ELECTROCARDIOGRAM
EASY LEARNING
BY : KARTINAIAGUS ASRIL
PENOLONG PEGAWAI PERUBATAN U32
HOSPITAL PENGAJAR UiTM
TOPICS
1) TOPICS 1 : KNOW YOUR HEART
ANATOMY & PHYSIOLOGY OF HEART
CIRCULATORY SYSTEM OF HEART
ELECTRICAL CONDUCTION OF HEART
2) TOPIC 2 : KNOW YOUR ECG MORPHOLOGY
ECG PAPER
LEAD ECG
ELECTRICAL AXIS
ECG LEAD PLACEMENT VS HEART LOCATION
3) TOPIC 3 : BASIC ECG INTERPRETATIONS
4) TOPIC 4 : ADVANCE ECG INTERPRETATIONS
5) TOPIC 5 : ADVANCED LIFE SUPPORT (TEAM DYNAMIC)
6) CARDIAC DRUGS
TOPIC 1
KNOW YOUR HEART
TOPIC 1
KNOW YOUR HEART
ANATOMY & PHYSIOLOGY OF HEART
LOCATION OF THE HEART
Between the lungs in the middle of the chest and behind and slightly to
the left of your breastbone (sternum)
LAYER TISSUE OF THE HEART
The outer layer : epicardium
The middle layer : myocardium
The inner layer : endocardium.
FUNCTION OF HEART
Circulatory system
Electrical conduction system
BLOOD VESSEL
Artery
Vein
Capillaries
BLOOD SUPPLY FOR HEART TISSUE (CORONARY ARTERY)
THE CARDIAC CYCLE OF HEART
ATRIAL SYSTOLE
Last for 0.1second
Atrial depolarization causes atrial systole
It contributes a final 25mls of blood each ventricle
End of atrial systole is also end of ventricular diastole
End-distolic volume is 130mls
VENTRICULAR SYSTOLE
Last for 0.3 second
It is cause by ventricular depolarization
The left ventricle eject about 70mls blood into the aorta
End systolic volume is 60mls in each ventricle
RELAXATION PERIOD (DIASTOLE)
Both atria and ventricles are relaxed
It last for 0.4second
When heart beat faster the relaxation time shortens
Ventricular repolarization causes ventricular diastole
CIRCULATORY SYSTEM FUNCTION OF HEART
Circulates OXYGEN and removes CARBON DIOXIDE
Provides cells with NUTRIENTS
Removes the waste products of metabolism to the excretory organs for disposal
Protects the body against disease and infection
Clotting stops bleeding after injury
Transports HORMONES to target cells and organs
Helps regulate body temperature
PULMONARY CIRCUIT
Moves blood between the heart and lungs
Transport DEOXYGENATED BLOOD to the lungs to
absorb oxygen and release carbon dioxide
The OXYGENATED BLOOD then flow back to the heart
SYSTEMIC CIRCUIT
Moves blood between the heart and the rest of the body
It sends OXYGENATED BLOOD out to the cell and returns
DEOXGENATED BLOOD to the heart
PULMONARY AND SYSTEMIC CIRCUIT OF THE
HEART
ELECTRICAL CONDUCTION OF HEART
The cardiac conduction system is a group of specialized cardiac muscle cells in the walls of the heart that send signals to the heart muscle causing it to
contract
The main components of the cardiac conduction system :-
SA node
AV node
Bundle of His
Bundle branches
Purkinje fibers
ELECTRICAL CONDUCTION PATHWAY OF THE HEART
ELECTRICAL CONDUCTION OF HEART VS ECG WAVES
TOPIC 2
KNOW YOUR ECG
MORPHOLOGY
ECG PAPER
ECG LEAD PLACEMENT
LIMB LEAD
PRECORDIAL LEAD @ CHEST LEAD
RIGHT SIDED ECG PLACEMENT
POSTERIOR SIDED ECG PLACEMENT
ELECTRICAL AXIS
ECG AND HEART LOCATION
ROLES AS PARAMEDICS
Inform patient and get the consent
Uncover chest,ankle and hands
Removes electrical equipment such as mobile phone
jellewery watches
Remove metal objects
Shave if there is hair on chest or hand/leg
Advise patient for not speak during the procedure
Clean the electrode after used
1) Count big box from R – R
2) 300 divided big boxes/1500 divided small boxes
Eg : 300 divided 4 = 75bpm
1500 divided 20 = 75bpm
ATRIAL DEPOLARISATION (contraction)
PRESENT ABSENT
1)Normal NO P waves (Atrial Fibrillation)
2)Peak P (P-pumonale/Right atrial enlargement) 4) sawtooth P (Atrial Flutter)
3)Bigid P (mitral stenosis/Left atrial enlargement) 5) Premature atrial Complex (PAC)
PR interval : NORMAL (3 – 5 small boxes)
Normal PR prolonge ?PR prolonge ? PR regular missed QRS? PR prolonge irregular missed QRS? absent PR ?
Present Absent
1)Normal Third Degree Heart Block
2)PR prolonge (First degree AV block)
3)PR interval prolonge Irregular Missed QRS 4)PR interval Normal (regular) Missed QRS
(second degree AV block type I) (Second degree AV block Type II)
NORMAL : Width (3 small boxes) if > abnormal
BROAD ? NARROW ? RM QRS ? WM QRS ? Premature Ventricular Complex ?
NARROW QRS
Regular Irregular
1)Supraventricular Tacycardia (SVT) Atrial Fibrillation (AF)
2)Atrial Flutter
Normal ?
ST ELEVATION ?
ST DEPRESSION ?
ST ELEVATION (ACUTE MYOCARDIAL INFARCTION)
SHAPE
ANTERIOR STEMI
INFERIOR STEMI
LATERAL STEMI
POSTERIOR STEMI
INFERIOR-LATERAL STEMI
CORONARY ARTERY AND MI LOCATION
ST DEPRESSION (sign of ischemia)
ST DEPRESSION (sign of ischemia)
Complete capture PQRST
1.SINUS RHYTHM
2.SINUS ARRYTHMIAS
3.SINUS ARREST
4.SINUS BRADYCARDIA
5.SINUS TACHYCARDIA
TOPIC 4
ADVANCE ECG
INTERPRETATIONS
SVT ECG
VT ECG
VF ECG
PERICARDITIS ECG (SADDLE SHAPE)
ATRIAL FIBRILLATION ECG
ATRIAL FLUTTER
COMPLETE HEART BLOCK
SECOND DEGREE HEART BLOCK TYPE 1
SECOND DEGREE HEART BLOCK TYPE 2
PULMONARY EMBOLISM
INFERIOR STEMI WITH FLUTTER
SECOND DEGREE HEART BLOCK TYPE 1 WITH
INFERIOR STEMI
AF WITH ANTERIOLATERAL STEMI
TOPIC 5
AVANCED LIFE SUPPORT
(TEAM DYNAMIC)
TOPIC 6
CARDIAC DRUGS
ADRENALINE
1) Cetecholamines with alpha and beta effects
2) Indication
Cardiac arrest
Symptomatic bradycardia
Severe hypotension
Anaphylaxis
3) Dose administration
Iv or io: 1mg (1ml 1:1000), administered every 3-5 minutes followed by 20ml flush.
Can be given through ett at dose of 2- 2.5mg for symptomatic bradycardia (2nd degree type 2 and
chb)
Infusion at 2-10ug/minute, titrated to response
for anapylaxis
Im: adult or children >12 years, 0.5mg as initial dose (0.5ml of 1:1000)
Iv: titrate 50-100mcg (0.5 to 1ml) according to response (use 10ml 1:10000)
4) Side effect
Severe hypertension
Tachyarrhythmias
Tissue necrosis if extravasation occurs
ADENOSINE
1) Naturally occurring purine nucleotide
2) Slows transmission across AV node.
3) Little effect on the myocardial cells
4) Highly effective for terminating paroxysmal SVT with re-entrant circuits that include AV node
(AVNRT)
5) In narrow- or broad- complex tachycardias, adenosine will reveal the underlying atrial rhythms by
slowing ventricular response.
6) Indication
Stable narrow SVT
7) Dose administration
6mg adenosine as a rapid IV push through a large vein followed by a 20mL saline flush.
If unsuccessful, this can be followed with up to two doses each of 12mg every 1-2 minutes.
6mg 12mg 12mg (adult)
Elevate hand right after administration meds
8) Side effects
Transient unpleasant side effects, nausea, flushing and chest discomfort.
Caution if need to be given in asthmatic patient bronchospasm
AMIODARONE
1) An antiarrhythmic with complex pharmacokinetics and pharmacodynamics properties.
2) Act on sodium, potassium and calcium channels.
3) Poses alpha and beta-adrenergic blocking properties.
4) A mild negative inotropic action.
5) Causes peripheral vasodilation through non-competitive alpha blocking effects.
6) Atrioventricular conduction is slowed, and a similar effect is seen in accessory pathway.
7) Indications
Refractory pulseless VT/VF
Unstable tachyarrhythmias (failed 3x cardioversion)
Stable tachyarrhythmias
8) Dose administration
Refractory pulses VT/VF; IV/IO 300mg bolus (dilute in 20mL Dextrose 5% solution)
Unstable tachyarrhythmias; 300mg IV over 10-20 minutes
Stable tachyarrhythmias; 300mg IV over 20-60 minutes
Maintenance infusion; 900mg IV over 24 hours
Cumulative doses >2.2g are associated with hypotension
9) Side effect
Hypotension
Bradycardia
Heart block
CALCIUM
1) Essential for nerve and muscle activity
2) Plays a vital role in the cellular mechanism underlying myocardial contraction
3) No data supporting any beneficial action for calcium after cardiac arrest.
4) Indication
Hyperkalemia
Hypocalcemia
Overdose of calcalcium channel blocker
5) Dose administration
Initial dose of 10ml 10% calcium chloride (6.8 mmol Ca) may be repeated if necessary.
Administer calcium chloride via a central line.
6) Side effect
Calcium can slow heart rate and precipitate arrhythmias
In cardiac arrest, calcium may be given by rapid intravenous injection
LIGNOCAINE
1) Sodium channel blocker
2) Indications
Alternative to amiodarone in cardiac arrest from VT/VF
Stable monomorphic VT with preserved ventricular function
3) Dose administration
Cardiac arrest from VT/VF initial dose: 1-1.5mg/kg IV or IO
For refractory VF: May give additional dose 0.5-0.75mg/kg and repeat 5-10 minutes up to 3 times
or maximal dose of 3mg/kg
4) Side effect
Slurred speech, altered consciousness, muscle twitching and seizure
Hypotension, bradycardia, heart block and asystole
MAGNESIUM SULPHATE
1) An electrolyte important for maintaining membrane stability
2) Hypomagenesemia can cause myocardial hyperexcitability especially in the presence of hypokalemia or
digoxin
3) Indications
Torsades de pointes
Hypomagenesemia
Life threatening ventricular arrhythmia due to digitalis toxicity
4) Side effect
Occasional fall in BP with rapid administration
Caution in renal failure
5) Dose administrations
1-2g diluted in 10mL D5% to be given over 5-20 minutes
Torsades de pointes with pulse or AMI with hypomagenesemia: Loading dose of 1-2g mixed with
50mL D5% over 5-60 minutes, followed with 0.5 to 1g/hour (titrate to control Torsades)
VERAPAMIL
1) A calcium channel blocking drug that slows conduction and increases refractoriness in the AV node.
2) The action may terminate re-entrant arrhythmias and control of the ventricular response rate in atrial.
3)
4) Indications
Narrow complex paroxysmal SVT (unconverted by vagal maneuvers or adenosine)
Arrhythmias known with certainty to be of supraventricular origin.
5) Dose administration
2.5mg-5mg IV over 2 mins: Repeated doses
5-10mg every 15-30 minutes to a maximum 20mg
6) Side effect
If given to patient with ventricular tachycardia may cause cardiovascular collapse
May decrease myocardial contractility and critically reduce cardiac output in patients with severe LV
dysfunction
SODIUM BICARBONATE
1) A strong alkaline agent with high sodium and bicarbonate load
2) Not recommended for routine use in cardiac arrest
3) Indications
Hyperkalemia
Metabolic acidosis
Prolonged resuscitation with effective ventilation
4) Dose administration
1 mEq/kg IV infusion
5) Side effect
May cause tissue necrosis if extravasation occurs
Do not administer together with IV line used for vasopressors or calcium.
DOPAMINE
1) A chemical precursor of noradrenaline that stimulates both alpha and beta adrenergic receptors.
2) There are receptors specific for dopamine (DA1, DA2, dopaminergic receptors)
3) Stimulate the heart through both alpha and beta receptors
4) Both a potent adrenergic receptor agonist and a strong peripheral dopamine receptor agonist.
5) Indications
Second-line drugs for symptomatic bradycardia
Hypotension
6) Dose administration
Rate is 2-20ug/kg/min and dose titrated according to response
7) Side effect
Tachycardia
Hypertension
Precipitate arrhythmias
Excessive systemic and splanchnic vasoconstriction for higher dose (10-20ug/kg/min)
Correct hypovolemia with volume replacement before starting on dopamine
DOBUTAMINE
1) Used as a positive inotropic drug of choice in the post-resuscitation period.
2) It has beta-agonist activity causes vasodilatation and increase in heart rate
3) especially direct stimulation of beta-1 receptors.
4) Indications
Hypotension
Pulmonary edema
5) Dose administrations
5-20 mcg/kg/min as continuous infusion
6) Side effect
May worsen hypotension at the initial treatment.
Can increase risk of arrhythmia, including fatal arrhythmias.
NORADRENALINE
1) Strong beta-1, alpha-adrenergic effects and moderate beta-2 effects.
2) A potent vasoconstrictor with positive inotropic effect.
3) Indications
Hypotension in post resuscitation period
Cardiogenic shock
4) Dose administrations
0.05-1mcg/kg/min as continuous infusion
5) Side effect
Cause tissue necrosis if extravasation occurs.
Increase afterload and beta-effects may increase myocardial work and oxygen consumption.
Very high dose can lead into peripheral limb ischemia.
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