Basic EKG 2

Dr. Wattana Wongtheptien M.D. Cardiologist Chiangrai Regional hospital

EKG 1
Basic Electrophysiology Basic heart anatomy and conduction system Normal EKG Systemic EKG interpretation

EKG 2
EKG in clinical application Cardiac chamber enlargement Myocardial ischemia Electrolyte imbalance Intraventricular conduction disturbance Miscellaneous Cardiac arrhythmia (in Arrhythmia lecture)

Conduction system
Sinoatrial node (SA ) Internodal pathway
Anterior internodal pathway Middle internodal pathway Posterior internodal pathway

AV node
Right bundle branch Left bundle branch
Anterior division Posterior division

Normal EKG
P
Amplitude < 2.5 mV Duration <3 mm P from SA node
Upright in II,III,aVF Inverted in aVR

PR interval
>0.2 sec First degree AV block

Normal EKG
QRS complex
Duration 0.06-0.10 sec

ST segment T wave

Cardiac chamber enlargement

Cardiac chamber enlargement

Atrium enlargement Rt atrium Lt atrium Ventricular enlargement Rt ventricle Lt ventricle

Atrial enlargement

Left Atrial Enlargement

Criteria
P wave duration in II 120ms (usually, but not necessarily notched) Or Negative component of biphasic P wave in V1 1 small box in area

Right Atrial Enlargement

Criteria
P wave height in II 2.5mm Or Positive component of biphasic P wave in V1 1 small box in area

 RA enlargement

LA enlargement

P > 2.5 mm

RVH
Right axis deviation R > S in V1 Deep S V5-6
Eg. Pulmonic stenosis Pulmonary hypertension

RVH

LVH
S in V1 + R in V 5 > 35 R in aVL > 11 Strain pattern in lateral leads Left axis deviation

LVH

 RVH

LVH

Intraventricular conduction disturbance

Left bundle branch block Right bundle branch block

LBBB
Criteria 1. QRS duration 120ms 2. Broad R wave in I and V6 3. Prominent QS wave in V1 4. Absence of q waves (including normal septal q waves) in I and V6

LBBB

LBBB

RBBB
Criteria 1. QRS duration 110ms 2. RSr pattern or notched R wave in V1 3. Wide S wave in I and V6

RBBB

RBBB

Myocardial ischemia and infarction

EKG Hyperacute T wave ST elevation ST depression T inversion Normal

Ischemic heart diseases

 EKG in IHD

Inferior
Anteroseptal Anterior

II, III, aVF

V1 to V3 V3 and V4

Anterolateral Posterior

V4 and V6, I, aVL V1 and V2

Arrangement of Leads on the EKG

Anatomic Groups
(Septum)

Anatomic Groups
(Anterior Wall)

Anatomic Groups
(Lateral Wall)

Anatomic Groups
(Inferior Wall)

Anatomic Groups
(Summary)

Hyperacute T in AMI

Anterior wall MI

Anteroseptal wall MI

Acute inferior wall MI

Inferior wall MI

acute infero-posterolateral AMI

Posterior wall MI

ST depression

T wave invertion

Pathologic Q wave

Electrolyte imbalance Hyperkalemia Hypokalemia Hypercalcemia Hypocalcemia

Hyperkalemia
A : normal B : peaking of the T wave ( K = 6-7 ) C :tall peaked,narrow base T wave (K =7-8 ) D :P wave amplitude decreases,the QRS widens (K+ >8 mEq/L). E : P waves disappear (sino- ventricular rhythm) and the QRS becomes sinusoid (K+ > 10 mEq/L)
V Fib usually follows

Hyperkalemia

Hyperkalemia

Hypokalemia
A : normal B : shows flattening of the T wave ( earliest change) C-D : "U wave" , ST-T wave flattening E-F :ST depression , U wave increases in amplitude

U wave
Normal Hypokalemia

Hypokalemia

Hypokalemia

Dyskalemia

Hypercalcemia

Miscellaneous
Pericarditis Pericardial effusion Digitalis effect Pulmonary embolism

Acute pericarditis
Diffuse ST segment elevation (concave) PR depression in all leads except I, aVR

Acute pericarditis

Diffuse ST segment elevation PR depression in all leads except I, avR

Pericarditis VS AMI

Pericardial effusion
Tachycardia Generalized low voltage Limbs leads < 5 mV Chectleads < 10 mV Electical alternans The QRS axis alternates between beats

Pericardial effusion

Digitalis
Digitalis effect
shortened QT interval characteristic down-sloping ST depression, reverse tick appearence

Digitalis intoxicity dysrhythmias

ventricular / atrial premature beats paroxysmal atrial tachycardia with variable AV block ventricular tachycardia and fibrillation many others

Digitalis effect

Digitalis effect

Digitalis Intoxication

Acute pulmonary embolus

S1Q3T3 pattern
a prominent S wave in lead I
a Q wave and inverted T wave in lead III

sinus tachycardia T wave inversion in leads V1 - V3 Right Bundle Branch Block low amplitude deflections

Acute pulmonary embolus

Pre-excitation syndrome
Wolff Parkinson white syndrome

Wolff-Parkinson-White syndrome

Wolff-Parkinson-White syndrome