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ECG Interpretation Criteria Review

ECG Interpretation Criteria Review. Left. Right. Axis Deviation. RAD = If R wave in III > R wave in II LAD = If R wave in aV L > I; and deep S wave in III. Axis Deviation Criteria. Axis Deviation. LAD = possible left anterior fasicular block RAD = possible left posterior fasicular block.

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ECG Interpretation Criteria Review

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  1. ECG Interpretation Criteria Review

  2. Left Right Axis Deviation • RAD = If R wave in III > R wave in II • LAD = If R wave in aVL > I; and deep S wave in III

  3. Axis Deviation Criteria

  4. Axis Deviation • LAD = possible left anterior fasicular block • RAD = possible left posterior fasicular block

  5. Right Atrial Abnormality Criteria • Tall P waves in lead II • (or III, aVF and sometimes V1)

  6. Left Atrial Abnormality • Lead II (and I) show wide P waves • (second hump due to delayed depolarization of the left atrium) • (P mitrale: mitral valve disease) • V1 may show a bi-phasic P wave • 1 box wide, 1 box deep • (biphasic since right atria is anterior to the left atria)

  7. Right Ventricular Hypertrophy Criteria • In V1, R wave is greater than the S wave - or - R in V1 greater than 7 mm • Right axis deviation • In V1, T wave inversion (reason unknown)

  8. Left Ventricular Hypertrophy Criteria • If S wave in V1 or V2 + R wave in V5 or V6 ≥ 35 mm... • ...or, R wave > 11 (or 13) mm in aVL or I... • ...or, R in I + S in III > 25 mm. • Also • LVH is more likely with a “strain pattern” or ST segment changes • Left axis deviation • Left atrial abnormality

  9. Right Bundle Branch Block Criteria • V1 or V2 = rSR’ - “M” or rabbit ear shape • V5 or V6 = qRS • Large R waves • Right chest leads: T wave inversion (“secondary changes” since they reflect a delay in depolarization not an actual change in depolarization). • Complete RBBB: QRS > 0.12 sec. • Incomplete RBBB: QRS = 0.10 to 0.12 sec.

  10. Left Bundle Branch Block Criteria • Wide QRS complex • V1 = QS (or rS) and may have a “W” shape to it. • V6 = R or notched R and may show a “M” shape or rabbit ears • Secondary T wave inversion • Secondary if in lead with tall R waves • Primary if in right precordial leads

  11. Incomplete Bundle Branch Blocks • RBBB or LBBB where QRS is between .10 and .12 with same QRS features

  12. Left Anterior Fascicular Block • Limb leads • QRS less width less than 0.12 sec. • QRS axis = Left axis deviation (-45° or more) • if S wave in aVF is greater than R wave in lead I • small Q wave in lead I, aVL, or V6

  13. Left Posterior Fascicular Block • Right axis deviation (QRS axis +120° or more) • S wave in lead I and a Q wave in lead III (S1Q3) • Rare

  14. Bifascicular Block • Two of the three fascicles are blocked. • Most common is RBBB with left anterior fascicular block.

  15. Subendocardial Ischemia Partial occlusion Transmural Infarction (MI) Complete occlusion

  16. A. Normal ECG prior to MI • B. Hyperacute T wave changes - increased T wave amplitude and width; may also see ST elevation • C. Marked ST elevation with hyperacute T wave changes (transmural injury) • D. Pathologic Q waves, less ST elevation, terminal T wave inversion (necrosis)  • E. Pathologic Q waves, T wave inversion (necrosis and fibrosis) • F. Pathologic Q waves, upright T waves (fibrosis)

  17. Infarction

  18. Anterior Infarctions • Abnormal Q waves in chest leads • Anterior MI can show loss of R wave progression in the chest leads

  19. Inferior Infarctions • Abnormal Q waves in leads II, III, and aVF

  20. Lateral • Lateral - V5 and V6 • High lateral when ST elevation and Q waves localized to leads I and aVL

  21. Posterior MI • Tall R waves in V1,V2 • R/S ratio > 1 in V1, V2 • The tall, anterior R waves are mirror images of a pathological, posterior Q waves. • Absences of right axis deviation (found with RVH) • ST segment depression in V1-V3 • Often seen with inferior MI

  22. Infarctions or BBB • RBBB & LBBB • T wave inversion and ST segment depression in V1 & V2 (RBBB) and V5 & V6 (LBBB) • MI • T wave inversion and ST segment depression in additional leads • Likely loss of R wave progression

  23. Infarctions and BBB • RBBB and MI • usual ECG changes in leads other than V1 and V2 • septal MI - upright T waves in V1 and V2 • with just RBBB the T waves should be inverted so upright T waves w/ RBBB are “abnormal” and indicated septal MI

  24. Infarctions and LBBB • Infarctions often damage the left bundle branch leading to a new or recent LBBB • expect to see upright T waves in left chest leads • septal MI are very difficult to assess with LBBB

  25. Subendocardial Ischemia • ST Segment depression • Anterior leads (I, aVl and V1-V6) • Inferior leads (II, III, and aVf) • may see ST segment elevation in aVr • T wave inversion • Poor R wave progression

  26. Subendocardial Infarction • No Q waves (non-Q wave infarction) • Persistent ST segment depression • T wave inversion

  27. Sinus Bradycardia • HR less than 60 bpm

  28. Sinus Tachycardia • HR > 100 bpm

  29. Premature Atrial Complexes (PAC) • Normal conduction • Conducted with aberration • a fascicles or bundle branch is refractory • wide QRS • Non-conducted • the AV node was still refractory; P wave will be close to the T wave • no QRS complex

  30. Atrial Tachycardia

  31. Figure 14-6 AV Nodal Reentrant Tachycardia • Rapid recirculating impluse in the AV node area (140-250 beats/min) • No P waves (hidden in QRS complex) or may be just before or after the QRS complex • Negative P waves in lead II

  32. Atrial Flutter • Sawtooth; F waves (easiest seen in II, III, & aVF) • Atrial rate of about 300 bpm • Ventricular rate150, 100 or 75 beats/min • 2:1, 3:1 and 4:1

  33. Atrial Fibrillation • No organized depolarization in atria. • Irregular “f waves” can range from looking almost like P waves to a flat line. • Atrial rate is about 600 bpm • Normal QRS w/ ventricular rate ~110-180 but random & irregular

  34. Junctional Rhythm

  35. Accelerated Junctional Rhythm

  36. WPW

  37. First Degree AV Block

  38. 2nd Degree AV Block, Type 1

  39. 2nd Degree AV Block, Type 2

  40. 2rd Degree AV Block

  41. Premature Ventricular Contractions • Characteristics • Premature and occur before the next normal beat • Wide (> 0.12 ms) and the T wave is usually opposite of the QRS • Bizarre looking • PVCs usually precede a P wave. • A nonsinus P wave may follow the PVC

  42. PVC • Unifocal (monomorphic) PVCs • same appearance in the same lead • small focus • normal and diseased hearts

  43. PVC • Polymorphic (multifocal and multiform) PVCs • different appearance in the same lead • multiform = different coupling intervals • multifocal = same coupling intervals • usually diseased hearts Multiform

  44. Idioventricular Rhythm

  45. Couplet

  46. Triplet

  47. Bigeminy and Trigeminy

  48. Ventricular Tachycardia ...more than three PVCs

  49. Torsades de Pointes

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