ECG Flashcards
What can we find on the ECG?
- Waves -> załamki
1) P
2) Q
3) R
4) S
5) T
6) U - Points -> J
- Segments -> odcinki
- Intervals -> odstępy
U wave origins
- The exact source of the U wave remains unclear.
- The most common theories for the origin are:
1) Delayed repolarization of Purkinje fibers
2) Prolonged repolarisation of mid-myocardial M-cells
3) After-potentials resulting from mechanical forces in the ventricular wall
4) The repolarization of the papillary muscle
J point
- Junction of the QRS and ST segment
Segments in ECG
- PR
- ST
- TP
Intervals in ECG
- PR-> from the beginning of P to the beginning of QRS -> (po polsku odstęp PQ)
- QT -> from the beginning of QRS to the end of T
- QRS interval = QRS complex
Limb electrodes in ECG location
- Red -> right arm
- Yellow -> left arm
- Green -> left leg
- Black -> right leg
Precordial electrodes location
V1 -> fourth right intercostal space (4R) in sternal line
V2 -> 4L in sternal line
V3 -> halfway between V2 and V4
V4 -> 5L in midclavicular line
V5 -> directly lateral to V4 in anterior axillary line
V6 -> directly lateral to V4 in midaxillary line
Women -> V4, V5, V6 -> should be positioned on the chest wall beneath the breast
Quantity of lines in normal 25 cm/s ECG
- Horizontal lines
- > 1 mm = 0,04 s = 40 ms
- > 5 mm = 0,2 s = 200 ms - Vertical lines
- > 1 mm = 0,1 mV
- > 10 mm = 1,0 mV
Every ECG examination algorithm
- Quality of reading
- General aspects
- Waves, intervals and segments morphology
- Rhythm
ECG Quality of reading examination algorithm
- Calibration -> should be 1 mV= 10 mm
- Paper speed -> should be 25 mm/s
- Electrode to skin contact -> back and forth movement of the isoelectric line
- Artifacts -> movement of patient
- Correctness of electrode placements
1) reversals
2) wrong placement especially V1 and V2 - Position of the patient -> ask if something is wrong
ECG examination algorithm General aspects
- Rhytm
- Rate
- Regularity
- Heart axis
ECG examination algorithm waveform analysis algorithm
- General contours
- Durations
- Positive and negative amplitudes
- Axes in frontal and transverse planes
Second to beats/minute exchange rate
- 0,2 s (one big square) = 300 bpm
- 75 bpm = 0,8 s (4 big squares)
- Algorithm to calculate HR:
HR=300/x [bpm],
where x = number of big squares between one R of QRS complex and the next
- Algorithm to calculate HR when >100 bpm:
HR=1500/y [bmp], where y = number of small squares - If HR< 100 bpm big squares are sufficient
- HR=100 bpm x=3
ECG examination algorithm Heart rate and regularity
- Look to intervals RR in all leads and see if they are +/- equal
1) if they are +/- equal -> HR is regular (variability of RR intervals should be ≤0.12 s)
2) they are almost never equal -> differences in phases of respiratory cycle - If HR is regular calculate HR between two succeeding R waves
- If HR is irregular:
1) count the number of cardiac cycles in 6 seconds (30 big squares) and multiply by 10
- > often there are markers at 3 second intervals (down)
2) the number of cycles over a particular interval of time should be counted -> if 6s is not sufficient
Identification of heart axis
-> use only limb leads
- Identify the transitional lead
- > lead in which QRS complex has the most equal positive and negative components - Identify the lead that is oriented perpendicular (90 degrees) to the transitional lead using hexaaxial reference system
- Consider predominant direction (positive or negative) of lead from step 2 -> if it’s positive -> the axis is positive and vice versa
Heart axis QRS -> easier determination
- I + aVF +
- > 0-90 degrees
2. I+ aVF - II + -> 0-(-30) degrees II - -> -30-(-90) degrees
- I - aVF +
- > 90-180 degrees - I- aVF -
- > -90-(-180) degrees
Hexaxial reference system
aVL: -30 and +150 I: 0 and 180 aVR: -150 (positive) and +30 II: +60 and -120 aVF: +90 and -90 III: +120 and -60
Degrees in hexaxial reference system -> what they mean
- -30 to +90
1) is normal axis of QRS complex
2) I and II -> positive QRS - +90 to +180
1) axis deviated right (RAD -> right-axis deviation)
2) I -> negative QRS
3) II -> positive QRS - -30 to -90
1) axis deviated left (LAD -> left-axis deviation)
2) I -> positive QRS
3) II -> negative QRS - -90 to 180
1) EAD -> extreme-axis deviation
- > rarely
2) I -> negative QRS
3) II -> negative QRS
Frontal plane axis -> differences between people
1) Age
1. Neonate -> rightward
2. Children-> vertical position
3. Adulthood-> leftward
2) Body posture
1. Slim -> more vertical
2. Fat -> more horizontal
ECG examination algorithm Waves, segments and intervals morphology
- P wave
- PR interval
- QRS complex
- ST segment
- T wave
- U wave
- QT interval
P wave morphology ECG
- Location:
1) before each QRS - General contour:
1) Monophasic or biphasic - Duration
1) normally ≤ 0.12 s - Amplitude
1) normally no more than:
1. 0.25mV in frontal plane leads
2. 0.3 mV in precordial leads
3. V1: positive ≤0.15 mV
negative ≤0.1 mV - Axis
1) positive or negative
2) axis of P-wave
- > could be determined according to the QRS
- > normal limits: 0 to +75 degrees
P wave morphology ECG - general contour
- Monophasic in all leads except V1 and possibly V2
- In V1 -> biphasic
- RA and LA differential
1. Beginning (1/3) -> RA
2. Middle (2/3) -> both RA and LA
3. End (3/3) -> LA
- > especially important to determine in V1
P wave morphology ECG - axis
- Entirely upright -> in leftward- and inferiorly oriented leads (to sinus rhythm: I, II, aVF+, aVR -)
1) I, II
2) aVF
3) V4, V5, V6 - Negative in:
1) aVR - Biphasic in V1 and possibly V2
PR interval morphology ECG
- Measures the time required for an electrical impulse to travel from SA to ventricular myocardium
- Durations -> adult: 0.12 to 0.20 s (childhood depends on age, can be <0.12 s)
- Varies highly with autonomic system activity
- > a major potion of PR interval depends on AV
- > Varies with HR - PR segment -> should be isoelectric