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Зүрхний цахилгаан бичлэг

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ECG normal

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Зүрхний цахилгаан бичлэг

  1. 1. 12 Lead ECG Interpretation: Color Coding for MI’s Zagarzusem.E MD 1
  2. 2. Objectives  review the ECG waveform and intervals  Define myocardial ischemia, injury and infarction  Identify the 5 major infarct areas on the 12 lead  Name occluded arteries common to the area  Differentiate ECG changes reflecting ischemia, injury and infarction  Identify cardiac enzymes associated with ACS 2
  3. 3. 3
  4. 4. 4 ECG graph paper
  5. 5. The 12-Lead view  Each limb lead I, II, III, AVR, AVL, AVF records from a different angle  All six limb leads intersect and visualize a frontal plane  The six chest leads (precordial) V1, V2, V3, V4, V5, V6 view the body in the horizontal plane to the AV node  The 12 lead ECG forms a camera view from 12 angles 5
  6. 6. Views from Augmented and Limb Leads- Frontal 6
  7. 7. Precordial lead snapshots  Think of each precordial lead as a horizontal view of the heart at the AV node  With the limb leads and the precordial leads you have a snapshot of heart portions 7
  8. 8. Unipolar and Bipolar  Limb leads I, II, III are bipolar and have a negative and positive pole  Electrical potential differences are measured between the poles  AVR, AVL and AVF are unipolar  No negative lead  The heart is the negative pole  Electrical potential difference is measured betweeen the lead and the heart  Chest leads are unipolar  The heart also is the negative pole 2004 Anna Story8
  9. 9. Lead Placement is Important  Each positive electrode acts as a camera looking at the heart  Ten leads attached for twelve lead diagnostics. The monitor combines 2 leads.  Mnemonic for limb leads  White on right  Smoke(black) over fire(red)  Snow(white) on grass(green) 2004 Anna Story 9
  10. 10. Precordial Leads 10
  11. 11. Arrangement of Leads on the EKG
  12. 12. Anatomic Groups (Septum)
  13. 13. Anatomic Groups (Anterior Wall)
  14. 14. Anatomic Groups (Lateral Wall)
  15. 15. Anatomic Groups (Inferior Wall)
  16. 16. Anatomic Groups (Summary)
  17. 17. The ECG Tracing: Waves  P- wave  Marks the beginning of the cardiac cycle and measures the electrical impulse that causes atrial depolarization and mechanical contraction  QRS- Complex  Measures the impulse that causes ventricular depolarization  Q-wave- may or may not be evident on the ECG  R-wave- first upward deflection following P wave  S-wave- the first downward deflection following the R- wave  T- wave  Marks ventricular repolarization that ends the cardiac cycle 18
  18. 18. Intervals and Segments  P-R interval-  Time interval for impulse to go from the SA to the AV node  normal 0.12-0.20 secs  QRS Interval  Time interval for impulse to go from AV node to stimulate Purkinjie fibers  Less than 0.12 secs  QT Interval  Time interval from beginning of depolarization to the end of repolarization  Should not exceed ½ the length of the R-R  ST segment  end of the S to the beginning of the T 19
  19. 19. The ECG Tracing 20
  20. 20. MI Definition  A result of occlusion of arterial flow to the myocardium.  Ischemia, injury and necrosis is result  Occlusion occurs via spasm, blood clot or stenosis 21
  21. 21. ECG Changes : Ischemia  T-wave inversion ( flipped T)  ST segment depression  T wave flattening  Biphasic T-waves 22 Baseline Inversion-tongoroh Flattening-havtgairah Depressed-dooshloh
  22. 22. ECG Changes: Injury  ST segment elevation of greater than 1mm in at least 2 contiguous leads  Heightenedөндөрсөх or peaked T waves  Directly related to portions of myocardium rendered electrically inactive 23 Baseline
  23. 23. ECG Changes: Infarct  Significant Q-wave where none previously existed  Why?  Impulse traveling away from the positive lead  Necrotic tissue is electrically dead  No Q-wave in Subendocardial infarcts  Why?  Not full thickness dead tissue  But will see a ST depression  Often a precursor to full thickness MI  Criteria  Depth of Q wave should be 25% the height of the R wave  Width of Q wave is 0.04 secs  Diminished height of the R wave 24
  24. 24. Evolving MI and Hallmarks of AMI 25 1 year •Q wave •ST Elevation •T wave inversion
  25. 25. Dissecting the 12 Lead ECG  Horizontal marks time  Vertical marks amplitude  6 limb leads  6 precordial leads  Positioning measures 12 perspectives or views of the heart  The 12 perspectives are arranged in vertical columns  Limb leads are I, II, III, AVR, AVL, AVF  Precordial leads are V1, V2, V3, V4, V5, V6 26
  26. 26. A Normal 12 Lead ECG 27
  27. 27. A Normal 12 Lead ECG 28
  28. 28. Color Coding ECG’s Anterior  Yellow indicates V1, V2, V3, V4  Anterior infarct with ST elevation  Left Anterior Descending Artery (LAD)  V1 and V2 may also indicate septal involvement which extends from front to the back of the heart along the septum  Left bundle branch block  Right bundle branch block  2nd Degree Type2  Complete Heart Block 29
  29. 29. Anterior MI 30
  30. 30. Color Coding ECG- Inferior  Blue indicates leads II, III, AVF  Inferior Infarct with ST elevations  Right Coronary Artery (RCA)  1st degree Heart Block  2nd degree Type 1, 2  3rd degree Block  N/V common, Brady 31
  31. 31. Inferior MI 32
  32. 32. As an aside….  Right sided EKG  Ever heard of it?  Ever done one?  Think about it…..  For your cases that are clearly inferior MI’s  Obtain a dextrocardiogram whenever ST segment elevation is noted in Inferior leads 33
  33. 33. Right Sided EKG????  RVI occurs around 40% in inferior MI’s  Significance  Larger area of infarct  Both ventricles  Different treatment  Right leads “look” directly at Right Ventricle and can show ST elevations in leads II. III. AVF, V4R , V5R and V6R  Occlusion in RCA and proximal enough to involve the RV 34 The single most accurate tool used in measuring RVI. 90% sensitive and specific
  34. 34. Clinical Triad of RVI  Hypotension  Jugular vein distention  Dry lung sounds 35
  35. 35. Color Coding ECG- Lateral  Red indicates leads I, AVL, V5, V6  Lateral Infarct with ST elevations  Left Circumflex Artery  Rarely by itself  Usually in combo 36
  36. 36. Lateral MI 37
  37. 37. Color Coding ECG- Posterior  Green indicates leads V1, V2  Posterior Infarct with ST Depressions and/ tall R wave  RCA and/or LCX Artery  Understand Reciprocal changes  The posterior aspect of the heart is viewed as a mirror image and therefore depressions versus elevations indicate MI  Rarely by itself usually in combo 38
  38. 38. Posterior MI 39
  39. 39. Color Coding ECG- SubEndo  No color for SubEndocardial infarcts since they are not transmural  Look for diffuse or localized changes and non – Q wave abnormalities  T-wave inversions  ST segment depression 40
  40. 40. SubEndo MI 41
  41. 41. More than one color shows abnormality  A combination of infarcts such as: Anterolateral yellow and red Inferoposterior blue and green Anteroseptal yellow and green 42
  42. 42. Putting it ALL together 43
  43. 43. 44
  44. 44. Practice 1 45 Anterior MI with lateral involvement ST elevations V2, V3, V4 ST elevations II, AVL, V5 Click for answer
  45. 45. Practice 2 46 Anteroseptal MI ST elevations V1, V2, V3, V4 Click for answer
  46. 46. Practice 3 47 Click for answer Inferior MI ST elevation 2,3 AVF
  47. 47. Practice 4 48 Click for answer Inferior lateral MI ST elevations 2, 3, AVF ST elevations V5
  48. 48. Practice 5 49 •Acute inferior MI •Lateral ischemia Click for answer
  49. 49. Additional Practice Strips 50
  50. 50. Additional Practice Strips 51
  51. 51. Additional Practice Strips 52
  52. 52. Additional Practice Strips 53
  53. 53. Additional Practice Strips 54
  54. 54. Additional Practice Strips 55
  55. 55. Additional Practice Strips 56
  56. 56. Additional Practice Strips 57
  57. 57. Additional Practice Strips 58
  58. 58. Additional Practice Strips 59
  59. 59. Additional Practice Strips 60
  60. 60. Additional Practice Strips 61
  61. 61. Additional Practice Strips 62
  62. 62. Additional Practice Strips 63
  63. 63. Additional Practice Strips 64
  64. 64. Additional Practice Strips 65
  65. 65. Cardiac Enzymes Indicating Infarct  Normals  CPK- 10-155u/liter  begin rise 3-6 hours and peaks 12-24 with return to norm 3-5 days  CPK-MB < than 5% IU/liter  LDH 85-200 IU/liter  Begin rise 12 hours, peaks 36-72 and normal around 10 days  LDH 1- 18.1% - 29% of total  LDH 2- 27.4% to 37.5% of total 66
  66. 66. Cardiac Enzymes Indicating Infarct  Troponins- Now the Gold Standard!  Rises after 3-6 hours  Negative Troponin within 6 hours of onset of S&S rules out the MI  Peaks at about 20 hours  May be raised for 14 days 67
  67. 67. Cardiac Enzymes Indicating Infarct  Troponin T  84% sensitivity for MI 8 hours after onset of symptoms  22% for unstable angina  Advantages  Highly sensitive for detecting myocardial ischemia  Levels may help to stratify risks  Disadvantages  Less specific than Troponin I  Increased in angina  Increased in chronic renal failure 68
  68. 68. Cardiac Enzymes Indicating Infarct  Troponin I  90% sensitivity for MI 8 hours after onset of S&S and 95% specificity  Level greater than 1.2 suggest MI  Negative rules out MI  Obtain two negative troponin values 4 hours apart  Normally exceedingly low Even a small elevation indicates myocardial damage 69
  69. 69. THANKS FOR ATTENTION
  70. 70. References  Хүний физиологи-Г.Дашзэвэг  Дотор өвчний оношзүй-Б.Гомбосүрэн  www.slideshare.net  www.wikipedia.org 71

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