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No, a standard cardiology station would be like this. You know, somebody presents with chest pain. Figure his to an examination, and then you're asked to performance PCG on them and then interpret the CT. So that's kind of focus in the latter aspect of that today that's up. Was recording in the C. G. This is something that you're talking very early on, um, at school and is a basic skill and comes up all time and again in skis. So when you're performing any C g, when you're performing any skin off ski, really, what is the first that you have to do before you start the skill? Can someone tell me in the chat patient DC eyes, Anything before that that you might have to do? Why, Yeah, someone said it. Perfect. So when you first enter the station, the first thing you have to do is wash your hands. That's what I thought. But that's bone like introduce yourself. Hi, I'm so hard, Uh, a 30 medical student on day and then you want to take patient details, as always, comes in on the name date of birth and protected the first of the address on Ben the Ian White stands for explaining the procedure so you can say something along the lines off. I've been asked to take a niece do for me today that's basically involves meat, putting some stickers and wires on to your chest and then recording a reading with this machine and tell us idea of how your heart is doing on. That's an example of an instruction you could do to explain the procedure very briefly, Um, and you would have explained to them that this requires them to expose their chest and take the top off. And so, for this reason, for female patients, it's very important that you offer a shopper own in the room when you do the procedure. And then once you've done that, you could take that consent to do the procedure on after exposure their chest. Also make sure to expose that lower legs on their risks as well, because you have to place your leads there as well. Make sure to ask them to lie on the bed on Do adjust the bed to 45 degrees on before you start any skin. Any procedure, any patient. Always ask if there any pain it'll on that time. Then we want the leads. Once you finish the basics the introduction When you taking any CG, you have 10 leads, right? So you have six chest leads. The view want to be six ones, and you've got four on your limbs. It's very important to check and make it very explicit to the Examiner that you're checking the expiry date on the electrodes to make sure that in dates, um, Andi, when you stick the leads onto their skin, you want to make sure that they're flat on. Do you want to make sure that they have good skin contact? But I mean good skin contact? I don't mean like slipping off like partially being removed on ways to tackle. This would be to offer shaving body hair off the areas or giving area quick wipe. Um, so in an Oscar station, you probably won't have to include a problem with this, but you could always mention it if it comes up, Um, or if there's like, um ah, lot of how the patient often leads on sticking. In that particular scenario, you could always mention that you would shave or you would offer to clean. So when it gets to the actual leads themselves, this's thie. Um, can anyone tell me where you but your chest leads? Okay, so tell me where the V one chest lead would go. The fourth intercostal space. Paris sternly. Yeah. Perfect. Great. Yeah. Um and then, yeah. And then your V two would go again in the fourth intercostal space Paris totally on the left side. And then you kind of walk you weight down to then your V for your feet for chest lease would go between the on the fifth intercostal space in the middle of a killer line, and finally or sticks just lead would go in the military line at the same at the same level. And if I would go in between those and then be three between regionally for Yeah, someone said it. Perfect. That's great. Thanks, guys. Um, so those are why you keep your leads? Um, looks sorry. Give me a second. So, But, like I say, Okay, we're back. Great. Okay. So, um, so once all the electrodes have on the other letters you have to add are the limb bleeds. So the pneumonic we use and you might hurt office called Ride your green bike. So you want to praise you are on this kind of tells you which leads. Put where. So your, um lead one would go on the reds, the red thing on the on the right arm. You put on the ulnar styloid process on the right arm. He then have yellow. The yellow lead would go on the other side that process off the left arm and then have the green lead which goes on the lateral or the medial malleolus off the left leg. And you have the black lead, which is the earth lead, and that goes on the medial a lateral malleolus off your right leg. So what you can tell in common is that you put all of these leads on bony prominences to get best reading on your E c g and why your green by kind of tells you which way to go. So ride your green bike on. That kind of helps to remember it. It's a great like to record your EKG. You want to turn on the machine on and you want to check one that there's paper that's been loaded? Second double check all the electrodes on the patient are still sticking, and having peeled off on Ben is very important. You make it very expressive. You ask the patient to remain still while you're doing the recording, because any moving or twitches or muscle movements can really mess with the reading on the EKG and then press the button to record. And once you've finished, switch off the machine on then because the label the sticky, they can be painful when you remove them to be very gentle. When you remove the stickers off off the patient, thank them, explain to them the procedure is not done and then proceed to label the EKG with patient details if it hasn't already on there. So that's kind of how you do the EKG Noski Station. Um, it's very the main points. I'd say. We're just to make sure that you have good patient communication. You offer them a shot per own on, but you make sure your electrodes on the right places. But let's give you the most points. So moving on to the main bit of this presentation, which is kind of going through easy so you would get an Oscar. The way I'm going to break her down today is we're going to start with just looking at a normal trace, understanding what it looks like. Why? Looks like that And then kind of looking at normal variations off these trace of these regular traces. And then we can look at where things go wrong. And I'm going to spend some time. They get access deviation, cause I think that's that's something that people come comedy quite intimidated by. And I am I was so intimidated by it. But I think once you understand it, it just makes so much sense. I'm going to try my best to clarify that today Any questions at all? Please put them down on the chat for myself. Knish. Magal, Get them soon as we can. Great. So that's out of the basics. So here we have a regular easy GI trace. Okay. The main part of any trace, as you can imagine. Um, your P wave your P wave is the wave over here. It signifies depolarizations of atrial muscle. You don't have. You're curious complex. You have a little Q wave over here. You have your are ways. And then the s wave to cure is complex signifies ventricular depolarizations. He then have the T wave. The T wave comes straight after that, and you have that signifies the report or is Asian of ventricular muscle on the report, or is a shin of atrial muscle happened somewhere here? But it's hidden because the ventricles are way or muscular on Do have way more of an impact on the EKG in terms off the most important segments to know about in an EKG, Look at your PR interval. The parents will start at the beginning of a P wave on to the beginning off the Q wave. And this is, um, this signifies the time in which the conduction off the impulse happens from the ab node. I threw the AB note on the bundle of this. Also very important to note. Be cute. The ST segment. The ST segment is from the beginning of the S wave to the end of the T wave, and this is the interval between the when the ventricle, the depolarizing and Repola rising. So a normal EKG or in Sinus rhythm, which is a regular normal EKG, is always one P wave, followed by one Sure is complex, followed by one T wave. And that's a regular Sinus. Easy trace. So let's say you're on the osteo and you're giving that easy, GI. What is the first thing you look at before Before the P wave? Patient details? Exactly. So you want to read out loud in the top left corner, You're like, Okay, this is John Smith, the correct patient with the correct date of birth. Um, and I know that I have the correct easy, G, what's the next thing you look at? Calibration. Okay, when you say calibration, what do you mean, speeds? Yeah, exactly. So you're looking at paper speeds. Your paper speed needs to be 25 millimeters of seconds on the voltage of your Easter. Your machine, which is 10 millimeters per mil a belt, which is over that to make sure those are correct as well. Read them out on to show the Examiner that you've noticed it and then you've acknowledged it. Great. Perfect. So when it comes to, um interpreting an EDG you, it always helps to have a system. If you have a system in your head, then even if you blank out in the osteo you know, you have a way of doing things and therefore you can always go back to the endo Monica or something that will help you work your way down. Um, so this pneumonic are used kind of rhymes. It's RP wst. It burns a little bit So RP Wst stands for rate rhythm P wave with off the cures complex QT interval ST segment t wave. So if you've covered these, you can be confident that you've covered the main bits often easy that you've given that you've been given Onda. Um and it could be like at least you've even if you can't make out what the diagnosis is only 80 g. If you're least acknowledge and address these fat aspects of an issue that you've been given, it shows that you kind of may know what you're talking about. So, um, this is what I use feel free to use that other demonic, but it primes and it goes in order. So So keep this in mind for the rest of the stock because this is what I'm going to keep getting back to when I when I'm interpreting, uh, the easy G's. So when you look at the sheet of paper with the e z e g. How do you know? Um, in terms of timeframes, numbers of intervals, how long a trace is taking. So a small square, which is like these tiny little dots the's Tony squares over here. Each of them signify 40 milliseconds are 0.4 seconds. So you can imagine that if you have five off these small squares, that would be 0.4 seconds Time five, which is 0.2 seconds. So one big square is therefore 0.2 seconds. Um so this is really essentially the basics. The building blocks literally often E c. G. So a small square is 40 milliseconds and a big square is 200 milliseconds. And this is relevant when you're looking at whether there's a prolongation, any segments are intervals here. Okay, so how do you calculate? Great, Because that's the first thing you want to look at. Religion. The CT after patient details after calibration, like a day, right. So let's say we have a regular easy unnecessary with a regular rhythm. Well, you wanna look at is look at the curious complexes in the rhythm strip. Look at the rhythm strip, which is at the bottom of the easy. This is the rhythm Strip on. Do you want to look at a pair off your is complexes and count how many big boxes there are in between them. Okay, so if you look at this one, you have, um, half a big box. One big box, one big box, one box, another half of big box, and so curative. Lee, you have four big boxes. So you've established that you can use this formula 300 divided by the number of big boxes you counted. So in this case, it would be 300 divided by four big boxes, and that gives you 75 BPM in and ask e specifically. Always give your aunt's. You always give your rate as a multiple of four because they kind of expect you to use this method of counting rate. And so it's always a safe choice toe. Give your answer of what the rate is and as multiple of force. It just kind of memories. The stay, because you want to most commonly gets, um and then if you just can't have her boxes roughly that you could like really quickly be like, Okay, two boxes. That's $200. You that's 150 BPM. So, um, always give it a multiple, uh, as one of these multiples that make sense. So now what happens? Obviously, there's only works If your EKG has a regular rhythm, because if it's in a regular rhythm like there's gonna be a different number of boxes between each curious into yours complex on, then this doesn't really work. So if you have an irregular over them, when you can do is count the number off curx complexes and the rhythm strip, so it might be six. Let me seven, maybe 10, and then multiply that by 10. And that gives you a rough estimate off the the right, Often irregular. Um, E C. G. So I've been talking about rhythm, but how do you identify whether the rhythm is regular, regular regular? Very good. To do this again is to look at, too a pair of cure extremities there next to each other and then count how many square is there are, and then look at the next cracks complex and see with the same number of squares. So if it's four squares, four squares, four squares, four squads, you know it's regular, but it was like 4342. Then you know it's irregular. Um, therefore, that's an irregular rhythm. So what is some really common regular rhythm that you might see to get Sinus rhythm, which is, like we said, P wave curious, complex T wave. That's normal. That means your atrial metrical they're working normally on we call that Sinus rhythm, then a Sinus tachycardia where you have finally threw them, which means you most likely have a P wave. That's what about your S and a T wave. But it's just happening quite fast to this signifies that conduction is happening normally, it's just happening faster We call the Sinus tachycardia. If this same Sinus rhythm is happening slower than normal, call it. Side is bradycardia. Where the rate is could be easy known as s and 60 beats a minute. Onda, in a really rogue scenario, if conduction is impaired, you know longer have Sinus rhythm. Um, I mean, you may have Sinus rhythm. You may have peewee ways QRS complex or t wave, but, um, it might just not be coordinated and we'll talk. Talk about this in more detail in a bit, but this could be complete Heart block so still regular, you still have a P wave in a curiosity wave, but it just happened a synchronously and therefore is not not really normal. So in terms of irregular rhythms, um, you could have Sinus arrhythmia, which is where you have a regular pee way touristy wave. But it's happening at, you know, random intervals. And there's no regularity between how often their car you can have ectopic beats. So, like normal, normal, normal. And suddenly there's a random ventricular ectopic. Um, and this usually happens, Um, when the patient is a tachycardia and if you have palpitations, age of formulation. This is the most common, irregularly irregular rhythm where there's absolutely no pattern to it. Waves not visible heavily tachycardia on gets very random on drinking afibrillation, which is a life threatening tachycardia. Acutely, absolutely no, think really at all here you can't make out any complex is really, um Onda. Um it's also irregular rhythm, as you can tell. Yeah, so the P wave, like we discussed, looks a bit like this, eh? So this is You get this trace. This is the P wave in each of these, right? So what makes so what makes a normal peewee waves? So when you look at the EKG and you're looking at the P waves have identified rage, but I don't if I'd rhythm And now you're looking at the P wave, right? So the first thing you want to do is identify whether there are people Aves and you want to look with the waves and all the leads. Okay, Um, on D after this, you say Okay, if there are no p waves, then you make note of that. And if there are people ages, you want to see whether how many there are because in Sinus rhythm you have one p wave and one tourist complex. But sometimes in heart block, for example, you could have many peewee leaves toe one curious complex there, for that's no longer Sinus rhythm. And that's a big irregular, right? So identify that up even exists on identify. That is one p wave toe, one curious. And if it's not that, then they could make a note of it. So next thing you do is look at the morphology of the P wave is a broad is a weird the broad Is it weirdly tall? Um, and he's a relevant because in something in conditions like pulmonary hypertension are tricuspid stenosis. You can get right atrial hypertrophy on in these. If it's bad enough, it can show up with an E C G. What a dust your P wave is that it makes it weirdly long like it makes it told. We call these peaks P waves of you can look at this. See GI trace these things. Here are people waves and if you compare it to the normal trace above it, obviously it's a lot taller, and it's it just looks very different. Doesn't a listen. Speak on. This is called people Manali. Um and so with people that are low, you get peak to pee waves like pee pee pee. That's how I remember it. Um, and you get this, like I said, with a condition that can cause right atrial hypertrophy, the other one where appeal, it can be unusually broads. Um, it's called P my trolley and the's is when your left atrium is hypertrophied and this usually happens in conditions like marshal stenosis. So what can happen here is that your P wave gets weirdly broad and also gets like once it gets to humps, you look at the trace over here and compare it back to the one above. You can see these people. Waves are not only wider, but also have a back have a benefit appearance deficits like tulips. Two humps within one. Um, and this can happen with that atrial hypertrophy, and it's called P my trolley. So the way I remember which is, which is, um people Nolly peaked pee those all peace on that. I just remember the first one. And if you run the first when you confront people, I try. Really, I hope it makes sense. So this is essentially all you need to know about peewee Aves Onda common like variations of them in a way, it looks different. Couldn't move on to the cure is complex. This is a normal QRS complex. As you could tell. Usually about 120 milliseconds 120 minutes seconds. Can someone tell me how many small boxes that would be? Three small boxes. Exactly. So if the cure is complex, is you know longer or less than three small boxes that you know that you know, potentially abnormal. But usually it's about 220 milliseconds, about three or four boxes. So what do you look for in a normal course complex? So foreign is yeah, the with. So it's no longer than three boxes, right? So what happens if it's abnormal? E wide? So what happens if it's broad on Do? It takes more than three boxes. There are many potential explanations for this, um, so the most common ones that you would want to know about is but any kind of bundle branch law, any kind of bundle branch block can cause widened cures. Complexes will talk about this more detail. When I took my body box box, ventricular escape beats like ectopic beats a Zarrella's is tachycardia. All of these are common causes off broad your AST complexes. So in each of these cases, the increased with basically indicates that the depolarizations has spread through the ventricles abnormally and is therefore slower, that each of these problems you have like some kind of kind conduction problem. Um, it can also be wide in with Parkinson. White syndrome is well, I haven't really got here, but yeah, so this is what it looks like. You have bundle branch block. You can tell if you compare it back to the regular easy G. That's a lot broader. Andi. Um, it starts there and ends there. So that's like 1234. Just over four boxes, um, for small boxes, and here it stops. There it takes almost one full big box. That's that's almost 200 milliseconds. That's really long as that's That's abnormally brought. Yeah, and the other thing that signifies a normal, curious complex is the height of it. So the first one was a with of it. But then you also want to look at the height of the cure is complex. So if you look especially at the lateral, leads the vitamin B six the height off the R wave, which is like this, this main peak wave should be less than 25 millimeters. Um, that's the regular the regular length. If, for example, it's taller, any kind of abnormally told your ast complex kind of signifies an increase in muscle mass. Um, so this could be caused by a number of things, for example. So when I said increased muscle mass. I mean particular hypertrophy. So if you have right ventricular hypertrophy on the height of the cure is complex, The height of the R wave is going to be increased. And usually with my particular hypertrophy, you could also get abnormalities like, um, upright, curious and be one, um, as well as a deep s wave in V six. As you can see here, if you have a pulmonary embolism that's caused right ventricular hypertrophy, you can also get, um, the same the same kind of pattern. Um, we'll go to that more detail and left ventricular hypertrophy is well can cause the tall are waves in the only six as well as some other changes. Other leads that you can do it here in time. So this is an example is what only a typical eighties you with left ventricular hypertrophy would look like. As you can tell, um, the R waves in V five and B six especially are peaks on day definitely over 25 millimeters. And this isn't always signified. Everything left ventricular hypertrophy, but and it's always like a This definitely means that interview hypertrophy is there, but it's kind of something that would contribute to the diagnosis and obviously depends on the clinical. Been yet off the patient. You also get abnormal Q waves. So Q waves are a implicated in two things. Um, one in acute am I, which will look at later, but you get like you get a small, small Q wave. Where's if somebody's had an old myocardial infarction and they come in for an HCG? If it was bad enough, and if significant enough portion of the myocardium is infarcted, you might be able to see this as a very deep Q wave. So, actually, if you look at this CCG, this is the P wave. This is a cute waves, and that's the R Wave. And sometimes, actually, there are ways even hidden. Um, so it's It's really deep, and it's called a deep Q wave and is a sign of old myocardial infarction moving on to the ST segments. So that's a good like we discussed. Is the interval between the depolarizations on the report or is a shin off ventricles on? Normally, can someone tell me what the ST segment should look like? Eyes electric? Exactly. So normally in ST segment should be flat along with the EKG line on the on the sheet. They should be fat. That's called Eyes Electric. And therefore you can notice abnormality when an EKG of ST segment is either elevated or depressed because, normally going to be flat. But if it's abnormal, elevated or depressed could be a sign of a pathology. So if it's elevated, you've got a couple of differentials, okay, but before you you want to know whether it's elevated in just specifically, so it's a localized or whether it's happening all around the city. That means many of the leader all the leads are showing an elevated ST segment. If the ST elevation is localized, just some leads, usually the chest leaves. This could be a sign off a acute myocardial infarction where a specific area off off off the heart isn't. It has been infarcted on their shows up as a localized ST elevation. However, if the acid elevation is diffuse along, many of the leads on all of these in the city very commonly that skin present in acute pericarditis. Can someone tell me, um, the shape, um, the classic ST elevation shape? Procrit itis the word saddle shaped ST elevation. Yeah, exactly. So that's all of these exams. Perfect. Great. So you're ST Elevation. It can mean these things. What about ST Depression? So, um, so if USC depression again, you could have two possible morphology. Okay, So you can either have horizontal depression where it's that she just goes down and is like flat, then comes up again, and this usually is a sign of ischemia. So if you look at these, you trace over here, that's your P wave. That's you're curious complex. And that's your ST segment that uti with that your ST segment. Just go horizontal depression, cause there's just flat horizontally on this can be a sign of a skinny. Like I said, this could happen. And stemi non ST elevation myocardial infarctions. Um, if you put somebody or exercise stress test on a treadmill, you might find some tm ST depression. That as well the other kind of ST Depression morphology is if you have a downward slope IgG pattern on. This is when if you compare, you can see a difference is it kind of is a downward slope on. This is may be a sign of digoxin toxicity on the call. It's the reverse takes bigger than like a logo which goes like this. If you just laterally invite it as a reverse stick so that, along with some other issues, changes that imagine below 10 suggest digoxin toxicity. So these are the different variations. You can see your ST segment. So what? The T waves the T way you should know is normally inverted in two leads. It's normally upside down in a VR on your V one chest lead the case that's normal. But things that tell you that they may be obnoxiously inverted is if somebody has a mild cardio infarction. You can all often get to, um, inversion. So after my card in infection, the first abnormality seen is ST Elevation. But, um, subsequently you can get two waves in inverted is well, like you can see here. Um, so in this case, um, the T wave only becomes inverted 24 hours after the onset of chest pain. As you can see here, um, so it's not exactly an extremely acute indicator, but it can present. It can give you, like, give you an idea off the timeline off the acute event and to you inversion. Also apparently, like apparently, it's It remains quite permanented. Lots of patients who have em eyes that it just remains the EKG for ages after, Well, you can also get a normal TV inversion in ventricular hypertrophy on back, I said with digoxin toxicity like we saw earlier. Um, and there's just something you can memorize. AST went to look out for the signs. Great. So just another reminder off the system that we talked about that we're going to go through with the C GS. But I wanted to talk about, um, The regular range is for the intervals, so your PR interval should normally be between 120 on 200 milliseconds. Stats between three and five. Boxes of curious complex to be about 100 20 milliseconds, which is about three small boxes, and you're Q T Interval can be between 364 140 minutes seconds. The's the most important interval to know, and you should probably memorize these Rangers reference. So those of the basics off hCGs the very basics of the trace. Ah, sickest short break. Now, before we get into the Cardec access on do STD pathologies But if you have any questions about the basics of easies program in the chat a real time. Okay, so let's talk about the Cardec access in hysteric trees on kind of what the different leads are. Right. So we know you have chest lease your chest leads V one to V six. Sit across your chest wall. They saw the center and they work their way down naturally towards the left side. Right. So from the cardiac point of view B one and B to that's it. Very personally, they're looking up the septum off your heart. You then have the three. And before that, your main anteriorly tell you about the anterior activity off. You're on my card, Um, on D v 56 of the lateral leads to tell you about the lateral activity of the myocardium. Uh, this is important, because when I talk about access, you kind of think about where the leads are. So let's talk about access. So your you know that you have limited 12 and three, right? If you remember, lead one goes in the left arm to the right arm, and as you can see here it goes horizontally left arm, too. Right arm, um, and then lead to is the left leg to the right arm. So it goes that way. So left leg, too. Right arm. That's why it's like that. And then lead three is from the left leg to the left arm. So it kind of goes that way. The left leg, the left arm. It goes that way. That kind of tells you why the levels are oriented this way. Then you have a V e r a v e l l a v f that basically just back to the leads on. They are calibrated based on the orientation of all your other leads. And they give you some information on the cardiac access. And here's why. So in a normal, um, in a normal heart. Okay, you have the wave of depolarizations going through right atrium down. Right. So it starts over here, it works its way down, and it actually goes there, and it goes to 80 nodes, and that splits into the bottle of Hess and then go see, uh, ventricles. So you need to know that you just remember that it starts to the right. So that tells you that the cardiac access, which signifies the wave of depolarizations, is going this way. Normally, yeah, And then what happens? What are the leads look like in this case? So the way is his work is that if a wave electric impulse is going toward the lead is going to be positive. In this case, you have your electric impulse going to words lead to, and therefore you're gonna get a positive deflection in lead to and a negative deflection in a VR because the lead is moving away from it. But impulsively away from a VR and two words, too. And you get negative infection here on a post infection that what does that look like on the other limb bleeds. So in lead one which is a bit further to aside from lead to you still get a positive defection because the electric impulse is still roughly moving the same direction, but not directly towards it. And the same applies to lead three. A swell electric impulse is still moving in the direction downwards, not directly towards one and three. But you know, not away from them for them to be negative. So normally in a normal cardiac access, you'll see that leads 12 and three would all have positive deflections and upward curious complexes. So when does this change? If somebody has right ventricular hypertrophy, like in this case, you can see this junky right ventricle over here. What's gonna happen is that the right ventricle now has much more often effect on. The cure is complex in the left ventricle has right because normally see GI, the cure is complex. Is a product off the strength off the right magical plus the strength of the left ventricle. And as we know, left ventricle has more myocardium than the right ventricle and therefore usually has a greater effect of the cure is complex. However, uh, if you have right ventricle, right, ventricular hypertrophy. This now means you have more muscle in your right ventricle and therefore you're right. Logical is gonna have a greater effect on the cure is complex on your EKG. And now your access will then swing a bit to the right like that because the biological now has a bigger effect. So the deflection in lead three becomes a lot more positive, becomes a lot stronger, a lot more upright, global positive whereas the deflection and lead one actually becomes negative because now the electric impulse is moving towards early three but away from lead one. And therefore you get this. This change lead to however, will still remain mildly positive lead to like a bit of the middle man. And therefore, um, one and three. Usually. Sure, the most drastic difference is right axis deviation. Like I said, the impulses moving the other side this time term on deaf, you get a positive direction and three and a negative deflection in one. This is mostly associated with conditions. Are pulmonary conditions that put a strain on the heart on dc'ing genital heart disorders as well. So no, there's just some common cause is great. So what happens to the other side? So let's say you have left ventricular hypertrophy. And now the left ventricle over here has has grown and has long myocardium. Uh, this is this is actually what's gonna happen now is that it's this myocardium is again have a massive impact on a curious because it was quite significant to begin with the left ventricle left ventricle. But now that it's hypertrophy, it has has much more profound effect on your QRS complex. So what's gonna happen is that the access may swing father to the left and the cure is complex, becomes predominantly negative and lead three because now it's moving away from lead three and very quite positive in one. Um, so, actually, commonly in clinical practice, you don't regularly see left axis deviation, and people have left ventricular hypertrophy like unless it's really, really significant. Um, you most commonly see left axis deviation in people who have, like, left bundle branch blocks like conduction abnormalities. Um, and I'll explain that in a second. This is actually the a sense of how it works. So in summary, when you're looking at an EKG and you're trying to figure out the axis orientation Okay, um, it's very helpful to look at leads one and a V f. Okay, that your best indicators it's easy to just look at that. So this is a normal Kartik access when they're both gonna be upright, okay, because theoretically impulses moving neutrally towards both of them. If you have a right bundle branch block, right bundle. So I left bundle branch block, um, which is going to be a branch block here. Your lead one is going to be more upright. A V F is going to be downwards on but the other way around. Interactive black block. This is just something you can kind of learn for the sake of exams. So when you spot on easy G, you kind of can say that you think may suggest some extent off Codec axis deviation. You could go into more detail Carter access learning the angles and stuff. But that's really not a safe are skis on. But you just know how to identify that stuff. So that's what we want. And easy, G. Now it's your turn to do a bit of talking. So if somebody can tell me, um what? You can't just start by looking at, um, the rate Can someone tell me the rate on this Easy g? Okay. Yeah, exactly. So you can't the number off you can't The number of boxes between the grass complexes, what should be about five? Um, and you divide it from 300 you get about 60. Perfect. Well done. So that's like at the rhythm. What's the rhythm like regular for them? Okay. Yeah, on D. Can you guys see any P waves. You can't. You sure about that? Look at all the leads. Yeah. So this is an example off when you kind of have to look at all the leads determines you can actually small p waves here. The, um And they might be his indeed. A lot of condition they have. Um okay, that's really curious complexes. What do you guys think of the curious complexes wide? Yes, they're broads. Um, okay, um and can you notice any particular kind of? And can you look at the T waves involved in the waves? Okay, um, but that that Okay, fine on anybody. Have any idea what this lot of you've already said it? Any idea what the issue might show? Yeah, right. What about book? Yeah, it's perfect. So it's like, what? Why it is it is that so? White bundle branch block is when you're conducting fibers on the right side in the bottle of his. Have some reason been blocked on. Do that. Electrical impulses are not being conducted normally, and as a result, on the impulses coming from us, a note on no longer able to get your ventricles and you usually get bradycardia. So, like we said, he has a beat here off 60 BPM, which is on the slower side. So with bundle branch block, you usually get wide. QRs complex is so here, as you're correctly pointed out on, the current situation is longer than 120 milliseconds. Um, Andi, usually the biggest indicator is that interrupted a lot. Flock, you get a, um this r s are pattern in V one to V three rs are is when you get to our waves. Okay, on this is because there's a delay in which ventricles are depolarizing. This means that basically everything about right bundle branch block. What's happening is that it's taking longer for the excitation to reach the right ventricle, right? It's going normally left ventricle, but it's taking longer to get to the right ventricle and the right ventricle. Therefore, depolarizing is after the left. This causes a second R wave to the first R wave is off left ventricle. As you could see on the second R wave is right ventricle depolarizing. Uh, and therefore it's called the R s are pattern because you haven't are away for buying s way, followed by another R Wave. Uh, this usually happens in the one to V three. Um, and very commonly couldn't get a deep s wave in V one. Like as you can see here, um, this way down here is called S Wave and wide QRS complex is, like we said, a very textbook way of identifying right bundle branch blocks. But that apparently don't turn up very much of a good practice is if you look at a V one. It looks a bit like an M um, over here. And if you could be six, you might have a bit of a double u shape. So we call this marrow because em shaped and w shapes of the one resect So marrow, This is kind of what they say in textbooks. But I brought sure how often it turns up in actually easy. Geez, but the best The best bet looking for right bundle Branch Block is looking for. The rest are pattern. So for to r waves envy want to be three. Um, okay, so it causes about right branch block. So a thing that causes right ventricle hypertrophy or interferes with the right ventricle can cause rbb be so Copaxone, Ali. Our family embolisms a swell a Z, my colitis and cardiomyopathies. Okay, this one. Can someone tell me, um, this just kind of stock through this again? Um, can we see people? Aves? Yes, We can see people. Aves? Yes. Um okay. Can we see curious complexes? And what are they like? Someone said, Rate 75. Silence. Perfect. Should have asked that. Great great job. Thank you. Yes, Wide QRS complex is very good. Um, good brought. Okay. T waves the okay. Yeah, I do that to you as a fine too. Yes. Lots of you said it. This is a typical left bundle branch block East gi again. Just like previously. Um, you have brought your complex is over 120 milliseconds on this time. You get these really dominant s waves in the one and two b three. See what you get. Is these really deep waves over here? As you can see, um, the's cook off the over here. These are s waves. Um, Andi really dominant. Um, you can also gets really broad. Are waves in 1 80 l on V five mg six lateral leads, but this may or may not always be present. The textbook way off in izing This would be, um So you know how he said in left, right? Better rush brought it was marrow over here. You look for the William Pattern where it's w N V one. Because it's now shaping downwards. And you may get an M shaped thing in b six, which you have here. I'm not again. I'm not sure how common this is clinically, but it's what they did. You in textbooks. Someone said, Why is this a stemi? Well, um, I could see what you mean by that. Maybe ST Elevation. However, you have no clinical vignettes on their four was kind of you can't really say this is a myocardial infarction without further clinical knowledge, but, yeah, the's, um, common causes off left bundle branch blocks. Your success is being a big one. Um, as well as anterior myocardial infarctions can cause this will quite common. Okay, this one Have anyone have ago? It's this Sinus regular. Okay, so that's that. Start again with Can you? Can you see Peewee Aves? Yes. Okay. Yeah. Can you see Curious complexes And what they looked like? Okay. I wouldn't say the narrow. I actually, I actually say that on the broader sides. Yes. Um, on, um, what about the rest of the city? Can you notice anything else until, well, the T waves in the ST segment Someone lost people saying ST Elevation, where you see in the ST Elevation Do you want to be three? Yeah. Perfect. So this is what you'd call actually a pseudo right bundle branch block, Because you're not really getting all the signs. Not really getting, um, not really getting that. That, um extremely typical double notched RSR pattern looks a bit different and you get ST Elevation along with it. And this is the typical brood Gardasil. Drummies e g regard syndrome is basically like a autosomal dominant genetic condition that leads to the abnormal cardiac conduction because of a fold in sodium channels. Um, and it can present, like, bright little branch block, but it's not really a bad block on. Do you get SCL a vacation? Usually if you want to be three. Um, it can also present as like, I imagine here polymorphic went to your tachycardia of the F. But again, it depends on the vehicle picture. You need to know the clinical. Been yet to be able to see what exactly this was. It's kind of a mean I needed you to show you to be honest. Okay, so we've talked very briefly about we talked in some detail about the cardiac access and conduction, but it's actually been more complicated than that. So, um, so let's look at this diagram before it's not complicated. I was gonna break it down, and this kind of represents the transmission off impulses through bundles of hiss. Okay, Do you have a V notable here? This is the model of this and want to get a bottle of this. It's going to devise into further bundles. Doubles, pry, eat of the right ventricle or the left ventricle. Correct. So you have one right bundle branch, which is this on? Do you have one left bundle branch? It's important to note that the right bundle branch does not really branched into any other branches, whereas the left bundle branch further branches into the anterior fascicle and the posterior fascicle. So this is the anatomy off. The bundles are supplying, um, your my cardio. I wear the impulse travels. Why am I going over this. This becomes relevant when you're looking at access deviation as well as other kinds of bundle branch block. So let's talk about in a second. So whenever you're looking at any kind of conduction, abnormalities are through the IV node on through the bundle bundle bundle branch. Is it born to remember that the septum itself is polarized from left to right? The Depo's not writing this bit. Always you polarizes first and then this, but gets depolarizing. Okay. And again, remember that every time on impulse goes towards the lead, it has a positive deflection on the Cardec. Access depends on the average direction off depolarizations. So if, um, the average direction off the polarization is going towards a certain number of leads that will determine which leads are positive deflections and which negative, which therefore determines the cardiac access. So, in a regular heart like a mentioned before, your left ventricle to left side of the heart has more muscle, more myocardium and therefore has a greater effect on your cardiac access. The right side. So why am I spending time talking about this? I want a kind of go over what could happen. Um, statin, a regular cardiac access. I want to kind of go over what would happen if you blocked one of these groups. So if you blocked this route, for example, if it just stopped working, if there was a disease in the anti of anterior fascicle, um, what's gonna happen? So what? The answer already? What's gonna happen is that the electric impulse can no longer travel there. It can only go down here to the posterior fascicle or go up, go over here to the right bundle branch. So the net effect that you're going to get is actually left axis deviation, and it's going to follow this arrow. This happens because, like I said, the left ventricle has more myocardium. And even though the anterior fascicle has now, you know it's no longer conducting your prostate. Fascicle is going to have a good effect on the cure is complex. It is going to push the axis more to the left like this. So if you have a unique a unique particular block due to the anterior for stick your brunch being blocked, you get left axis deviation. This is like a differential of left axis deviation basically so easy. GI for that would kind of look like this. Okay, so if you look, if you have left Axis deviation, can someone tell me can point out futures easy, g of Why this much your left axis Deviation. Lead. One is most positive. Positive and negative. Yet which ones? So we said lead ones most positive downward. A V f Exactly. Yes, it just like a one in a V f. Or you could like a 12 and three because he won. And 80 after going in opposite directions. And therefore, this is, as we discussed earlier, potentially pointing towards left axis deviation. And this and this example could be due to an anterior fasciculus block, like in the side gram. Um, so this is his description of disease, E g. Okay, now, what would happen if I blocked out the pasta fascicle if I blocked the pasta fascicle? Uh, what's gonna happen is that the net effect is the cardiac access is going to deviate towards the right side. So it's gonna go this way. There was the right bundle branch that you get right axis deviation with the posterior of article block. And then what would happen if we blocked um, the right middle bunch. So if you block the right bottle blood, can someone tell me why you would get no axis deviation? Why would you not get any access? Deviation with right bundle, Branch block left compensation? Yeah, exactly. Yeah. So the impulses still traveling to the left side, which is normal. So normally, the impulse travels from there to there from the right atrium to the left ventricle. This way. So if you block out the right bundle branch, that's all really affecting the direction of travel off the letter impulse and therefore you still get a normal cardiac access. Were just traveling that way as you get no access. Deviation. Perfect. Good. Uh, and then what happens if we block out to bottle branches? If we broke out the right bundle branch on, we block the anterior fast ical. This is called a bi fasciculus block because you're blocking too fast. Icals. As a result, it's gonna have a more profound effect on the C G. So not only are you going to get left axis deviation like we saw earlier when you just the anterior fascicle was blocked. You're also gonna get right bundle branch block because your white but Raj is blocked. So what does that look like on an easy G? Can someone point out, um, left axis Deviation, Honesty CG. Why is it left Axis deviation? Yeah, it's hard to say was last time you got a positive. It's a positive infection in lead, one at a negative in a V F on the opposite. And that kind of points towards left axis deviation. Another clue again would be looking at leads to at three leads to add three of both negative. Which means that the impulse is definitely going towards lead one that away from two and three, which is also a sign of left axis deviation. And that will tell me why this might be also showing right bundle branch block. Oh, someone's pointed out tomorrow. Okay. Yeah, are sort of you on that. So I'm looking for perfect guys. So again, you can see to r waves in V one as you can see one for each ventricle. And if you really wanted, you could see I could double u shaped b six. But I don't think it's convincing enough to be a double you to be honest with you, I guess. Could cause Got a deep wave. Um, but yeah, it was good. This the marrow thing would also work for this easy, cheesy M and W. This is an example off a by fasciculus block where your anterior fascicle and you're right bundle are blocked and you get left axis deviation and are BBB. Great. So that's ah, bit of a world window off the Cardec access onda conduction abnormalities in the bundles. Um, let's quickly go over cardiac territories because it's really how yield is very important to know which artery supply, which readings of the heart and which areas on the EKG represent. This so leads one. A v E L V five and V six are lateral leads, leads to three, and a V F are in fairly to the inferior surface of the heart, leads V one and V to represent the septal part of the heart and breathe three and before the anterior surface of the heart in terms of the arteries that supply them. If you think about the lateral surface of the heart, which is the blue ones, lateral surface of the heart is supplied by the left circumplex artery and the diagonal branches off your lady left anterior. Descending your inferior aspect of your heart are surprised by the right coronary artery on also potentially your left circumflex your cept this your card except it is supplied by the left anterior descending on your anterior region is supplied by the left, and he said it was up. Which of the greed bits again, There's just something you have to learn. This is significant because if you identify a potential ST elevation myocardial infarction on HCG, you kind of want to be able to say which part of the heart has been. In fact, it's so if it's an anterior stemi, you might see our profile dust the elevation or leads be three and before because he's anteriorly, for example, So very flags. Easy G's. So, uh, generally, when you looking any see GI things, these are these are basically size. I can get you thinking about certain pathologies. Obviously, you have to use the signs in conduction in conjunction with your clinical vignettes off the patient. But they help to kind of pointing differential diagnosis that you're looking at that. So if somebody has somebody static arctic they could point at, um, if they're hypovolemia or something, if they have an infection, Um, if they have a formulation, this could be due to acute alcohol intake. For example, any kind of heart disease or recent surgery can cause complete heart block. If, like we discussed earlier, ST segment changes can be due to either escape me A. Or it can be due to digoxin, for example. Wide, curious complexes again can be caused by a number of things like bundle, branch block. And we talked about earlier, for example, um, and heart block. Um, and these kind of just kind of these decided you pick up on that, get you think it help you with the dye differential diagnosis. So at this point, I'm gonna suggest another shot. Breakthrough other two minutes. So we come back at 20 past eight. Um, yeah. So be kids. Um, So, uh, can you please repeat that? What would you like me to repeat? Yeah. Can you let the last images green, please? Yeah, sure. Why does bright bundle branch block not cause access deviation? Okay, that's because if you think of a normal heart, the normal cardiac access goes to your right atrium to left ventricle. Right. And that's your card. It access is normally moving that way. Um, so if you then block out your right bundle branch, which is over here, it's not gonna have an effect on the Cardec access because of anything. The impulses going to travel more towards the left side, which is normal. Um, and it's kind of the right side just getting Lord. Basically, the heart has to make an extra effort to supply, to give an impulse to the right side of the heart, and therefore the rest of the heart doesn't exist. That is actually easier on the access is I'm deviated. Have that make sense. So coming up next, we got some more pathologies. I'm gonna be going over heart block as well as, um, tachycardia. Does Aziz Well, as some ischemic andi ineffective as well as some electrolyte abnormalities. Um, that's what you want to look forward to. It's a mega. Second time. I just been messages. Not Megan. So much of the check is the chance. Been as so overwhelming. You guys, have you sent the home and there's two. There's two forms. There's a Google form. If It's an optional form. You don't have to fill it out if you don't want to, but it's all the questions. They're not required that we do appreciate. You can fill out some of the questions, but if you submit, that's you get the metal, the metal link. And if you fell of the metal link request catch up content. Um, you received the slides on the recording off the today's session? Yeah, uh, I was I make sure to take it picks or the live instrument give away in a couple of you might have joined in late. Remember, we have a life instagram giveaway that happens during these sessions. So take it takes years and it's still up stories and tag. The cost is the official page. You know, a couple of you already done it, so keep keep talking. Yes. Okay. I'm gonna continue. Great. I hope that was enough of a break. I know I'm like sitting in a lot into one session, but I hope it's useful. And again, you have any questions? I'm sure initial again and myself more than happy Jonathan in the chat. So if I see it a lot under it out loud. Okay, Great. Okay, so let's do an E c g. So I like you guys toe have like this. And first tell me, let's use our our our P w qsc name on it. Um, and that's all the great concern. One. Tell me what the rate is. 100 beats a minute. Perfect that we calculate that I'm gonna repeat one more time if you count the number off boxes between The cure is complex is the rhythm strip divide that by 300. In this case, we have approximately three boxes. So $300 by three is 100. And that was 100 beats a minute Approximately. Okay, What about the rhythm? What we think of the rhythm regular. Okay, signs for them. Perfect. Um, what about people Aves present? Okay, um what about, um, cures complexes? What we think about normal. Yeah, it was normal. The normal. I think about 33. Small box says I would say if you look okay. Onda, what about, um, the ST segment? Yeah, I could see above ST Elevation that Okay. All right, Onda, um, anything else? It'll guys that you like to come comment on someone says Lots of you've already said the diagnosis. I mean, the answer. The interpretation off CCG. Yes, that's first degree atrioventricular block. So the key to identify actually, first of the AB block is looking for a prolong PR interval. Lot of you have mentioned already edgy and say on purpose, but you want a look so normal, PR If your PR interval is more than 200 milliseconds, which is more than one big box, more than one big box, that's abnormally long. Um, on that could be a sign off the first degree A V block. So really, when you're 80 block is only first degree. You're not gonna see any problem with the QRS complex is or with irregularities are asynchrony between the P waves of curious complexes. Really, it's It's still early enough for the only abnormality to be, um, pr interval A port on PR interval. Um, a very important high yield cause or first degree heart block is hyper clean. Me A. She could look out for that. Um, that could be a potential explanation of why you're getting peaks. He waves here, But I'm not going to strike that from because I don't have a clinical picture of his patients. Easy. Gee, okay, Another one. Can someone tell me up or they think of this? E C. G again, The rate. What's the rate? 50. We think it's 50. Think again. It's very idea to give me multiples of like we talked about earlier, because that's kind of what you want to see your skate sound. I'd say the rhythm is could be potentially irregular here. There were lowered counter, a curious complexes multiplied by 10. Um, so it's about 75 BPM. What about the rhythm oil? Which showed the answer? Um, this is second degree A V block on diets, and it's type one can put the answer there already. Sorry, asthma. Ask you that. Basically, you can have two types off a second degree, every block type one and type two you type one is called Wanke back on. This is where you have progressive prolongation of your PR interval. It becomes progressively longer and longer until there's a non conducted people, which means you have a P wave and you have a cure. It's complex, right? Andi, your pee. The PR interval could get longer until there's no cure is complex that turns up off the P wave. So in this example, you could see that here. Okay, so let's look over here. You have a P wave in a curious, and then you can see that the PR interval is getting longer. And then finally, you have a P wave here, but there is no cure. It's complex after. So that's kind of typical off second degree every block type one. Um and can someone tell me what type two is? What is Type two Constant PR interval Perfect. But then, what do you look for in type two 82nd degree regular PR until a drop? Curious? Yes, exactly So. Whereas in a type one second degree really block in the one key back, you get progressive PR prolongation until a curious is dropped. And in moments, type two, you get the PR interval. That doesn't kind of get longer longer. It remains constant. However, you will see intermittently dropped curious complexes along the way. Mobitz Type two is particularly more acute, more dangerous on Beijing's kind of have to be admitted immediately, whereas people may be asymptomatic if they have type one second degree, every block. Okay, this one, um, again, let's start with our rate. So our our p w que ST So that's what about the rate. So, what is the rate on this? Easy, g. Sorry. If you guys really appreciate if you didn't annotate just because it kind of caused the screen ups of refrain from Anna. Dizzy, if you can. Thank you. Okay, 40 30 55. 30. Okay, As you can tell, this is probably an irregular rhythm. So what you're going to do is count the number of curious complexes you could see, so 1234. Uh, I'm not sure it can't. That is a curious. Um, so about 40 So 40 to 50 probably could guess somewhere there. Okay, so on the answer Could someone tell me why this might be civic complete heart block, given the easy. What would indicate in this? Easy G? What does a be dissociation mean? No relationship between pee waves and curious complexes? Yes. And this easy, for example, if you look, it's just completely random. So you got a P wave here, and then you got your eyes complex on D and they got a P wave and then a curious complex turns up a lot later like it doesn't come with the same time. The PR interval is just really random on. There's no pattern to it on gets longer, and sometimes there's no cure is complex at all after this P wave. So this called complete heart block, Um and this is most commonly duty and inferior my card in induction or following valve replacement surgery. Onda again. This is also very acute, and most patients require either temporary or permanent pacemaker is to be implanted after these complete high block is all to call for a degree. Heart block? Yes, Um, someone just asked someone just asked about If I get over them how to calculate? Great. Basically, when the rhythm is irregular on your rhythm strip count the number of curious complexes and just multiplied by 10 to get a rough estimate off the beat that works up, if that makes sense. So instead of into 10 all the time. Six. Sorry. This time six. My dad's is time six. Yes, it's time. Six. The long story time. Six. Um Okay. Tachyarrhythmia as so, um can someone have a look of this EKG on dtilles me about the weight, please. Yeah, 150. I would agree. Okay. Okay. Uh, what about the rhythm regular? Okay. Yeah, on. But what about Peewee Aves? Okay. Yeah. Okay. Uh, curious complexes. Yeah, I say that normal onda, um, anything to do with the ST segment or the, uh, t? Yeah. You guys will got it. It's sinusitis. Cardio. So basically, inside the psyche cardio. What's gonna happen? Essentially, there's no real abnormality. All that's there is all of your the morphology of all your waves Got a normal on what you're getting just increased heart rate. So sounds like a cardio is that is defined by a heart rate of more than 100 BPM at rest. This's what it looked like. And actually, in terms of peewee waves, I see the pew is actually hidden in a lot of places. It's hard to tell. Um, but, um, yeah. Out to the only abnormality is that it's it's It's faster, normal, good. And regular. Omega, um, rhythm. Lots of things can cause san stocky cardia of a rise of things. So it could either be due to a disease like hyperthyroidism are our primary embolism, which is quite common. Or it can even be due to just anxiety or infection. If somebody's bleeding out, they're losing blood. They're going to compensate by increasing heart for exercise. Tachycardia on also got a whole host of pharmacological causes. You could have, like, beat agonists like adrenaline or suboptimal sympathomimetic. So, like drugs like cocaine on better means they can cause tachycardia on day or so many drugs. I could go on and on, but there's the most important wants to know, I think. Okay, next one, um, right off the CCG. Yeah. You guys already had a game. Some of the sbt. This is SPT why is it s p t. Why is it supraventricular tachycardia? Why is it Cipro? Ventricular? What tells you short stack a cardio? I agree. The rate is very high. Claritin Plex. Exactly. So when you're looking at the, you know, get a curious complexes when you say SPT, If the curious complexes are less than three box take less than three small boxes that's classified as a narrow complex on before could usually signifies that the with me is coming from the above, above the ventricle to the Atria usually so can someone someone's of the answer atrial flutter wise in atrial flutter. Sure, we've got a high heart rate. That's fine. Yet oxycodone and the sort of appearance. Yes, if you look at the morphology off the cures complexes here, usually between the easy upside down, looks very much like a sore tooth. And that's atrial flutter. So with atrial flutter the most important, if you ever confused, like whether it's atrial flutter or potentially agent fibrilation, look at the heart rate because the heart rate usually doesn't go extremely high in front of it stays between 132 170. Where's in a fib? It usually goes around 200 or higher. Um, is what someone is what doctor once told me. So in this case we've identified it's narrow, complex tachycardia. You got a ventricular rate about 100 50 beats a minute, and you got the sore tooth P waves over here that are classic of atrial flutter. Okay, what about this one? Guys, let's talk about, um I'm gonna I'm just going to tell you this is talking Kartik 150 BPM. So how about 180 BPM? Um Onda. Can someone tell me what the rhythm was? The rhythm. It's irregular. Irregularly irregular. Yeah. So the most common cause, often irregularly irregular rhythm is aging population, and someone said it could identify this by the absent P waves. You're not able to really make company P waves in this rhythm. Uh, and there's no trend to the complex as you can. There's it's completely irregular. Um, so someone says, ovary boarding in chat. So with atrial flutter, the rhythm itself is irregular. However, it happened at regular intervals. You can predict when the next one is gonna be, whereas in atrial fibrilation is irregularly irregular. So that's a very important difference as well. Yeah. Um, great. So sorry. Also, ignore this pink box, the ST Thing that's from a previous lives. Ignore that. That's that's on one for a fib. Again. You have a whole host, of course, is the age of preparation that weren't going to now, but I would definitely look into them important. Once your skis, I'd say, would be keeping Kansi's hypokalemia hyper magazine year on diet oxyco sis, a swell acute alcohol intake. So this is a quick floor charts on how to identify what kind of varicose blacks tachycardia is. Um, so when you do get any C g and you've seen that, firstly, the rate of the EKG is above 100 BPM on. But you've identified that the with the cure is complex, is is quite narrow, so less than 120 milliseconds. That's meant to say milliseconds. Excuse me. He didn't want to know what kind of our complex tachycardia it is, right? The first thing you do is identify um, whether it's kind of whether it's a very distinct pattern. Eso of example. If if you know for a fact that you cause any peas or you know for a fact that you can see salt tooth at the sort of appearance, you can make a quick diagnosis of age, population or Asian flutter. Um, but if you call it and thought so obvious, then you kind of want to go into a more deep analysts. You can start by checking with the weights. That's always a very good indicator of rhythm and a very good place to stop. So stop drinking and peeing waste if you can see Peewee aves than continue on a look at the rate off the atrium in the ventricles. If you could imagine a second imagine in complete heart block, the atria and ventricles were completely separate, and they had The atrial rate was completely different than the ventricular, right, Um, and therefore, if this can also happen in some narrow, complex tachycardia does so if your atrial rate is higher than your ventricular it, then this could be just kind of signify something like a jockey. Cardio. It'll flutter. Whereas if it isn't if the ventricular rate is greater than the H one rate or the same, then you can go on to further analyze the R P. Interval to the R. P. Interval is the'tr time between three r wave off curious complex on the next P wave, Um, the next week, off the next off the next unit. So if the distance is shot, if the next two p wave appears in, um, very soon after the existing QRS complex that's called a short RP where is usually less than 70 milliseconds, this can signify something like a V nodal uh, 80 and artie on this one also not have any P waves as well. So if you look at a slow chart If somebody firstly has no p waves, if somebody has a short our pee out of the up of the arteries less than 70 milliseconds, this could signify a the NRT. Whereas somebody has a long RP, this could signify you. The A v e r t e o h a tachycardia is a very simple flow chart of a generic for a generalized way of kind of classifying in our complex tachycardia is, um on. But if you're looking at an EKG not really sure how to navigate it, this could help. So this is an example of one. So let's work through this one together. Um, So let's stop this. We established the fact that this is a narrow, complex tachycardia. Okay, Um, so can you guys see any distinctive pattern? It'll Do. You think this is a federal or atrial flutter? Neither. No, I agree. Okay. Can you see Peewee Aves? No. Great. Fair enough. Yeah. So that kind of already just takes you to a B and are see, um, so that's kind of an example of how you do use that. We could be for the sake of time. I didn't really the longer example. Something up. I'd have time to talk through. Feel free to go back and use the floor charts and cross check with the seizures you can find online and see if it works for you. Okay, um, this easy g is a bit of a different one. So let's start again with, um I'm going to tell you now, the the rate is about 110 BPM on this one on, but, um, would you just think of the rhythm blanket over them? Sinus rhythm? Yes. Okay. Yeah. What about people? Aves. Can you see them on? Do what do you think of that? Present A good morphology. Yeah, I agree. Okay. Um And what about curious complexes? What we think of them. Someone's mentioned it. Um, yes, that they're brittle. A broadside? I'd say. Firstly, that curious complexes on day, someone's mentioned the elephant in the room. We see this thing, we see the slurred upstroke over here with us complexes on. This is called a Delta wave. Um, and someone's mentioned again. This is typical in wolf, Parkinson White. Um, uh, kind of, uh, morphology where you get a shot to PR interval, which is over there you get an EKG Delta wave, which is the slurred upstroke, as you can see, um, and get a widened. Curious. So the cure is a bit on the broader side. Um, this is a new orthodromic wolf Parkinson white PCG. But you could also get an anti drug on. This is to do with the conduction pathways in the 80 nodes on the bundle of Kent on day, depending on which, depending on whether the impulses traveled through the bottle of Kent or through the IV nodes, this will cause orthodromic or a anti dropping batter. So this is the closer look at the, um a slowed up stroke, the delta wave in the WPW pattern. Um, I've taken this from one of viciously ides from when he did the cardiology station. Like about a month ago. And this kind of the acute management for a regular symptoms supraventricular tachycardia. You could read this back in your own time. I have to how to manage them. Great. Um, what we think of this easy, gi guys. Ventricular tachycardia. Why is it ventricular here? Wide complex, Exactly. Is looking for Broadcom Plex broad Q waves on D. Would you say it? Boys hear by the rhythm regular? Yeah, So someone earlier mentioned said ventricular fibrillation. I would disagree, because Reggie give a relation would be completely irregular on. As you can tell, this is a regular rhythm and therefore, um, it wouldn't be that. But also, can someone tell me a bit more about the cures the Crestor plexus here, which are the main, obviously the main site to see? How else could you classify them or talk about their morphology to their broad There? Monomorphic. Exactly. That's what I'm looking for so that this is in fact called a more normal thick ventricular tachycardia. So it's irregular, and it's brought complex tachycardia. You get uniform curious complexes within each leads. Okay, so every curious is most identical in each lead motor. More fit is when I eat curious complexes. Just just one hum. Polymorphic is when you didn't get like something that some some are thinner, some a wider. Some are more wonky. They just looked very different, all of them. But as you get older, this CTG, they all look the same. They all look identical to each other. That's called. It's called the Uniformity. So that's called Morning. Okay, so again, many causes for these. Um, but you could be here on time. What about this one? Guys, what am I seeing here? Let's start again. I'm gonna go ahead and say that the, um beats the right is about 90 to a minute. And this one? What you guys think off the what? You guys think of the rhythm? The rhythm? Yeah, the rhythm is regular yet, but it is regular. Yes. Okay. Yeah. Okay. Uh, everything, uh, the elephant in the room is the tourist side. That part the desired. The points to the because a TDP physical pronunciation Teepees are in fact, a polymorphic type of entry to tachycardia. So whilst earlier we saw a morning off it, magic tachycardia by all the conferences looked quite identical to each other. Here, you can see there's a great variation in what they look like. Clinical polymorphic medical doc, you cardia, and the main risk factor for development off your side. That part is a prolonged QT. So if you have a long UTI, this is, um, very, very high risk of developing into TDP, which is what This is so, um can someone tell me, uh, what's by the way? This is like the cute, emotive This is really bad. And this is something you kind of really? You have to be able to identify a doctor. It's really important. And someone tell me some common causes off. Um, long Q t that can cause macrolides. And it's like or six? Yep. Amiodarone. Yeah. Some of that hypocalcemia. Yeah. Perfect. Yeah. Perfect. You guys are on it. You know, it's great. So common. Common causes of a long to ti times a drug of macrolide medical Promide I understand cortic drugs on day lots of electrolyte abnormalities in cause it so hypokalemia of hyper mania. Hypocalcemia have a hyper buying the See me? Um, A Z well, as obstruction. Heart disease is well, but does the main ones you need to know. Great Onda. What does this show? Death? Spit house. Um ventricular flatter ventricular fibrillation. Yes. So this shows that your defibrillation get someone Tell me why Irregular? Exactly? Yes, Wides. Polymorphic. Exactly. It's irregular. It's polymorphic. It's just a bit chaotic. Every looks different there. No, identifiable like waves at all. On great can be extremely high up to 500 BPM. This is a life threatening emergency again on do you require need to be cardioverted as soon as possible. Um, again, this is a flow chart taking from one of mission slides from the cardiologist. A shin talking about the management off that in got said, uh, advanced life support for adults with the management off these rhythms. Medications like he called you great. Another shot break for another, I'd say, Um, two minutes to move back at 51 past. Put some stuff, Savannah. Oh, I don't, um some was asked the feedback for how many sliders lest Okay, almost done. Guys, After this, I'm gonna go ischemia us like different types of stem ease. Um, well, as, um, pericarditis on do electrolyte abnormalities, I'd say, um, so let's we want to ski me on inflammation. Um, great. So starting with this one, let's use our our P W Q S t pneumonic again. Can someone tell me the chart what the rate is? Please. I think it's quite difficult to tell because of the rhythm strip, to be fair. Um, but it's about 60 I tell you that are well done. It's about 60. Yes. Okay. What about the rhythm again? No rhythm strips are about that. Um, but I'd say it's about regular Cassie P waves. Curious, isn't he? Weighed? Yes. Okay. Um, what we think about the P waves Visible cure. Okay, what about cures complexes? Narrow present. Okay. On what about the the T waves and the ST segments of that T wave inversion? Yes, I would agree with that. Which leads? They invited? Yeah. Okay. And, um, what would that tell you about potentially the clinical picture off this person? T wave inversion worth of differentials he talked about earlier. Given the way to know is it's, um we got a syndrome. Yet you get too involved in that. We said, Well done. Um, what else can commonly cause TV version? Yeah, ski me a perfect. So was that by phasic View it p waves as well. Our T waves. Yeah, that's perfect. So basically, this is actually a non ST elevation myocardial infraction. Obviously, you could have known that because there was no clinical picture. But I will say that there were signs of ischemia because T waves can indicate ischemia, aunts and patients so in in this case because he envied three. And we for, um get TV of inversion Onda. Sometimes when you get tv, Evan, worsen do t wave inversion due to ski me Oh, you can also get these things called by phasic t waves in the five and least envy 25. Um, you get by phasic t waves in the in the leads adjacent to the T wave inversions. So because we have t wave inversion due to ski me A in V three and the four we've got by phasic t waves, which means that they have, like, it goes up and then it goes down, as you can see. So this whole thing is a T wave the bit that goes up on the bed that goes down, um, you get them in the adjacent leads on do this is a sign of ischemia. Um, yeah. Okay. Next one, um, I'm not gonna get to do a thing with, um on this again, because it's been difficult of the rhythm strip. But I'm going to tell, you know, this is 100 10 BPM approximately on gum leg. You're with them, but can someone point out any abnormalities in, um, the P waves or the cure is complexes. Anything ST Elevation in? Yeah. Okay. The one to be full. Right. Okay. Yeah, Someone's that anterior stemi. Okay, I'm telling you, there's more to this E c g that an anterior stemi. You know all of that. You know, all of that card. It acts of stuff we talked about. How about you have a look at that for a second, and then we know you think Yeah. Amazing guys. Exactly. So we could see if I have a left axis. Deviation. Here. You see an upright to your scalp, maximally one on kind of a negative. A very deep s wave. Mostly negative deflection in a V f as well as the through. Need to kind of suggesting six even amount of left axis deviation. And therefore, this person in conjunction went there. ST. Elevation in their chest leads basically has a anterior lateral myocardial infarction. Plus left anterior conduction block. So this could be LBBB. Plus, um, an anterior and lateral am I Could someone tell me why it until a lateral. How did you decide on the, um, location off the infection uh, seven in one area involved as well as we want to be for exactly. So one and a V e l electrolytes be 1234, anterior and septal leads. And therefore, you have an entire natural stemi. Perfect. With some left anterior hemiblock. Great. Okay. What about this one? Um, again, I'm going to tell you that all the rate is about 70 BPM. Um, their insides with them, but, um, something else going on here, it could be paced. See what you mean. That's not what's happening here. Um, can you see anything happening with SC depression? Uh, essentially. Okay, so this is actually really mean one. Um and actually, posterior, am I on do without little picture again, you would like There's no way. It's really, really difficult deidentify this basically what it is here. The main finding in this easy gene is the fact that the r waves in the one quite dominant, more dominant, unusual, um, and upright, for that matter on basically this happens usually in right ventricular hypertrophy, if you remember. And therefore, a lot of times, this EKG is just missed so somebody could have a poster. Am I but ago that just gets dismissed because they think that the double it always in the one I just ventricular hypertrophy when really, this could be a sign of a posterior. Am I? Um, so, again, this is this is not something. You get your ski because it's it's really hard to make a diagnosis with his EKG on. Do you need a very comprehensive medical picture? But that's that's what this shows. Okay, next one, Um, can someone tell me what they think of this one? Yeah, you guys got it. Perfect. If you can notice, you could see that the There's ST Elevation on. It's not just it's not localized. So we met. We talked about earlier. We talked about classifying ST Elevation, right? We said it could either be localized to some weeds, or it could be diffuse where it's happening throughout on many leads. So in this case, we can see ST Elevation A number of leads we see in V one c CBC lead one lead to, um, because he had been lead 38 e f um, we could see it in the chest. Leads V 23345 and six on Diffuse ST Elevation is a, um, saddle shaped. Um, this is a very classical sign off acute pericarditis, Which is what this shows. You also get reciprocal ST Depression on D. P s e depression and PR elevation over here, if you could see, um, those the classic findings. Acute peritonitis. So let's move on to the final bit to the stock, which is electrolyte abnormalities. This is arguably where you're most likely to get your skin exam. I think, um, can someone tell me Let's break this down. This is the last thing you're going through. This is that's your properly. Can someone tell me about the rate the rates? Oh, you guys are really on it. You said it, but I'm just gonna go through anyway. So the grapes, Yeah, 100 beats a minute. Perfect. Good. Rhythm. Regular. Okay. Yeah. Um, what about peel Aves? It's kind of hard to make out this one. What? To be there and what's not. Yeah, um, what about the, um, pr interval? These These actually be waves will tell you now these little bits problems? Yeah, you can kind of see that. It prolongs. Okay on, but, um, great on But what is it that makes you think this Hypokalemia Why is this You have so quick? Say what made you think told her dpt where it's exactly so hopefully me A The classical sign is peaks T waves To get the speaking of these T waves get prolonged pr. Um, Andi, um, you could see quite broad P waves usually sees the classic signs of hyperkalemic and something you should be able to pick up on quite soon. So how do you differentiate between Hypokalemia and Hyperkalemic? Can someone tell me what you had seen? Hypokalemia You waves flat and pee waves. Yeah. Okay. What else? So hypokalemia get? Yeah, In the hyperkalemic, you get peaks T waves in hypokalemia you get inverted t waves. So really, the the opposite. So there's this thing. I found our life in the fast lane, which is really useful. Remember it? They call it the pushing and pulling phenomenon. So in hypokalemia, you're kind of pushing down. And so you get T wave inversion and ST Depression on this. You weigh because you're pushing down. Where is it? Hyperkalemic a You get peaks. He waves where you get it. It's like it almost pulling up the T wave to get the 10 30 waves you get. Um, and that's the classic sign, basically. So these are kind of is comparing the two findings. Um, and that brings us to the end of this talk. Um, thank you. So it's sticking out, maybe two out.