logging in or signing up ECG READING praveenks97 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 9408 Category: Education License: All Rights Reserved Like it (16) Dislike it (0) Added: November 14, 2009 This Presentation is Public Favorites: 14 Presentation Description ECG READING ; Pediatric Cardiology Comments Posting comment... By: ksash (7 month(s) ago) Please allow download Saving..... Post Reply Close Saving..... Edit Comment Close By: Khayecee (19 month(s) ago) It's very good in giving information. Please allow to download for study purpose. Thanks Saving..... Post Reply Close Saving..... Edit Comment Close By: drhmk22 (20 month(s) ago) its very informative plz allow dwnload Saving..... Post Reply Close Saving..... Edit Comment Close By: tsharshal (21 month(s) ago) plz allow dwnload Saving..... Post Reply Close Saving..... Edit Comment Close By: fakgha123 (23 month(s) ago) THANK YOU VERY MUCH PLEASE ALLOW DOWNLOAD Saving..... Post Reply Close Saving..... Edit Comment Close loading.... See all Premium member Presentation Transcript Slide 1: Thiruvananthapuram G r e e t i n g s F r o m Demystifying Pediatric CardiologyE C G R E A D I N G How To Make Sense Of The Black Squiggles : Demystifying Pediatric CardiologyE C G R E A D I N G How To Make Sense Of The Black Squiggles M. Zulfikar Ahamed Professor of Pediatric Cardiology Medical College Trivandrum The Machine & The Man : The Machine & The Man ECG Machine : ECG Machine ECG INTERPRETATION : ECG INTERPRETATION CHD Acq HD Arrhythmias In adult In The Young TODAY’S PLAN 7 point formula : TODAY’S PLAN 7 point formula 1. Introducing the Basics of reading an ECG 2. ECG Reading format 3. Abnormalities 4. Frequently Encountered Issues & Problems 5. Clinical Scenario with ECG 6. FAQ 7. Conclusion demo ECG Slide 8: ECG Basic concepts - Recording Recording in heat sensitive paper Page writer using ink Slide 9: Single channel / Multi channel Paper speed : 25 mm / sec 1 small div = 40 msec Voltage : 1 mv = 10 mm 1 small div = 0.1 mv TAKING A NORMAL ECG Slide 10: ECG PAPER Slide 11: BASICS Paper speed : 25 mm/ sec Double speed : 50 mm/ sec Standardization : 1 mV = 10 mm Half / Double Over damped tracing Under damped tracing Different Types of Leads : Different Types of Leads Standard Limb Leads I, II & III Augmented Unipolar Limb Leads aVR aVL aVF Unipolar Chest Leads V1 V2 & V3 Unipolar Chest Leads V4V5 & V6 Slide 13: ECG - Basic concepts Bipolar Limb Leads / Standard Limb Leads Unipolar Limb Leads Unipolar Chest Leads 14 LEAD ECG Why ? V3R to V6R in Dextrocardia V3R and V4R in TOF and Cong HD V3R and V4R in RVMI, RVH Slide 14: Rhythm Analysis Rhythm strip or Long lead Lead II and V1 Slide 15: STANDARDIZATION Slide 16: READING A NORMAL ECG Slide 17: ECG Reading Format Paper speed Standardization Rhythm & Heart Rate P wave PR interval QRS Width / Axis / Morphology R / S in V 1 : V 6 ST segment T wave QTc U wave Slide 18: Normal Sinus Rhythm Normal P wave – Upright in lead I, II and inverted in aVR Normal morphology Each P to be followed by a QRS with a normal PR interval - Normal PQRST Fairly regular PP interval Slide 19: Heart Rate Usual paper speed : 25 mm / sec Distance moved by the paper in one minute / 60 seconds = 25 X 60= 1500 mms Heart rate = 1500 / R-R interval Average of multiple beats in AF Slide 20: CALCULATING THE HEART RATE 1500 RR interval in no. of small divisions Slide 21: HEART RATE Tachycardia newborn > 160 / mt infant > 120 / mt child / adult > 100 / mt Bradycardia newborn < 90 / mt infant < 80 / mt child / adult < 60 / mt Slide 22: ECG - Waves P : Atrial depolarization QRS : Ventricular depolarization T : Ventricular repolarization “Ta wave” : Atrial repolarization U wave Slide 23: ECG - Intervals PR interval QT interval Slide 24: ECG - Segments PR segment ST segment TP segment Slide 25: P wave Look at II V1 Width . Height . Morphology. Polarity. Absent ? Slide 26: P wave Normal Upright in Lead I, II and inverted in avR Leads II and V1 Height: < 2.5 mm in Lead II < 1.5 mms in Lead V1 Width: < 110msec in Lead II in adults < 100 msec in child Slide 27: PR interval Beginning of atrial depolarization to beginning of ventricular depolarization. Measured from beginning of P wave to beginning of QRS Normal in adults: 120 – 200 msecs Short PR interval and Prolonged PR interval Slide 28: 200 ms MEASURING PR INTERVAL Slide 29: PR INTERVAL Short PR : < 80 msec Long PR : > 180 msec > 200 msec New born : PR interval - > 145 msec Infants and children - > 180 msec Slide 30: PR segment Measured from end of P wave to beginning of QRS Normally iso electric PR segment depression in pericarditis QRS Interpretation : QRS Interpretation Axis Width . Voltage q wave if any R / S in V1 and V6 Transition Abnormal morphology eg: RBBB etc Slide 32: QRS axis Normal RAD LAD Right Upper Quadrant Axis Slide 33: QRS Complex - Axis Determination Normal : 0 0 to + 90 0 RAD : +90 0 to + 180 0 LAD : 0 0 to - 90 0 RUQ : - 90 0 to + 180 0 Slide 34: Quick Determination of Axis If I & aVF are Positive If I Neg aVF Positive If I Positive aVF Negative If I & aVF are Negative Normal RAD LAD RUQ Slide 35: Normal QRS Axis in children At birth : + 60 to +190 degrees 1 – 3 months : + 30 to + 115 degrees Slide 36: QRS Axis in adults Normal: - 30 degrees - + 110 degrees RAD : Beyond + 110 degrees LAD : Beyond – 30 degrees Slide 37: Abnormal axis in children : RAD - > 120° LAD - < 0 ° Slide 38: DETERMINATION OF AXIS - EXERCISE Slide 42: QRS DURATION Slide 43: QRS duration Narrow QRS Wide QRS in children - > 100 msec Wide QRS in adult : - > 110 msec Slide 44: Wide QRS Ventricular complex Pre excitation ( WPW) Bundle branch block Intraventricular conduction abnormalities Electrolytes / Drugs “Aberrancy” with fast heart rates Slide 45: Normal QRS in V1 Varies with the age R / s in infants & young children - > 1 r / S in adults with r / S ratio < 1 Slide 46: ECG – 5 DAY OLD INFANT Slide 47: 8 month old infant Slide 48: 6 year old child Slide 49: 22 year old adult Slide 50: R in V1 and V6 in children R wave usually prominent in right precordial leads R wave in V1 up to 20 or 25 mms can be normal in term newborn R wave in V1 rapidly decreases in the first week of life and R in V6 becomes prominent R / s in V6 in infants & children almost always > 1 TRANSITION OF QRS precordial leads : TRANSITION OF QRS precordial leads Normal : At V3 V4 Early : At V2 V1 Late : At V5 V6 ST - Segment : ST - Segment Normal Depressed Elevated Normal ? Abnormal ? ST Segment Elevation : ST Segment Elevation ST segment Depression : ST segment Depression T wave : T wave a . T wave polarity < 3 - 4 days - T is upright in V1. V3R > 3 - 4 days - 12 years - T inverted in V1 V3 R V2 (V3) b. T wave Height Shape Crucial T wave : T wave Slide 58: T wave in V1 Almost always upright in term new born infants Becomes inverted by 4 -7 days of life Negative T waves persist up to 8 years and sometimes longer. “Persistent juvenile T wave pattern” Upright T in V1 between 7 days to 7 years may signify RVH. Slide 59: QT interval Measured from beginning of QRS to end of T wave. Usually Lead II in single channel recorder / Precordial lead Earliest onset of QRS in any lead to end of T wave in any lead in a multi channel recorder Bazett formula for corrected QT interval QT in msec / sq root of RR in secs Slide 60: MEASURING QT INTERVAL – QT PROLONGATION Slide 61: QT interval Normal : < 0.44 sec Borderline : 0.44 to 0.46 sec Abnormal : > 0.46 sec Congenital QT prolongation – LQTS Drugs Slide 62: QTc prolongation LQTS Hypokalemia Hypocalcemia Hypothermia Anti arrhythmic drugs I A or III Ischemia Slide 63: Chamber Enlargement Atrial Overload / Enlargement LAO / RAO / BAO Ventricular Hypertrophy LVH / RVH / BVH Systolic and Diastolic overload pattern CHAMBER ENLARGEMENT : CHAMBER ENLARGEMENT LV Pressure Volume Pressure Volume RV RA. LA Slide 65: RA overload Slide 66: Left Atrial overload Slide 67: Bi atrial overload Slide 69: RVH Systolic overload pattern Diastolic overload pattern Slide 70: RV SYSTOLIC OVERLOAD Type A Slide 71: RVH Type B Slide 72: Ecg #302 RVH Type C Slide 73: Left Ventricular Hypertrophy LV VOLUME OVERLOAD : LV VOLUME OVERLOAD Slide 75: Biventricular hypertrophy Katz – Wachtel phenomenon R + S in mid precordial leads Infant > 60mm Child / Adult > 45 mm Slide 76: Biventricular hypertrophy Slide 77: Ectopic beats Premature Escape beat Supraventricular / Ventricular Slide 78: Supraventricular ectopic Slide 80: Ventricular Ectopic Slide 82: Sinus tachycardia Slide 83: Sinus Bradycardia Sinus Node Dysfunction : Sinus Node Dysfunction Sinus bradycardia Sinus arrest SA block Brady-tachy syndrome Chronotropic incompetence Slide 85: SA block First, Second and Third degree Only second degree can be diagnosed from ECG Type I and Type II second degree Slide 86: Second degree SA block Slide 87: AV block First degree Second degree – Type I and II Third degree ( Complete) Slide 88: First degree AV block 340 MS Slide 89: Wenckebach phenomenon Mobitz I Slide 90: Mobitz II Slide 91: Complete AV heart block Regular PP interval Regular RR interval Varying PR interval AV Dissociation Slide 93: LBBB Slide 94: RBBB Slide 95: Tachy arrhythmias Narrow QRS Wide QRS Slide 96: TACHYCARDIA VT A. Narrow QRS (< 120 msec) B. Wide QRS (>120 msec) SVT with RBBB Aberrancy Drugs Pre excited Tachycardia QRS width Slide 97: A. Narrow QRS tachycardia Irregular Atrial fibrillation Multi focal atrial tachycardia Regular Automatic Atrial Reentry AVNRT } SVT AVRT Slide 98: SVT Slide 100: SVT Slide 101: WPW Syndrome PR interval < 120 msec with normal P Wide QRS > 110 msec Initial slurring of QRS – delta wave Secondary ST – T changes Slide 102: Pre excitation NS VT : NS VT VT : VT VT : VT Slide 106: Tachycardiomyopathy Dilated LV with global reduction in contractility related to very fast heart rate Clinical picture simulates dilated Cardiomyopathy or myocarditis Immediate termination of arrhythmia required Slide 107: Atrial fibrillation Absence of P waves Varying RR interval Fibrillary waves Slide 108: ATRIAL FIBRILLATION Slide 109: ATRIAL FLUTTER Slide 110: PACEMAKER Slide 111: ECG Reading Format - “ Rule of 10” 1. Rate 2. Sinus or not 3. P wave 4. PR interval 5. QRS Axis 6. QRS R/S Addl observation if any 7. ST segment 8. T wave 9. QTC 10. Other remarks In V1 in V6 Slide 112: CONGENITAL HEART DISEASE ECG Slide 113: P waves in CHD Looked at not only for chamber enlargement - RA or LA or biatrial but for SITUS Situs solitus - Upright P in I ; Negative in aVR Situs inversus - Negative P in I ; Upright in aVR PR Interval in CHD : PR Interval in CHD IF long : Strongly s/o Rheumatic etiology : Digitoxicity : Some interesting CHD Familial secundum ASD AV Canal Defect ( including primum ASD) DORV . L - TGA. Ebstein. Slide 115: QRS Voltages In deciding high/ low always apply voltage criteria ( modified Sokolow criteria) Children tend to have high voltage precordial QRS In infants and children myocarditis and DCM need not produce low voltage complexes Slide 116: Q in QRS To decide whether Q is Abnormal Apply definite criteria Deep q in II. III. aVF are occasionally found in normal infants Deep q in a specific coronary artery territory is suspicious II. III. aVF I. aVL, V4 -V6 V1 -V6 Slide 117: Deep Q found in 1. LV volume over load situation II. III. aVF, V4 -V6 2. Infarction pattern ALCAPA Kawasaki Myocarditis Slide 118: qR in VI Can not be Normally Present ! If qR in V1 or V3 R Suprasystemic RVSP ( severe PAH or PS ) Ventricular inversion - L-TGA EMF - giant RA No q in V5 V6 - ? SINGLE VENTRICLE Slide 120: TRANSITION OF QRS precordial leads Normal : At V3 V4 Early : At V2 V1 Late : At V5 V6 Slide 122: R/S relationship in precordial leads Progressive decline of R in V1 to V6 ? Dextrocardia r / S in all precordial leads ? Cor pulmonale RVH adult ? Single Ventricle infant Slide 123: QRS Axis In infants RAD is normal ; Most Abnormal heart in infancy will also have RAD ! * if > + 1350 - likely abnormal Unusual Axis - LAD , RUQ are most useful in diagnosis Slide 124: LAD in CHD 1. AVCD - including primum ASD 2. Tricuspid Atresia 3. Inlet or multiple muscular VSD 4. L - TGA 5. Single ventricle A Funny looking baby presents with CHF , mild Cyanosis . Has cardiomegaly, PAH, PSM and MDM . : A Funny looking baby presents with CHF , mild Cyanosis . Has cardiomegaly, PAH, PSM and MDM . Slide 132: A 12 Year old with H / O fever, cough and severe dyspnea. IN HYPOTENSION. Slide 133: Ecg #313 Slide 134: Sinus rhythm Narrow, tachy @110 Normal axis/int’s The QRS complex morphology is variable… Dx: Electrical alternans Due to the heart swinging freely inside a large pericardial effusion A 4 Month old baby with CHF, Cardiomegaly, apical murmur with h /o Episodes of extreme irritability : A 4 Month old baby with CHF, Cardiomegaly, apical murmur with h /o Episodes of extreme irritability TACHYCARDIA ? : TACHYCARDIA ? Ecg #303 Slide 139: Wide complex tachycardia DDx: V T or SVT with aberrancy… 80% of wide complex tach’s are VT; hence this is VT until proven otherwise Palpitations, DOE , Syncope : Palpitations, DOE , Syncope Ecg #307A Slide 141: Extremely fast rhythm (240bpm, must be Supraventricular, VT rarely this fast) Irregular! (VT & torsades are always regular) All QRS complexes have initial upsloping Dx: Afib & pre-excitation Wide complex tachycardia Same patient… after DC CV : Same patient… after DC CV Ecg #307B A Child of 10 years Abnormal facies, short stature andEjection Systolic Murmur at PA : A Child of 10 years Abnormal facies, short stature andEjection Systolic Murmur at PA Slide 145: Infant CHF Acyanotic Normal Femorals murmur Diagnosis : VSD - large ECG : RAD . Katz Wachtel phenomenon Slide 146: CASES & ECG Infant ‘ Asymptomatic VSD’ ECG: RAD . RVH - TOF ? LAD . BVH - AVSD ? Suspected to have CHD in Newborn period. LFU. Now 12 YRS, has DOE, Mild cyanosis : Suspected to have CHD in Newborn period. LFU. Now 12 YRS, has DOE, Mild cyanosis Slide 151: CASES & ECG Asymptomatic Child Hyperkinetic Precordium Insignificant M at Lt USB wide split S2 ? ASD ECG: RAD r S R in V1 or V3 R Slide 154: CASES & ECG Asymptomatic ; long m Lt USB EJ click + ? PS ECG : Monophasic R in V1 V3 R RAD. No early transition Good correlation with severity Slide 158: CASES & ECG 4 month old symptomatic CoA ECG : will show RVH - not LVH if LVH - additional abnormalities PDA - VSD mitral Anomalies Slide 160: CASES & ECG TOF like clinical picture RAD RVH Early transition ( peaked p wave + ) Slide 164: V1 l - TGA Slide 165: TOF like Picture LAD Tricuspid Atresia AVCD PS L- TGA PS TOF like 1 AV block DORV VSD PS AVCD VSD PS TOF like no q in V5 V6 L- TGA Slide 166: Neonate Deep Cyanosis . Mild CHF Think of D TGA Slide 169: Cyanotic new born with RDS If ECG shows RVH + strain Think of PPHN TAPVC CoA Slide 170: 17 yr old girl . Previous VSD LFU Now clinically PAH . Operable ? ECG: RVH . PA pressure ? Slide 173: Asymptomatic boy 8 yrs murmur ECG: T inverted in V1 - V6 Think of primary myocardial diseases HCM DCM 13 Year old GirlH / O frequent Palpitations : 13 Year old GirlH / O frequent Palpitations PR interval if SHORT : PR interval if SHORT Think of WPW look at Other causes ( Pompe ; LGL etc ) are rare ! QRS A 14 Yr old Boy. History of Syncope.Basal harsh ESM. ? Cause : A 14 Yr old Boy. History of Syncope.Basal harsh ESM. ? Cause Bradycardia ? Cause : Bradycardia ? Cause TACHYCARDIASinus or SVT ? : TACHYCARDIASinus or SVT ? The next - Tachycardia ? Wide or Narrow : The next - Tachycardia ? Wide or Narrow Newborn in CHF & in Shock.Why ? : Newborn in CHF & in Shock.Why ? A 6 Yr old boy referred as BRADYCARDIA . History of ‘ Syncope’ ? Cause : A 6 Yr old boy referred as BRADYCARDIA . History of ‘ Syncope’ ? Cause Slide 190: ECG 2 Slide 191: FAQ I . Why should we take an addl. V3R in infants and children ? Up to What Age ? II. In Dextrocardia which are the addl. Leads to be taken ? III. Right Axis Deviation is normal in infancy. Up to what Age it remains normal ? Slide 192: FAQ IV . Can you normally get T inversion in V4 - V6 in children as a variation ? V . What is Juvenile pattern of ECG ? VI. VPC in child. When will we order a detailed investigation ? Slide 193: FAQ VII. Sometimes we get rSR pattern in limb leads Is it significant ? VIII. Q R in V1 is generally indicative of severe PAH - suprasystemic . Does it hold good for V3R, V4R also? IX. Which are the clinical conditions in which we expect WPW ? Slide 194: FAQ X. Indications of ECG in chest pain syndrome in children ? XI. What are the early ECG findings in Digoxin toxicity ? XII. T inversion in precordial leads; what is normal and what is abnormal ? Slide 195: FAQ XIII. QRS duration in children vs adults . Is there a major change ? XIV. When is ST elevation significant in children ? XV. rSR m ASD ; Is it useful for follow up ? Slide 196: FAQ XVI. In which CHD , follow up can be done utilizing ECG alone, instead of Echo ? XVII. In a child with bradycardia, how is a diagnosis reached ? XVIII. What are early repolarisation changes in ECG ? Slide 197: Thank you very much ! Usha. Maharashtra IAP. All my fellow Pediatricians You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.