ECG Interpretation for Health Professionals

1. 1.1 Why the ECG matters here6 min
2. 1.2 The conduction system and the PQRST8 min
3. 1.3 Paper, boxes and calibration7 min
4. 1.4 Recording a good ECG8 min
5. 1.5 Pacemakers of the heart6 min

Objectives. Explain how the normal cardiac impulse travels from the sinus node to the Purkinje fibres and how each part of the PQRST reflects it. State the standard paper speed and calibration and read time and voltage from the grid. Place the ten electrodes for a 12 lead ECG correctly and recognise common artefacts. Name the three pacemakers of the heart and their intrinsic rates. Explain why the ECG matters for the cardiovascular burden seen in African hospitals.

1. 2.1 The method6 min
2. 2.2 Step 1. Rate8 min
3. 2.3 Step 2. Regularity7 min
4. 2.4 Step 3. P waves7 min
5. 2.5 Steps 4 and 5, and the summary8 min

Objectives. Calculate heart rate from a strip by the six second method and by the large box sequence. Classify regularity as regular, occasionally irregular, regularly irregular or irregularly irregular. Assess P waves for presence, uniformity, rate and relationship to the QRS. Measure the PR interval and the QRS duration and compare them with normal limits. Write a five line rhythm summary and an interpretation.

1. 3.1 Normal sinus rhythm6 min
2. 3.2 Where arrhythmias come from7 min
3. 3.3 Sinus rhythms that are too slow or too fast7 min
4. 3.4 Classifying any rhythm6 min

Objectives. State the five parameters of normal sinus rhythm. Explain how problems in the sinus node, atrial cells, AV junction and ventricular cells each produce a family of arrhythmias. Describe re-entry and ectopic focus formation in plain words. Classify any rhythm by the site of its origin and the mechanism. Recognise sinus arrhythmia and other normal variants that should not be treated.

1. 4.1 The narrow or wide rule6 min
2. 4.2 Premature atrial complexes7 min
3. 4.3 Premature ventricular complexes8 min
4. 4.4 Aberrancy and the wide beat that is not ventricular6 min

Objectives. Recognise premature atrial complexes and premature ventricular complexes on a strip. Explain why supraventricular beats are narrow and ventricular beats are wide. Distinguish uniform from multiform, and isolated from patterned, ventricular ectopy. Decide when premature beats need investigation and when they need reassurance. Recognise the dangerous contexts, ischaemia, electrolytes and cardiomyopathy.

1. 5.1 Atrial fibrillation, the diagnosis7 min
2. 5.2 Atrial fibrillation, the plan9 min
3. 5.3 Atrial flutter7 min
4. 5.4 Paroxysmal supraventricular tachycardia8 min

Objectives. Recognise atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardia on a strip and describe each in five lines. Explain the mechanism of each and why it matters for treatment. Apply the CHA2DS2-VASc score and explain anticoagulation choices available in African hospitals. Describe first line management of a stable and an unstable narrow complex tachycardia per ESC and AHA guidance. Recognise atrial fibrillation in rheumatic mitral stenosis as a high stroke risk that needs warfarin.

1. 6.1 Ventricular tachycardia8 min
2. 6.2 Ventricular fibrillation and pulseless VT8 min
3. 6.3 Asystole, PEA and the reversible causes7 min
4. 6.4 Torsades and the long QT7 min

Objectives. Recognise ventricular tachycardia, ventricular fibrillation, torsades de pointes, asystole and pulseless electrical activity. Classify arrest rhythms as shockable or non shockable and state the first action for each per ILCOR based guidelines. Manage a wide complex tachycardia with a pulse, stable and unstable. Recognise the reversible causes of arrest and the ECG clues to hyperkalaemia and long QT. Lead the first two minutes of a cardiac arrest in a hospital with a manual or automated defibrillator.

1. 7.1 First degree AV block6 min
2. 7.2 Second degree AV block type I, Wenckebach7 min
3. 7.3 Second degree AV block type II7 min
4. 7.4 Third degree, complete heart block8 min

Objectives. Recognise first degree, second degree type I, second degree type II and third degree AV block on a strip. Explain the site and mechanism of each block and why type II and third degree are dangerous. Describe the causes of AV block seen in African practice, including drugs, inferior infarction, rheumatic and infective disease. Apply the AHA bradycardia algorithm, atropine, transcutaneous pacing and infusions, and know when to refer for a pacemaker. Communicate a heart block diagnosis clearly by telephone using the five lines.

1. 8.1 Twelve views of one heart7 min
2. 8.2 ST elevation and the STEMI criteria9 min
3. 8.3 Localising the infarct and watching it evolve8 min
4. 8.4 Reperfusion in an African hospital9 min

Objectives. Explain what each of the twelve leads looks at and group them into inferior, lateral, septal and anterior territories. Apply the Fourth Universal Definition criteria for ST elevation and recognise reciprocal changes. Localise an infarction to a coronary territory from the leads involved. Distinguish ST elevation from non ST elevation acute coronary syndromes and describe the evolving changes over hours and days. State the time targets for reperfusion and how a district hospital in Africa delivers fibrinolysis or transfer.

1. 9.1 The QRS axis7 min
2. 9.2 The intervals8 min
3. 9.3 Hypertrophy and enlargement8 min
4. 9.4 Bundle branch blocks8 min
5. 9.5 Patterns that change management today8 min

Objectives. Determine the QRS axis from leads I and II and name left, right and extreme deviation. Measure and interpret the PR, QRS and corrected QT and list their common causes. Apply voltage criteria for left and right ventricular hypertrophy and P wave criteria for atrial enlargement. Recognise right and left bundle branch block from V1 and V6 and explain why new LBBB matters. Recognise the ECG patterns of hyperkalaemia, pericarditis, pre-excitation and digoxin effect.

1. 10.1 The six steps7 min
2. 10.2 Worked case one, the young man after trauma9 min
3. 10.3 Worked case two, the hypertensive man8 min
4. 10.4 Reporting and handing over7 min
5. 10.5 Your ECG protocol and unit plan, capstone10 min

Objectives. Apply the six step method to any 12 lead ECG and write a structured report. Integrate the ECG with the patient to reach one of four decisions, treat, refer, repeat or reassure. Hand over an ECG finding by telephone using SBAR and the five or six lines. Audit ECG timeliness and reading quality in a unit using two simple indicators. Write a personal ECG reading protocol and an improvement plan for the unit.