اصول EKG

سیستم هدایتی  SA node  Pacemaker  bpm  P waves up in I, II, aVF  Internodal Pathways  AVN; RA contraction  Interatrial Pathways  LA to depolarize

سیستم هدایتی  AV node  Delays impulse by.1s  PR segment  AV junction  AV node & His  bpm  Purkinje/bundles  Ventricular depol  bpm

سیستم هدایتی

 Repolarization  Direction is same as depolarization  Autonomic Nervous System (ANS)  Sympathetic Nervous System (SNS)  Parasympathetic Nervous System (PNS)

اصول EKG

اصول EKG: موج P  Normal  Width <.11 secs  Height.5 to 2.5 mm  Morphology  Flat  Biphasic  Absent

اصول EKG: موج P  Abnormal  Inversions  Amplitude  P-Pulmonale > 2.5 mm  Duration  P-Mitrale >.1 sec (or 2 ½ boxes)  Absence

اصول EKG: موج QRS  Impulse travels quicker down the left bundle branch (LBB) than the right bundle branch (RBB). Septum depolarizes L to R resulting in a downward deflection  Both ventricles are activated simultaneously. Since the RV is smaller, depolarizes quicker resulting in the downward deflection  LV depolarizes resulting in the R wave

اصول EKG: موج QRS

6 ویژگی موج QRS 1.Duration: Secs 2.Amplitude: > 5mm; < 20 mm in limb, < 25 in anterior leads 3.Presence of Q waves < 0.04 msec and < 2 mm normal in I, aVL, aVF, V5 4.Axis 5.Progression: Zone of transition V3-V4 6.Configuration

اصول EKG: موج T و U  T waves occur in  Same direction as QRS  Height: < 5 mm in limb leads, <10 mm in anterior leads  U waves  After T wave  Best seen in lead III  Hypothermia/hypokalemia

اصول EKG

لیدهای قفسه سینه

EKG استاندارد EKG استاندارد  12 leads and rhythm strip  Limb leads  I, II, III, aVR, aVL, aVF  Anterior leads  V1-V6  Speed = 25 mm/sec  Height = 10 mm

متغیرهای نوار قلب  Source  Age, Sex  Body weight  Chest configuration  Heart position  Food intake  Temperature, Exercise  Smoking, Hyperventilation  Position of precordial leads

متغیرهای نوار قلب  Ideal time for EKG  Bayes’ Theorem  Normal hearts have abnl EKGs  Normal EKG does not r/o heart disease

رویکرد منظم  Rate  Rhythm  Axis  Wave Morphology  P, T, and U waves and QRS complex  Intervals  PR, QRS, QT  ST Segment

تعیین ریت قلب On 6 sec strip, count QRS complexes, X 10 QRS on dark line of tracing, count large boxes, ÷ into 300

تعیین ریت قلب

دپلاریزاسیون

دپلاریزاسیون

اصول EKG

موج P در لید II

دپلاریزاسیون بطن ها در لید قفسه سینه

محور قلب  Find the quadrant  Isolate the isoelectric lead  Smallest QRS voltage  Isolate the perpendicular lead  Isolate the vector  Double check your findings

پیدا کردن ربع

پیدا کردن لید ایزوالکتریک

پیدا کردن محور

ریتم / آریتمی  Sinus  Atrial  Junctional  Ventricular

آریتمی سینوسی : معیار و انواع  P waves upright in I, II, aVF  Constant P-P/R-R interval  Rate  Narrow QRS complex  P:QRS ratio 1:1  P-R interval is normal and constant

آریتمی سینوسی : معیار و انواع  Normal Sinus Rhythm  Sinus Bradycardia  Sinus Tachycardia  Sinus Arrhythmia

Normal Sinus Rhythm Rate is 60 to 100

Sinus Bradycardia Can be normal variant Can result from medication Look for underlying cause

Sinus Tachycardia May be caused by exercise, fever, hyperthyroidism Look for underlying cause, slow the rate

Sinus Arrhythmia Seen in young patients Secondary to breathing Heart beats faster

آریتمی دهلیزی : معیار و انواع  P waves inverted in I, II and aVF  Abnormal shape  Notched  Flattened  Biphasic  Narrow QRS complex

آریتمی دهلیزی : معیار و انواع  Premature Atrial Contractions  Ectopic Atrial Rhythm  Wandering Atrial Pacemaker  Multifocal Atrial Tachycardia  Atrial Flutter  Atrial Fibrillation

Premature Atrial Contraction QRS complex narrow RR interval shorter than sinus QRS complexes P wave shows different morphology than sinus P wave

Ectopic Atrial Rhythm Narrow QRS complex P wave inverted

Wandering Atrial Pacemaker 3 different P wave morphologies possible with ventricular rate < 100 bpm

Multifocal Atrial Tachycardia 3 different P wave morphologies with ventricular rate> 100 bpm

Atrial Flutter Regular ventricular rate 150 bpm Varying ratios of F waves to QRS complexes, most common is 4:1 Tracing shows 2:1 conduction

Atrial Flutter Tracing shows 6:1 conduction

Atrial Fibrillation Tracing shows irregularly irregular rhythm with no P waves Ventricular rate usually > 100 bpm

Atrial Fibrillation Tracing shows irregularly irregular rhythm with no P waves Ventricular rate is 40

Atrial Tachycardia Tracing shows regular ventricular rate with P waves that are different from sinus P waves Ventricular rate is usually 150 to 250 bpm

 P wave  May be absent  Buried in QRS  If present  inverted in leads I, II, and aVF  Inverted after QRS آریتمی جانکشنال : معیار

 PR interval < 0.12 Secs  Rate: Varies  Narrow QRS complex آریتمی جانکشنال : معیار و انواع

آریتمی جانکشنال : انواع  Premature Junctional Contractions  Junctional Escape Rhythm  Accelerated Junctional Tachycardia  Junctional Tachycardia  Reentrant Tachycardia  AVNRT

Premature Junctional Contractions R-R interval is shorter Beat is early, narrow QRS complex Inverted P wave P wave can be buried in QRS complex

Junctional Escape Rhythm Junctional origin Rate is 40 to 60

Accelerated Junctional Tachycardia Junctional origin Rate is 60 to 100

Junctional Tachycardia Junctional origin Rate is > 100

Secondary to bypass tract within AV node Premature Atrial Contraction (PAC) depolarizes AV Nodal Reentrant Tachycardia (AVNRT) AV Nodal Reentrant Tachycardia (AVNRT)

Rate Summary  Sinus Tachycardia BPM  Atrial Tachycardia BPM  Atrial Flutter BPM  Junctional Tachycardia BPM

بلوک های گره AV Delay conduction of impulses from sinus node If AV node does not let impulse through, no QRS complex is seen AV nodal block classes: 1 st, 2 nd, 3 rd degree

1 st Degree AV Block PR interval constant >.2 sec All impulses conducted

2 nd Degree AV Block Type 1 AV node conducted each impulse slower and finally no impulse is conducted Longer PR interval, finally no QRS complex

2 nd Degree AV Block Type 2 Constant PR interval AV node intermittently conducts no impulse

AV node conducts no impulse Atria and ventricles beat at intrinsic rate (80 and 40 respectively) No association between P waves and QRS complexes 3 rd Degree AV Block

Caused by bypass tract AV node is bypassed, delay EKG shows short PR interval <.11 sec Upsloping to QRS complex (delta wave) Wolfe-Parkinson-White (WPW)

Delta wave, short PR interval WPW

آریتمی های بطنی : معیار و انواع  Wide QRS complex  Rate : variable  No P waves  Premature Ventricular Contractions  Idioventricular Rhythm  Accelerated IVR  Ventricular Tachycardia  Ventricular Fibrillation

Occurs earlier than sinus beat Wide, no P wave Premature Ventricular Contraction

Escape rhythm Rate is 20 to 40 bpm Idioventricular Rhythm

Rate is 40 to 100 bpm Accelerated Idioventricular Rhythm

Rate is > than 100 bpm Ventricular Tachycardia

Torsades de Pointes Occurs secondary to prolonged QT interval

Unorganized activity of ventricle Ventricular Tachycardia/Fibrillation

Ventricular Fibrillation

هایپرتروفی بطن ها و دهلیزها

 Differential Diagnosis  Hypertension (HTN)  Aortic Stenosis (AS)  Aortic Insufficiency (AI)  Hypertrophic Cardiomyopathy (HCM)  Mitral Regurgitation (MR)  Coarctation of the Aorta (COA)  Physiologic Left Ventricular Hypertrophy (LVH)

 False positive  Thin chest wall  Status post mastectomy  Race, Sex, Age  Left Bundle Branch Block (LBBB)  Acute MI  Left Anterior Fascicular Block  Incorrect standardization Left Ventricular Hypertrophy (LVH)

Estes Criteria: Diagnosis of LVH

Right Ventricular Hypertrophy: Causes  Chronic Obstructive Pulmonary Disease  Pulmonary HTN  Primary  Pulmonary Embolus  Mitral Stenosis  Mitral Regurgitation  Chronic LV failure

Right Ventricular Hypertrophy: Causes  Tricuspid Regurgitation  Atrial Septal Defect  Pulmonary Stenosis  Tetralogy of Fallot  Ventricular Septal Defect

Right Ventricular Hypertrophy

 Reversal of precordial pattern  R waves prominent in V1 and V2  S waves smaller in V1 and V2  S waves become prominent in V5 and V6

Strain

 Mitral Stenosis  Mitral Regurgitation  Left ventricular hypertrophy  Hypertension  Aortic Stenosis  Aortic Insufficiency  Hypertrophic Cardiomyopathy بزرگی دهلیز چپ : علل

بزرگی دهلیز چپ : معیار  P wave  Notch in P wave  Any lead  Peaks > 0.04 secs  V1  Terminal portion of P wave > 1mm deep and > 0.04 sec wide

Lead II

موج P: بزرگی دهلیز چپ

بزرگی دهلیز چپ

 CHD  Tricuspid Stenosis  Pulmonary Stenosis  COPD  Pulmonary HTN  Pulmonary Embolus  Mitral Regurgitation  Mitral Stenosis بزرگی دهلیز راست : علل

 Tall, peaked P wave > 2.5 mm in any lead  Most prominent P waves in leads I, II and aVF بزرگی دهلیز چپ : معیار

بزرگی دهلیز راست

Bundle Branch Blocks بلوک شاخه ای دسته ای

 Normal variant  Idiopathic degeneration of the conduction system  Cardiomyopathy  Ischemic heart disease  Aortic Stenosis  Hyperkalemia  Left Ventricular Hypertrophy بلوک شاخه ای دسته ای چپ : علل

بلوک شاخه ای دسته ای چپ : معیار  Bizarre QRS Morphology  High voltage S wave in V1, V2 & V3  Tall R wave in leads I, aVL and V5-6  Often LAD  QRS Interval  ST depression in leads I, aVL, & V5-V6  T wave inversion in I, aVL, & V5-V6

Left Bundle Branch Block

بلوک شاخه ای دسته ای راست : علل  Idiopathic degeneration of the conduction system  Ischemic heart disease  Cardiomyopathy  Massive Pulmonary Embolus  Ventricular Hypertrophy  Normal Variant

بلوک شاخه ای دسته ای راست : معیار  QRS morphology  Wide S wave in leads I and V4-V6  RSR’ pattern in leads V1, V2 and V3  QRS duration  ST depression in leads V1 and V2  T wave inversion in leads V1 and V2

بلوک شاخه ای دسته ای راست

ایسکمی و انفارکتوس

Normal Complexes and Segments

J Point

اندازه گیری

ایسکمی T wave inversion, ST segment depression Acute injury: ST segment elevation Dead tissue: Q wave

EKG Changes: Ischemia → Acute Injury→ Infarction

لیدهای قفسه سینه

محل لیدهای قدامی  V1  Right 4 th ICS  V2  Left 4 th ICS  V3  Left Sternal border  Between V2 and V4  V4  Left MCL  5 th ICS  V5  Anterior axillary line  5 th ICS  V6  Mid axillary line  5 th ICS

خونرسانی به قلب  Left Anterior Descending (LAD) artery  Bulk of LV  Anterior wall  Apex  Part of lateral wall  Part of septum

خونرسانی به قلب  Right Coronary Artery (RCA)  Right Ventricle  Sinus Node 60% of the time  Right Atrium  Posterior Descending Artery (PAD) 90% of the time

خونرسانی به قلب  Left Circumflex (LCFLX) artery  Lateral Wall & Posterior Wall of LV & LA  SA node 40% of the time  PDA 10% of the time  Posterior Descending Artery (PAD)  Off RCA 90%/LCFLX 40%  AVN, prox BB, IW/PW, basal septum

View of the Leads  II, III, aVF  Inferior Wall//RV  RCA distribution  I, aVL  Lateral Wall  LCFLX/distal LAD distribution  aVR  R side of heart  V1 & V2  Intraventricular septum  Proximal LAD  V3 & V4  Anterior wall  Mid LAD  V5 & V6  Lateral wall  Distal LAD

Standard EKG

Anterior MI

Anterior-septal MI

Inferior AMI

Right Sided Leads

Right Ventricular AMI

Lateral MI

Posterior Leads

Posterior AMI

Inferior-RV-Posterior AMI

تغییرات موج ST-T

Strain in Hypertrophy

Strain in LVH

Strain in RVH

Strain vs. Infarction

پریکاردیت

تغییرات دیوگسین

موج T

خسته نباشید