The Essentials of 12-lead ECG & Rhythm Recognition.

A presentation I put together for a teaching session for non-speciality band 5s.
Due to the session being only 45 mins, this is a streamlined presentation of the basics, but may be of interest to those wanting a whistle-stop tour.

Transcript

1. Simon Mark Daley (2020).
2. Objectives; Understand why and how to obtain an ECG and perform 3, 4, 5 lead rhythm monitoring. Identify the features of a "normal" ECG and heart rhythm, as well as what might not be normal. Understand how to approach the interpretation of a heart rhythm. Recognise red-flag abnormalities and when to get help.
3. Why obtain a 12 lead ECG? Acute chest pain Palpitation Syncope / pre-syncope Unexplained clinical deterioration / High NEWS Post cardiac arrest Drug overdose; deliberate or accidental Breathlessness Significant hypertension Why cardiac monitor? (3, 4, 5 lead) Arrhythmia / risk of / suspected arrhythmia Bradycardia / tachycardia Drug infusions - pro-arrhythmic/inotropic, electrolyte replacement etc Risk of further clinical deterioration
4. 3, 4 or 5 lead cardiac monitoring; Remember that most of these units will not record and will demonstrate live telemetry (as it happens) only.
5. Obtaining a 12 lead ECG; limb leads
6. Obtaining a 12 lead ECG; chest leads
7. A "normal" 12 lead ECG;
8. Electrical Conductive System;
9. Timing/intervals; ECG paper speed should always be pre set at 25mm/s. ECG amplitude (height) shuld be pre set to 10mv.
11. Timing/intervals; 120-200ms (0.12-0.20 seconds) 3-5 small squares PR INTERVAL QRS INTERVAL <120ms (<0.12 seconds) <3 small squares QT INTERVAL <450ms Clinicians will refer to the corrected QT or QTc - this is the QT interval corrected for HR
12. CHECK THE DETAILS WHAT IS THE CONTEXT? Right patient? Right time (check date) First things first; Why was the ECG performed? What were the corresponding symptoms? How does this ECG relate to other vital signs such as BP? WHAT HAS CHANGED? How does this compare to previous ECGs and/or rhythm monitoring?
13. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW). ADDITIONALLY FOR 12 LEAD ECGS; WHAT IS THE ST SEGMENT DOING? How to interpret the rhythm; If you can answer these questions and communicate this, you can describe a rhythm/ECG to another HCP without needing to fully interpret what you are seeing.
14. Calculating HR (ventricular rate); Method 1 Method 2 Count the large squares between QRS complexes. Divide 300 by this number. Eg; 300 / 4 = 75bpm. Count the number of QRS complexes within 30 large squares (6 seconds) and multiply by 10.
15. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW).
16. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW).
18. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW).
19. Underlying atrial rate is 300; ergo the HR in flutter will generally be a multiple of this (150 /100 /75 bpm.
20. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW).
21. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW). LIFE THREATENING TACHYARRHYTHMIAS Ventricular tachycardia Ventricular fibrillation Torsades de pointe
22. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW). Bradycardias; Sinus bradycardia Asystole Ventricular standstill or "P wave asystole"
23. IS THERE ATRIAL ACTIVITY PRESENT? (P WAVES). IS ATRIAL ACTIVITY RELATED TO VENTRICULAR ACTIVITY? IF YES, WHAT IS THE RELATIONSHIP? (RATIO OF P WAVES TO QRS COMPLEXES). WHAT IS THE VENTRICULAR RATE? (HR). IS THE VENTRICULAR RATE REGULAR OR IRREGULAR? IS THE QRS COMPLEX WIDTH NORMAL OR PROLONGED? (BROAD OR NARROW). Heart blocks; 1st degree AVB 2nd degree AVB - Mobitz 1 2nd degree AVB - Mobitz 2 3rd degree AVB - Complete Heart Block
24. Myocardial Ischaemia;
25. Myocardial Ischaemia;
26. NON-ISCHAEMIC ST SEGMENT ELEVATION ST SEGMENT DEPRESSION T WAVE INVERSION Myocardial Ischaemia;
27. ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI); Myocardial Ischaemia;
28. ST DEPRESSION; Myocardial Ischaemia;
29. T WAVE INVERSION; Myocardial Ischaemia;
30. Red flags. ST SEGMENT ELEVATION ST DEPRESSION DYNAMIC T WAVE INVERSION HEART BLOCK WITH HAEMODYNAMIC COMPROMISE HR<40 TACHYARRHYTHMIA WITH HAEMODYNAMIC COMPROMISE HR>150 BROAD COMPLEX
31. Thank you for listening. Comebacks queries or concerns? This presentation (and others that may be of interest) can be found at speakerdeck.com/simonmark