elevation. So where you're classically going to see this is leads. Be one to be for work and on do in terms of your culprit best that's most commonly going to be your left until you're descending. Um, lateral um, and then your post your ears, our lead to three and a V F on. Most commonly, that's the right Kearney artery again. Why? It's important for us to work out What territory And what vessel, um, is affected is because some of these patients behave different. Different least something specifically inferior. Am I your right coronary arteries affected? Um, most commonly, your supplies, your ab. No, it actually comes to the right coronary artery. So up to 20% of the inferior, um, I can develop, um, complete heart block. I'm not something that we might be looking out for more protected. And that subgroup of patients. Um, the last one that we don't want to miss is the worst ear and my, um, and often it will come along with a lateral. Um, I'll just be an extension of it. But it it can happen in isolation and can be ms because you're not gonna get classical changes in the last you do your grocery, CJ and so classical presentation on, um, a c g for posterior am. I is ST depression in your being one and be three. And so for you to actually probably pick it up, you need to identify. This is a potential push here. Um, I asked for your posterior hcg to be done on. Then what you'll see is your ST elevation and leads be 79. And so we're gonna just do a quick look at me. See here. Um, now, how can I see if there's a chapter in the great? I just want to see if we can get a little bit of feedback as to what? What you think's going on in the CCG. Does anyone wanna Ah, probably message to say what? Just say what you can see. Johnny's not be able until someone put something in. If no one applies, I'm gonna have to rings are here. I'm making I describe it awfully slow. What? Typing. But they also lately my state. Oh, Okay. Here we go. Perfect. So, what we got? Yep. So it's a very strict up ST Depression envy one to be for it yet. Ah. Yep. So you can see that. Yeah. There's about a one or two meals of ST elevation in your needs to be three a VFC. That's your inferior leads. And you can probably pick up. There is about a million ST Elevation mi 56 a swell. Um, so in this case, obviously there is a bit of ST elevation in other regions, but we've asked for a procedure. Your E C t to be done on tape. Rest 02. Leads be 79. Actually, there was ST Elevation there as well. So So this is important to know. So these air really sort of multi territory. And FARC's, um, patients end up and severe patient that comes from this. So, um, as I said, often the posterior Seminis happen in conjunction with other charities, but can happen in isolation, and we and we don't want miss them. So, um, don't be scared. Ask your posterior refugees. I'm going to talk briefly. Just about the recess kind solutab he read me. The guidelines have recently changed. We're probably, well, hopefully vaguely familiar with this, um pathway, which is up in posters and recess. And this has been our attack age with me. A guideline porous, Long as I can remember, Um, response. You have recently released this shining new guideline. Mm, which is fairly similar in terms of its approach of tachyarrhythmia. This is just one or two, um, changes, which is just helpful to know. So, um, the main thing really is in relation. Teo Narrow, complex, regular tachyarrhythmia so classically your SPT and the dosings for data. Seems I changed. They've recommended where it used to be. 6, 12 and 12. It's not a 6 12 and 18 mg for your third dose of unsuccessful. Um, And they've also added in in just a few, um, extra sister line treatments to beta blocker verapamil. Although sometimes you have used these in a way and you're bradycardia um, God, that was actually haven't changed. Huge. They, um But they've just been to rebound too much. And is there any questions? Just avoid our muscle structure of access. Acute coronary change, uh, keep cardio syndrome or anything about those tachyarrhythmia, um, changes. If not, I'm gonna bore you by blood gases after it's, um yeah. Uh, okay. So we're gonna just Yeah, thanks for emotionally. That was gets That's a good run free of the cities. So you have all learned something there? Um, thankfully, about this for me to see if you have questions before you asked. Um