[PDF] The Basic 12 Lead Electrocardiogram

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The Basic 12 Lead Electrocardiogram

Teresa Camp-Rogers, MD Department of Emergency Medicine Virginia Commonwealth University Medical Center Richmond, Virginia The Basic 12 Lead Electrocardiogram

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Teresa Camp-Rogers, MD

Department of Emergency Medicine

Virginia Commonwealth University Medical Center

Richmond, Virginia

The Basic 12 Lead

Electrocardiogram

Objectives• How do they work?

• Common mistakes • How to read an EKG • Artifacts • Cases What is an EKG?• Tracing of electrical activity of the heart

History of the EKG• William Einthoven

• Early 1900's • String galvanometer

How does an EKG work?

Voltmeter

Saline

Bucket

Saline

Bucket

How does an EKG work?

How does an EKG work?

How does an EKG work?• Einthoven I, II, III

How does an EKG work?• Wilson augmented leads • aVF, aVR, aVL

How does an EKG work?• Pre-cordial leads

•V1 -V6 • Standardized in 1938 by the AHA

Why PQRST?• Uncorrected tracings - ABCD

• Corrected tracing - PQRST - Familiar with Descartes - Middle of alphabet (afterthought)

Indications• Chest pain

• Syncope • Shortness of breath • Nausea/Vomiting • Palpitations • Diaphoresis • Stroke symptoms • Before and after cardioversion • Hemodynamic instability • Suspected electrolyte disorder •Overdose • Arrhythmia

Common Mistakes • Limb lead placement

RIGHTWRONG

Common Mistakes • Pre-cordial lead placement

- Angle of Louis -V1 - What about breast tissue?

How to read an EKG

• The Paper • The Waveform •The Plan

How to read an EKG • The paper

- Up and down 1 box = 0.1 mV -Across 1 box = 4 ms • The rate - 10 seconds per page

How to read an EKG • The Waveform

How to read an EKG •P wave

How to read an EKG • PR segment

How to read an EKG • QRS complex

How to read an EKG • ST segment

How to read an EKG •T wave

How to read an EKG • QT/QTc

How to read an EKG •R-R

The Plan

•Rate •Rhythm •Axis • Interval • Disease Rate • 300 method - 300, 150, 100, 75, 60 Rate • 10 second method • Each EKG is 10 seconds • Count total QRS complexes • Multiply by 6 Rate • Normal

60 - 100

• Bradycardia < 60 • Tachycardia > 100

Rhythm

• Sinus •Atrial • Supraventricular • Junctional • Ventricular

Narrow QRS

Wide QRS

Rhythm

• Normal Sinus • Sinus Arrhythmia • Sinus Arrest

Rhythm

•ATRIAL - Atrial Flutter - Atrial Fibrillation - Premature Atrial

Contraction

Rhythm

• Supraventricular - Catch all term - Supraventricular

Tachycardia

Rhythm

• JUNCTIONAL - Junctional Escape - Accelerated Junctional - Premature Junctional

Contraction

Rhythm

•VENTRICULAR - V Fibrillation - V Tachycardia - Premature Ventricular

Contraction

Axis• General direction of electrical activity • Will not change your management

Interval•PR

- Block between atria and ventricles - Heart Block • First, second, and third degree • QRS - Block in the conduction system - Bundle Branch Block • LBBB, LAFB, LPFB, RBBB •QT/QTc

P-R Interval

•1 o heart block •2 o heart block - Type I •2 o heart block- Type II •3 o heart block (complete)

QRS Interval

• QRS complex = ventricular depolarization • QRS widening = delay in depolarization

QRS Interval

• Causes of QRS widening - Ventricular rhythm - Damage to the conduction system • BBB •MI - Metabolic/Drugs

QRS Interval

QT/QTc Interval

•QT - Normal - Prolonged

EKG Artifact

• 60 Hz interference • Muscle tremor • Wandering baseline

12 leads• So far we've just done basic rhythm

recognition with a single lead. • What about the other 11 leads?

12 leads• Each lead represents a different view of

the heart • More = better.

12 leads• II p waves

• Axis • Diseases - Myocardial infarction -PE - Hyperkalemia - Pericarditis

Practice

Practice

Practice

Practice

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