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ECGs for acute block – a suggested approach: Information to check on every ECG: Identifying information: name/unit number Date/time Voltage (10mm/mV) Speed (25mm/s) Rate: Remember 1 small square is 0.04s, 1 large square is 0.2s, 5 large squares is 1 second (one small square is 1mm) 300/number large squares between R-R (eg if there are 5 large squares between complexes then the rate is 60/min) Rhythm: Is it regular or irregular? Easiest way to tell is to use scrap paper to mark R waves and check they are regular. Are there P-waves? (if no then atrial fibrillation, SVT or ventricular rhythm) Is each P followed by a QRS? If no then 2nd or 3rd degree heart block present Normal PR interval 0.12-0.2s (3-5 small squares): If prolonged PR interval but constant then 1st degree heart block: If progressive prolongation of PR interval, then a P wave with no subsequent QRS then it is Mobitz type 1 2nd degree heart block (Wenkebach): If PR interval is constant but there are P waves with no subsequent QRS then it is Mobitz type 2 2nd degree heart block: 2nd degree heart block can also be regular 2:1, 3:1, 4:1 block etc Higher grade blocks are more dangerous (more at risk of asystole) If there is no relationship between the P waves and QRS complexes then it is 3rd degree (or complete) heart block: Is each QRS preceded by a P wave? If no – atrial fibrillation, ectopic beats, junctional escape rhythms Axis: I and II positive = normal axis I positive, II & III negative = left axis deviation [“Leaving”] I negative, II & III positive = right axis deviation [“towaRds”] QRS: Normal QRS <0.12s (3 small squares) width Wide QRS = either a beat arising from the ventricle (ectopic, escape rhythm, VT) or a conduction defect – usually bundle branch block Left bundle branch block [WiLLiaM] Right bundle branch block [MaRRoW] LVH criteria V4, V5, V6 R wave = >25mm R wave in V5 or V6 plus S wave in V1 = >35mm ST segments: ST elevation: STEMI, left bundle branch block, (pericarditis if global) STEMI criteria if: 2mm in 2 consecutive chest leads, or 1mm in 2 limb leads ST depression: ischaemia, posterior MI, NSTEMI, digoxin T-wave: Tall – hyperkalaemia, LBBB Flat – ischaemia, hypokalaemia Inverted - ischaemia How to tell which area of the heart is ischaemic/infarcted: ST changes Area of heart Coronary artery V1 – V6 Anterior LAD V1 - V4 Septal LAD I, aVL, V5, V6 Lateral Circumflex II, III, aVF Inferior RCA/circumflex V7-9 Posterior Circumflex Other resources: ECG made easy, Hampton. Making sense of the ECG. Houghton & Gray (and they have a self assessment book) ECGs by example, Jenkins & Gerred Online resources: (FOAM!) Overview at foamedstudent.com Dr Smith’s ECG blog: http://hqmeded-ecg.blogspot.com.au/ Amal Mattu’s ECG blog: http://ekgumem.tumblr.com/ Learn the heart: http://www.learntheheart.com/ecg-review/ecg-quiz/ Ecglibrary.com