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Data Interpretation, Bradycardias, Back to basics SMILE, ST Changes, ECGs …
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Bradycardias
Kahoot Questions
If sinus node doesn't work--> junctional rhythm becuase AVN works
If AVN doesn't work --> escape rhythm from his-purknje
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Trifasicular block- RBBB, left axis deviation and prolonged PR
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BBB
(Broad QRS)
Left BBB
Negative QRS in V1,
Left axis deviation
QRS positive in V5 and V6
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QRS
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Broad
Rhythm?
Regular
P waves?
Present
Relationship to QRS?
1:1
PR interval?
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AVN
Prolonged PR interval, narrow QRS, narrow QRS
RBBB- prolonged PR, broad QRS, V1 double QRS (bunny)
Bradyarhthmias
(Tom Resp)
Heart Blocks
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3rd= complete heart block, no relationship between P:QRS
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Causes
Physiological / nocturnal / medication
Sinus node- sinus bradycardia, junctional rhythm
AV Node- first defree HB (delay in going to AV Node)
Bundle of His (narrow escape rhythm)
Conduction system disease (broad escape rhythm) 0 1st degree, L and R BBB
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Left bundle split into left anterior fasicle (LAF), left posterior fasicle (LPF)
Bifascicular block- RBBB + one of LAF / LPF
Back to basics SMILE
Approach to ECG
R wave
Progression
Normal
V1 and V2 more negative,
V3 equal positive+negative (transition complex)
V4-V6 more positive
Poor/late
R wave height <3mm in V3
Causes= prior anteroseptal MI, LVH, inaccurate lead placement, dilated cardiomyopathy,
Height
Small
Pericardial effusion- ECG signal has to go through fluid, so smaller signal
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Axis- What is most positive lead (wave depolarisation going towards that lead), if AVL most positive- left axis deviation, if lead 3 most positive= right axis deviation Look which lead is the most positive, most positive should be somewhere between lead I and lead II.
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Rhythm
Check spacing between QRS, check if there is a P wave before each QRS
Sinus arrhthmia- regularly irregular e.g breathing in increasing heart rate
Irregularly irregular- atrial fribrilation
Axis
Check which lead (I, II, III, AVR, AVL, AVF) is the most positive - not biggest, most positive!
AVL most positive= left axis deviation
Lead III most postive= right axis deviaton
Everything in AVR negative= normal axis
QRS
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Represents conduction between AVN and ventricular depolarisation, normally fast
PR interval
Check PR interval in a lead where the QRS is positive,
Normal is 3-5 small squares
Short= WPW (+delta wave / slurred upstroke from Q-R)
Long= slow conduction ?BBB (longer than 1 square)
RBBB- slurred S wave
LBBB- left axis deviation, V1 negative, broad QRS, positive QRS in V6
QT interval
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Prolonged= MI, ischaemia, LVH, LBBB/RBBB, hypoK/Mg/Ca, DKA, drugs
Reduced= hyperCA
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Cases
Case 1-
What is rate? What is ryhthm? Is P wave before each QRS?
Axis
Intervals: PR, QRS,
R progression *transition complex at V3,
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V1-3, reciprocal leads: indicate things in posterior wall
Lateral wall-
Inferior wall- II, III, AVF
ST Changes
QRS prrogression
Normal
Negative in V1, V2
Isoelectric in V3
Positive in V4, V5, V6
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Poor R wave progression
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Causes: prior anteroseptal MI, LVH, dilated cardiomyopathy,
normal variant, inaccurate lead placement (transposition V1, V3)
Cardio Anatomy / Regions
Heart Regions
Anterior= V1-4
Lateral= V5-6, I, AVL
Inferior= II, III, AVF
Posterior= V7-9 or anterior ST depression
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T wave changes algorithm
T wave inversion?
Leads Affected?
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Regional
E.g V1-V4 or II, III,AVF
NSTEMI / Structural HD, (consider R wave)
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QT
Prolonged: MI, ischaemia, structural heart disease, LVH
LBBB, RBBB, Hypo K, Mg, Ca
Short= hypercalcaemia
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