ECG Guru - Instructor Resources

A gathering place for instructors of ECG and cardiac topics.

       

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The ECG GURU is devoted to providing resources for ECG teachers and their students. Follow the links above or the search terms to the left to find what you are looking for.  

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Instructors' Collection ECG of the WEEK, February 17, 2015 __ Left Bundle Branch Block

Tue, 02/17/2015 - 22:54 -- Dawn

This ECG shows a “classic” left bundle branch block pattern. 

The ECG criteria for left bundle branch block are:

·        Wide QRS (.12 seconds or greater)

·        Supraventricular rhythm (ventricular rhythms do not travel via the LBB)

·        The QRS in V1 is negative, and the QRS in Leads I and V6 are positive. 

The left bundle branch (LBB) can be blocked permanently, temporarily, intermittently, or in the because of a fast rate.  When the LBB is blocked, conduction proceeds from the AV junction down the right bundle branch, depolarizing the right ventricle.  The impulse travels from the right ventricle across the left ventricle, cell by cell.  Conduction is slower this way, and there is asynchrony of the ventricles. This slow conduction and asynchrony of the two ventricles causes widening of the QRS complex.

NOTE:  It is "normal" for wide-complex rhythms to have ST segment elevation in leads with negative QRS complexes and ST depression in leads with positive QRS complexes.  This can make it a bit difficult to determine the ST changes of acute M.I. 

 

 

ECG Challenge: Grouped Beating - Double Tachycardia

Sun, 01/25/2015 - 18:42 -- Dawn

This very interesting set of strips was donated to the ECG Guru by Arnel Carmona, well-known to many of you as the Administrator of the blog, "ECG Rhythms" and the FB page by the same name.  He is a frequent contributer to the FB page, "EKG Club", and is an ECG Guru!  This set of strips was previously posted to his blog and to the EKG Club.  In case you haven't already seen it, we will withhold the interpretation for now to give everyone a chance to comment.  In one week, we will post the interpretation.

SEE THE INTERPRETATION AT THIS LINK

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Can Atrial Fibrillation be regular?

This strip is from a pt admitted for UTI.

This cropped lead II strip is from several hours of saved data and specifically posted in order and not necessarily in chronology to highlight a point.

1 - You can see a regular narrow complex tachycardia (NCT) at a rate of about 140’s. How will you read it? SVT? Atrial flutter? AF with RVR? ST with P waves buried in the T waves?

2 - There is still a regular NCT but there is a slowing with no discernible P waves. So AF RVR?

3- The same regular NCT but you can see  regularly-irregular QRS activity. Isn’t it that AF should be irregular and will not show any regularity?

4 - There are groups of 2 QRS with same R to R intervals. It is called GROUP BEATING.

5- There is a regular RR interval at a rate of about 70's with no discernible P waves. REGULARIZED AF?

A few interesting things the strip revealed:

1. The fastest rate was about 140's and the regularized rate was about 70's.

2. There is group beating. For beginners, it is hard to see the group beating but probably as you mature or, as you get so crazy and obsessed in looking at strips,  then you see it.  A few people would and most won't.

Most of us will think, can this be atrial flutter? This is what my other good friends in the ECG Club thought. I checked more than 72 hrs of tele-recordings and could not find the flutter waves. (BTW pt had chronic AF)

What do you think?



ECG Basics: Normal Sinus Rhythm With Premature Ventricular Contractions

Sat, 02/21/2015 - 18:22 -- Dawn

This ECG shows an underlying rhythm of normal sinus rhythm at a rate of 80 / min.  There are two premature ventricular contractions (PVCs).  The sinus rhythm actually continues uninterrupted, causing a “compensatory pause”.  If you march out the P waves, you may even see hints of the hidden P waves in the ST segments of the PVCs.  The P waves that occur in the ST segments of the PVCs land in the refractory period of the ventricles, and so are unable to continue into the ventricles and cause a QRS. 

 

It is also permissible to call these beats “ventricular premature beats (VPBs)” or “ventricular premature complexes (VPCs)”.  

Are You New to Laddergrams?

Fri, 02/20/2015 - 22:34 -- Dawn

A laddergram is a diagram of conduction through the heart, presented in a minimum of three tiers, one for the atria, one for the AV junction, and one for the ventricles.  Laddergrams are very useful for presenting and testing your theory of a dysrhythmia.  Instructors often use them to illustrate complex dysrhythmia mechanisms.  

If you don't yet have experience in using laddergrams, go to this LINK to find a short PowerPoint presentation that will give you the basics to get started.  Be careful - it can be a bit addicting to construct laddergrams, like working a puzzle.  If you want to use laddergrams to teach your students, this PowerPoint presentation can help you introduce them to the concept.  

Our thanks to Jason Roediger, ECG Guru and dysrhythmia expert, for the laddergram depicted here, and the many LADDERGRAMS featured in his blog posts on this site  to see the discussion accompanying this ECG, go to this LINK  (Warning: this is an ECG Challenge, which is advanced material)  

 

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