ECGs by example

239 Pages·2011·7.52 MB·English

by  Richard Dean Jenkins

ECGs by
Example
For Elsevier
Senior Commissioning Editor: Laurence Hunter
Development Editor: Carole McMurray
Project Manager: Cheryl Brant
Designer: Charles Gray
Illustration Manager: Gillian Richards
ECGs by
Example
Dean Jenkins Stephen Gerred
MB BCh DipMedEd FRCP MBChB FRACP
Honorary Consultant Physician Consultant Gastroenterologist
Royal Cornwall Hospital Middlemore Hospital
Truro Auckland
UK New Zealand
THIRD EDITION
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2011
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First edition 1997 injury and/or damage to persons or property as a matter of
Second edition 2005 products liability, negligence or otherwise, or from any use or
Third edition 2011 operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN 978-0-7020-4228-7
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Notices
Knowledge and best practice in this field are constantly
changing. As new research and experience broaden our
understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Printed in China
ACCOKNNTEONWTLSEDGEMENTS v
Introduction vii 31 Polymorphic ventricular tachycardia 65
An approach to the ECG viii 32 Polymorphic ventricular tachycardia –
Acknowledgements x ‘torsade de pointes’ 67
33 Ventricular flutter 69
34 Ventricular fibrillation (VF) 71
Section 1 Supraventricular rhythms
1 Normal sinus rhythm 3 Section 3 Bundle branch block
2 Normal sinus rhythm with a normal
U wave 5 35 Right bundle branch block (RBBB) 75
3 Sinus arrhythmia (irregular sinus rhythm) 7 36 Incomplete right bundle branch block 77
4 Sinus tachycardia 9 37 Left bundle branch block (LBBB) 79
5 Sinus bradycardia 11 38 Incomplete left bundle branch block 81
6 Atrial bigeminy 13 39 Left anterior hemiblock 83
7 Atrial trigeminy 15 40 Left posterior hemiblock 85
8 Ectopic atrial rhythm 17 41 Right bundle branch block with left anterior
9 Multifocal atrial tachycardia 19 hemiblock (bifascicular block) 87
10 Atrial fibrillation 21 42 Right bundle branch block with
11 Atrial fibrillation with rapid ventricular left anterior hemiblock and
response 23 long PRinterval (‘trifascicular’ block) 89
12 Atrial fibrillation and bundle branch 43 Phasic aberrant ventricular conduction 91
block 25
13 Atrial flutter 27
Section 4 Heart block
14 Atrial flutter with 2:1 AV block 29
15 Atrial flutter with variable AV conduction 31
44 First degree heart block 95
16 Accelerated junctional rhythm 33
45 Second degree heart block – Mobitz type 1
17 Junctional bradycardia 35
or Wenckebach AV block 97
18 Paroxysmal SVT – AV nodal re-entry
46 Second degree heart block – Mobitz
tachycardia 37
type 2 99
19 Paroxysmal SVT – AV reciprocating
47 Second degree heart block – 2:1 AV
tachycardia (orthodromic) 39
block 101
20 AV reciprocating tachycardia
48 Second degree heart block – high grade 103
(antidromic) 41
49 Third degree heart block – wide complex
21 Wolff–Parkinson–White syndrome with atrial
escape 105
fibrillation 43
50 Third degree heart block – narrow complex
22 Supraventricular tachycardia with aberrant
escape 107
conduction 45
51 Third degree heart block and atrial
23 Sick sinus syndrome 47
fibrillation 109
Section 2 Ventricular rhythms
Section 5 Pacemakers
24 Ventricular premature beat (VPB) 51
52 Ventricular pacemaker 113
25 Ventricular bigeminy 53
53 Dual chamber pacing (AV sequential
26 Accelerated idioventricular rhythm 55
pacing) 115
27 Ventricular tachycardia – atrioventricular
54 Problems with pacemakers – failure to
dissociation 57
sense 117
28 Ventricular tachycardia – capture and fusion
55 Problems with pacemakers – failure to
beats 59
capture 119
29 Ventricular tachycardia – morphology of
56 Polymorphic VT with cardioversion and
VPB 61
pacing by an implantable cardioverter
30 Ventricular tachycardia – myocardial
defibrillator (ICD) 121
infarction 63
vi
Section 6 Ischaemic heart disease 78 Hyperkalaemia (extreme ECG
features) 171
57 Myocardial ischaemia – ST depression 125 79 Hypokalaemia 173
58 Myocardial ischaemia – T wave inversion 127 80 Hypocalcaemia 175
59 Myocardial ischaemia – non-specific 81 Hypercalcaemia 177
changes 129 82 Digoxin (digitalis) effect 179
60 Acute extensive anterior myocardial 83 Tricyclic antidepressant overdose 181
infarction 131
61 Acute anterolateral myocardial
Section 9 Technical issues
infarction 133
62 Acute anteroseptal myocardial
84 Electrical interference 185
infarction 135
85 Skeletal muscle interference 187
63 Acute ‘high’ lateral myocardial
86 Regular skeletal muscle
infarction 137
interference 189
64 Acute inferior myocardial infarction 139
87 ‘Technical’ dextrocardia 191
65 Very early acute inferior myocardial
88 Misplaced chest leads 193
infarction 141
66 Acute right ventricular infarction 143
67 Acute posterior myocardial Section 10 Miscellaneous
infarction 145
68 Acute anterior myocardial infarction in the 89 The athletic heart 197
presence of left bundle branch block 147 90 Acute pulmonary embolus (PE) 199
91 Cardiac amyloidosis 201
92 Arrhythmogenic right ventricular dysplasia
Section 7 Hypertrophy patterns
(ARVD) 203
93 Left ventricular aneurysm 205
69 Right atrial abnormality (P-pulmonale) 151
94 Acute pericarditis 207
70 Left atrial abnormality (P-mitrale) 153
95 Pericardial effusion 209
71 Biatrial hypertrophy 155
96 Pericardial effusion with electrical
72 Right ventricular hypertrophy (RVH) 157
alternans 211
73 Left ventricular hypertrophy (LVH) - limb lead
97 Wolff–Parkinson–White syndrome (1)
criteria 159
(ventricular pre-excitation) 213
74 Left ventricular hypertrophy (LVH) - chest
98 Wolff–Parkinson–White
lead criteria 161
syndrome (2) 215
75 Biventricular hypertrophy 163
99 Lown–Ganong–Levine syndrome 217
100 Congenital long QT syndrome
(LQTS) 219
Section 8 Systemic disorders and
101 Dextrocardia 221
drug effects
102 Auxiliary (heterotopic or ‘piggyback’) heart
transplant 223
76 Hypothermia 167
77 Hyperkalaemia (subtle ECG changes) 169 Index 225
AINCTKRNOODWULCETDIOGNEMENTS vii
‘Real ECGs on the ward never look like the Heart Association (Fish C et al 1995 Clinical
diagrams I’ve seen in textbooks.’ competence in electrocardiography. Journal
of the American College of Cardiologists
‘I’ve read and understood the ‘The ECG
25(6): 1465-1469). This report lists the
Made Easy’ but I still get lost when
electrocardiographic features that a
confronted with the real thing.’
competent physician should be able to
These are typical of the comments we have recognise.
heard when trying to teach electro-
cardiography to medical students, nurses, How to use this book
paramedics, or junior doctors. They are the Each individual case consists of a full size
reason why we have written this book. They ECG with a brief sentence summarising the
are the reason why this book is different. patient’s clinical presentation. Below each
ECG there is a critique starting with a list of
If you’ve read and understood an diagnostic features, then a full report of the
introductory ECG book, such as John ECG and any other clinical details that may be
Hampton’s “The ECG Made Easy”, but still important. On most pages there is also a box
get fazed by the real thing when it confronts of common causes or associations. There are
you in the Emergency Department or on the also a number of relevant radiological images.
ward, then this book is for you. All the You may wish to read the book as a text, use
examples are actual ECG recordings as they it to test yourself and others, or simply use it
would appear in everyday practice. Each for reference purposes.
recording is at standard speed and size;
25 mm/sec, 1 cm/mV. We have endeavoured Becoming competent at interpreting real
to include as many as possible of the ECGs depends on seeing as many examples
commonly encountered abnormalities as well as possible and discussing them with a
as some less common ECG findings which senior colleague. You may wish to use this
are of clinical importance. This third edition book as a guide to building a comprehensive
sees the addition of several new cases as ECG collection of your own.
well as a number of updated cases. The
content is based on a joint report by the
American College of Physicians, American 2010 Dean Jenkins
College of Cardiology and the American Stephen Gerred
viii AN APPROACH TO THE ECG
We are not going to expand a method for The ECG is the best bedside tool for cardiac
the systematic interpretation of the arrhythmias and the investigation of
electrocardiogram as this has been done in suspected acute coronary syndromes but
many other ECG books. This book is about even in these cases remember to request an
the ECG in the context of everyday practice - ECG, or record one yourself and,
giving examples of how it appears in the importantly, multiple copies of the ECG
clinic or on the ward round. We’d like to when the clinical circumstances change, a
share a practical approach to the ECG in procedure is performed, or the existing
clinical practice so that it can be used to its ECGs are not diagnostic. It is better to have
best advantage. multiple ECGs that can be archived in the
patient’s notes than to be wishing that one
First you need to remember to use the ECG. had been taken at a certain point in the
It is a tool that can be overlooked especially past.
when it has been taken, as a matter of routine,
by someone else in the clinical team before you In the acute setting you need to be tactical
have even seen the patient. As a bedside with the use of the ECG. Sometimes it is
instrument that is available in many healthcare better to have a poor recording, or just the
settings it can be very useful in making a printout from a monitoring chest lead
clinical diagnosis. Situations where it may be [page 67 for torsade des pointes VT], when
overlooked are those that are not obviously other clinical circumstances prevent the
cardiac. Look at the systemic disorders and careful recording of a 12-lead ECG.
drug effects [Section 8] and the miscellaneous Rhythm and morphology aren’t always
[Section 10] parts in this book for many necessary to have at the same time.
example of how an ECG can help clinch a Acute medicine is often about judging
diagnosis or management plan. In general it is priorities.
a tool that has high specificity but low
sensitivity. The ECG often confirms a diagnosis Assuming that a good 12-lead recording is
but it is not soo good at excluding a diagnosis. required then the best way to prepare for
This is discussed in particular in the section on interpretation is to start by taking the
hypertrophy patterns [Section 7]. Screening for recordings yourself. They don’t take long to
left ventricular hypertrophy is better achieved do and, with practice, you can take the
by the use of echocardiography however, history from the patient as your setting up
where the diagnostic criteria are present on the electrodes saving time and building a
the ECG, it can identify cases accurately. rapport with your patient.
ix
Become familiar with where the wires are – V5 anterior axilliary line (same level as V4)
attached: – V6 mid axilliary line (same level as V4)
– both ankles and both wrists
– V1 right 4th intercostal space at the See the section on technical issues [Section 9]
sternum for details of common problems that may
– V2 left 4th intercostal space at the sternum occur with the recording of an ECG.
– V3 halfway between V2 and V4
– V4 at the apex beat (5th intercostal space,
midclavicular line)
Mid clavical line
Angle of Louis Anterior axillary line
1 2 Mid axillary line
3
4 5 6