WEBVTT 1 00:00:23.360 --> 00:00:29.790 I welcome everybody to another introductory family practice residency lectures and 2 00:00:29.800 --> 00:00:34.690 this one is in Taiwan he introduction or approach to the electrocardiogram and I 3 00:00:34.700 --> 00:00:39.510 think you'll find that you know with all our technology you know as sort of 4 00:00:39.520 --> 00:00:44.600 a little quote that it says with all our modern technologies our modern sort of 5 00:00:44.990 --> 00:00:51.750 magic with electronics. I think that nothing is still going to 6 00:00:51.760 --> 00:00:57.960 replace going to replace it careful physical examination of their old history and 7 00:00:57.970 --> 00:01:04.560 well interpretive electric The scene was invented over 100 years ago. By doctors 8 00:01:04.570 --> 00:01:10.710 Waller and I'm told and and it still has tremendous utilization today and frankly 9 00:01:10.720 --> 00:01:14.080 even though we have computerized analysis or departing hands now it's 10 00:01:14.090 --> 00:01:18.880 a lot easier you still need to look at the cage yourself because don't rely on 11 00:01:18.890 --> 00:01:24.920 a computer and asks the computer is still down it still makes mistakes and I think 12 00:01:24.930 --> 00:01:28.750 it was an article in medical journals of Cardiology journals that just came out 13 00:01:28.760 --> 00:01:35.150 yesterday the pitfalls and the dangers of the line only until after argument gets 14 00:01:35.160 --> 00:01:38.910 interpreted by the computer you will find not commonly they still get phone calls 15 00:01:38.920 --> 00:01:43.700 like this a lot if the computer is a acute myocardial infarction acute m.r.i. 16 00:01:43.700 --> 00:01:44.950 . Not 17 00:01:45.440 --> 00:01:50.830 a snap or each of the relation Rachel's letter in fact the patient. 18 00:01:52.770 --> 00:01:57.200 Not uncommon that you'll see in the patients above it will provision in what the 19 00:01:57.210 --> 00:02:01.690 patient period and in fact it is an old saying. Garbage in garbage out well there's 20 00:02:01.700 --> 00:02:05.290 not a good electron is not good data put in the letter cardiogram of there's 21 00:02:05.300 --> 00:02:09.470 a lot of artifacts you're not going to be able to interpret them so what I'm 22 00:02:09.620 --> 00:02:11.760 telling you and I have to confess I've got to give you 23 00:02:11.770 --> 00:02:15.880 a present you can show this actually persone you know this is just and I'll bring 24 00:02:15.890 --> 00:02:20.170 my what's here and you know that show you guys later but this is actually I was 25 00:02:20.230 --> 00:02:26.480 interested. In the k.g.s. I have tremendous training in my training program in c. 26 00:02:26.530 --> 00:02:29.040 Books in the city in k.g.s. 27 00:02:29.160 --> 00:02:33.560 Him when I was studying for the cardiology boards there are lots of you get your 28 00:02:33.570 --> 00:02:38.600 books out there there are hundreds to get you. There but there are very few to 29 00:02:38.610 --> 00:02:45.390 actually train you specifically to study for the cardiology for which one full 30 00:02:45.400 --> 00:02:48.230 day's testimony came and I'm looking for 31 00:02:48.240 --> 00:02:52.680 a book and I decided you know. I can write a book and there isn't 32 00:02:52.690 --> 00:02:56.390 a book there just wasn't there so 7 years later and 33 00:02:56.400 --> 00:03:01.430 a lot of headache and trouble but anyway so this is actually all over the world and 34 00:03:01.440 --> 00:03:05.300 it's in the 2nd edition translated into Chinese in Portuguese and it's kind of 35 00:03:05.310 --> 00:03:12.040 falls off so it's in the library it's in the White House on Amazon. I don't want 36 00:03:12.050 --> 00:03:16.840 your help I think but I'm actually working on another book right now which I will 37 00:03:16.850 --> 00:03:21.820 be asking for your input to be honest with you because I really would like this 38 00:03:21.860 --> 00:03:25.720 this is written primarily for part of our cardiologists it's 39 00:03:25.730 --> 00:03:29.340 a little bit more advanced We're cardiology training but it is actually still 40 00:03:29.580 --> 00:03:30.220 really just 41 00:03:30.620 --> 00:03:37.170 a study of the works but. The book I'm working on right now is actually the work 42 00:03:37.180 --> 00:03:42.500 for any. Dissent that everybody how much training by the way to people and he by 43 00:03:42.510 --> 00:03:46.320 the way I have very little in that school if you have any formal lectures in 44 00:03:46.330 --> 00:03:50.090 Katie's going to. Be in my area. 45 00:03:53.190 --> 00:03:58.470 Every penny of that was. Merely body of some some to some people meant when I had 46 00:03:58.480 --> 00:04:05.460 very little in my command school. Yeah you know here going by the 47 00:04:05.470 --> 00:04:09.090 way this is the norm going to really go some people have some so don't feel it all 48 00:04:09.100 --> 00:04:12.870 right or have any training everybody else has something you know you can't joke in 49 00:04:12.880 --> 00:04:17.290 frankly it is helpful that we do have you we're trying to interpretation if you are 50 00:04:17.300 --> 00:04:21.760 a little bit weak but you'll find that this is the we still very very important you 51 00:04:21.770 --> 00:04:25.630 do this now this is just going to be approachable have some fun looking at some of 52 00:04:25.640 --> 00:04:30.930 the electrocardiogram stand. Will find 2 is that you know everybody I mean sure you 53 00:04:30.940 --> 00:04:34.550 have your calendars you know I don't speculate on how that would be these things. 54 00:04:35.900 --> 00:04:40.810 Are very helpful you sold your calendars. Which will help you you know into 55 00:04:40.820 --> 00:04:46.240 a good deal a few years now it's less important now because there's a lot the u.k. 56 00:04:46.250 --> 00:04:51.540 G.'s do figure out you know story and figure out the rates the news that used to be 57 00:04:51.550 --> 00:04:51.790 just 58 00:04:51.800 --> 00:04:56.650 a blank piece of paper until fairly recently but now the intervals in the media are 59 00:04:56.660 --> 00:05:02.290 pretty good now I want to give you just the basic basic you describe for this to 60 00:05:02.300 --> 00:05:09.250 just this approach just the. Doctor and. It's not that 61 00:05:09.260 --> 00:05:12.590 tough in terms of learning how to approach and just 62 00:05:12.600 --> 00:05:17.830 a very very basic step by step guide number one you want to dig in and look at the 63 00:05:17.840 --> 00:05:21.970 really look at the cardiac rhythm and by looking at the Cartier rhythm you want to 64 00:05:21.980 --> 00:05:27.780 see is as Dr Mariano said sure sure lucky and the trick here he said the difficulty 65 00:05:27.780 --> 00:05:29.510 . Is there are a p. 66 00:05:29.520 --> 00:05:30.810 Wave Q 67 00:05:30.820 --> 00:05:36.770 r s and his or if you are us very people that's how you will and either the ways 68 00:05:36.780 --> 00:05:41.350 and others you are assessed That's the 1st thing you want to look at in terms that 69 00:05:41.360 --> 00:05:46.820 will help you determine the rhythm then we look at determining the rate. There is 70 00:05:46.830 --> 00:05:52.370 the real rate and the future to the rate they may not be the same. You want to do 71 00:05:52.380 --> 00:05:58.550 indeed you could but. You would describe the relationship between the each real to 72 00:05:58.560 --> 00:06:02.930 suit the Chamber of. Chavan tickles the lower chambers of the key ways and if you 73 00:06:02.940 --> 00:06:07.070 are asked you want to determine the relationship because sometimes depending on the 74 00:06:07.080 --> 00:06:13.630 rate the hair not always the way. You will measure the intervals look at the 75 00:06:13.640 --> 00:06:20.480 electrical axis. Look at it or at the top of complexes premature interest premature 76 00:06:20.490 --> 00:06:24.910 super contributor premature contributor once was and then you look at the ways 77 00:06:25.330 --> 00:06:30.470 squiggles I remember when I did my 1st rotation it Brown was on 78 00:06:30.480 --> 00:06:34.390 a surgical rotation in the surgeon goes let's go talk to the squiggly governors you 79 00:06:34.400 --> 00:06:36.540 know we need to find out pretty on this we knew that it was 80 00:06:36.550 --> 00:06:41.050 a cardiologist because we deal with all this work. Well you will look at those 81 00:06:41.090 --> 00:06:45.420 labels the waves in the segments and we will go over this in another session this 82 00:06:45.430 --> 00:06:45.570 is 83 00:06:45.580 --> 00:06:50.690 a basic session here and just absent. You look for conduction error maladies on the 84 00:06:50.700 --> 00:06:55.190 range of blocks the Secure the blocks chamber enlargement of 85 00:06:55.250 --> 00:06:58.610 a drill and contributor you look at the s.p. 86 00:06:58.620 --> 00:07:03.190 Segments for a skin Union and infarction to look at the Q waves you are assuming 87 00:07:03.430 --> 00:07:08.080 a 2nd course. Creates citation w w 88 00:07:08.690 --> 00:07:15.340 n various Maslany as conditions conditions like poor geisha and. Electoral have you 89 00:07:15.350 --> 00:07:22.120 know so in the middle and when I like to say if you identify the findings 1st 90 00:07:22.740 --> 00:07:29.190 identify the findings both normal and abnormal and then synthesize and that's 91 00:07:29.200 --> 00:07:31.930 really true of on most things you look at an x. 92 00:07:31.940 --> 00:07:36.090 Ray you have made the identification normal a normal and then say this is either 93 00:07:36.100 --> 00:07:36.950 a normal chest x. 94 00:07:36.960 --> 00:07:42.950 Ray work there are some abnormalities there that appear to resemble something well 95 00:07:42.960 --> 00:07:48.530 that's truly letter card and dental 5 their findings and then synthesize them by 96 00:07:48.540 --> 00:07:52.680 means into what you're going to get graphic diagnosis All right so let's look at 97 00:07:52.690 --> 00:07:55.590 some of these and Sunny we will get to some of these We'll get to some of the 98 00:07:55.600 --> 00:08:00.400 slides we'll be able to actually pick people only I want to reject the. So we could 99 00:08:00.410 --> 00:08:05.850 stand up so this is going to be 2nd best 2nd best Let's look at the 1st one we 100 00:08:05.860 --> 00:08:12.670 can't. So. Let's look at the rate and frankly be would say 101 00:08:12.910 --> 00:08:18.360 Good now is that we do have the rhythm stripped down about how. You look most of 102 00:08:18.370 --> 00:08:22.280 the E.K.G.'s that are presented they are the findings of the above and then there's 103 00:08:22.290 --> 00:08:28.310 a lead to rhythm strip and it's all simultaneous at the same time so let's just do 104 00:08:28.320 --> 00:08:30.430 this we're going to go through these quickly because we only have 105 00:08:30.440 --> 00:08:35.090 a half an hour so we will do now. Is there 106 00:08:35.350 --> 00:08:39.560 a people way for every few hours just we could do all the bottom here is your if 107 00:08:39.570 --> 00:08:44.790 you were asked very busy way. So really and we're and we're not going to get broad 108 00:08:45.210 --> 00:08:49.960 tied up on the rate but if you remember from sort of counting it if you look at the 109 00:08:49.970 --> 00:08:54.970 rate here you'll put your caliper or you can count it visually counting the big 110 00:08:54.980 --> 00:09:01.940 boxes 301-5175 number counting down 301 to be 175-6050 in 111 00:09:01.950 --> 00:09:07.470 the big boxes you put that in the Raiders in the mid $77070.00 comes out by the 112 00:09:07.480 --> 00:09:11.800 computer their age are always the same as the contributor rate so there's 113 00:09:11.810 --> 00:09:16.340 a constant relationship between the 2 if you're looking at the intervals there or 114 00:09:16.350 --> 00:09:16.960 the p.r. 115 00:09:16.970 --> 00:09:23.510 Interval. It's pretty good right counting your small boxes about point 16 or 116 00:09:23.520 --> 00:09:30.030 so if you are asked is about a point oh wait. The cue t.v. 117 00:09:30.040 --> 00:09:35.410 Or looking is about. Point $35.00 and remember the Q 118 00:09:35.420 --> 00:09:39.640 t interval they're raised with the heart rate the normal cutie interval vary but 119 00:09:39.650 --> 00:09:44.920 there are great slow are great she was more prolonged we're not going to get bogged 120 00:09:44.930 --> 00:09:50.770 down in that today because they're so here's this letter cardiogram Well let's 121 00:09:50.820 --> 00:09:57.470 listen target the rhythm is. Scientists. Looking through on their any 122 00:09:57.480 --> 00:09:58.030 s.t.t. 123 00:09:58.040 --> 00:10:04.780 We have to Mounties here in. When he sees no right to correct. The we 124 00:10:05.120 --> 00:10:10.560 can looking at the voltage. The voltage in the Middle East looks good the bold in 125 00:10:10.570 --> 00:10:15.330 the recordable leaves looks good doesn't look in March so this in this e.k.g. 126 00:10:15.340 --> 00:10:21.911 Is normal can't have that's an easy way I want to give you that. Next 127 00:10:22.731 --> 00:10:28.451 Tracy. We should be able Coakley in order to know what show me as you can see 128 00:10:29.191 --> 00:10:33.011 they're all right so let's look at this all right let's looks down at the rhythms 129 00:10:33.021 --> 00:10:35.001 Rubeus your own people way with every q.r. 130 00:10:35.011 --> 00:10:39.801 Resnik your eyes with every the way looking along there is there is some neck 131 00:10:39.811 --> 00:10:43.741 Tawfiq beach there but is there a peak or you are asked in a curious for every p.d. 132 00:10:43.751 --> 00:10:48.691 Answer is Yes Ok so we know then this is likely to be 133 00:10:48.701 --> 00:10:54.971 a sinus rhythm as we go through. Will measure our intervals here. 134 00:10:56.491 --> 00:11:03.411 In Samoa point 18.08 and we're going to just sort of skip on the cuties right now 135 00:11:03.681 --> 00:11:08.391 and you just in time so we can go through those looking for it or else you know we 136 00:11:08.401 --> 00:11:13.441 didn't do we didn't talk about the electrical axis problem of the electrical axis 137 00:11:13.451 --> 00:11:19.101 is sometimes not the computer's figure this out for us if you like the axis is not 138 00:11:19.141 --> 00:11:23.811 always that intuitive concept that there are actually go to the board 139 00:11:23.821 --> 00:11:29.531 a little bit. The way to look at the electrical axis and I remember my 1st lecture 140 00:11:29.541 --> 00:11:30.091 an e.k.g. 141 00:11:30.101 --> 00:11:34.511 And I don't know what the heck are they talking about Electoral Act axis so you 142 00:11:34.521 --> 00:11:36.601 look at the way to do that is to look at the Q 143 00:11:36.611 --> 00:11:42.141 r s we can do it in this one here. The 1st thing you do folks you do remember I'm 144 00:11:42.151 --> 00:11:46.241 always trying on something I actually will get out now you look at it I hold this 145 00:11:46.251 --> 00:11:52.451 trial. And you look at. Your sleeping one. 146 00:11:53.881 --> 00:11:54.681 Here's a.t.f. 147 00:11:54.681 --> 00:12:00.931 . Lead to lead 3 and they're a.v.l. 148 00:12:01.921 --> 00:12:05.591 The are and. They're making 149 00:12:05.601 --> 00:12:10.921 a row the name of that this will help you determine the election last looking at 150 00:12:10.931 --> 00:12:17.501 this elector card. Is patience here here's your approach to determine the asses 151 00:12:18.211 --> 00:12:25.111 1st look at least one. Just leave one positive thing. So we know 152 00:12:25.381 --> 00:12:27.601 drawing vectors that that x. 153 00:12:27.611 --> 00:12:32.071 Is is somewhere in least in this direction. We want to. 154 00:12:34.641 --> 00:12:37.241 Look at the. A.d.f. 155 00:12:37.251 --> 00:12:43.770 Is actually I selected here so I select. So we do something here 156 00:12:44.310 --> 00:12:50.020 my school algebra I selector is actually going to be 90 degrees to 80 x. 157 00:12:50.850 --> 00:12:56.610 So maybe after this I selector. Which means it's neither of us that have already 158 00:12:56.620 --> 00:13:01.550 been doing this with so what is positive or negative it has to be either this way 159 00:13:02.360 --> 00:13:05.440 or this one. With the x. 160 00:13:05.830 --> 00:13:11.360 We just said to leave one is positive so we know that the axis is going to be. 161 00:13:12.830 --> 00:13:18.980 Approximately 0 and in fact the computer well says it's the axis 3 162 00:13:19.730 --> 00:13:25.670 centuries. Let's actually go back to the previous one time just to give the answer 163 00:13:25.670 --> 00:13:32.460 . You. Get Is it relatively positive 164 00:13:32.760 --> 00:13:33.850 sorry to leave one is 165 00:13:33.860 --> 00:13:39.520 a relatively positive or negative while it is slightly So that's 166 00:13:39.530 --> 00:13:45.120 a little bit of. So we know it's here. And this is the 167 00:13:45.730 --> 00:13:52.400 normal axis so most of our views are going to be an actor. In almost anything that 168 00:13:53.160 --> 00:13:58.050 most Americans are going to hear something's wrong starts here where it's positive 169 00:13:58.060 --> 00:13:59.690 in League One and a.d.f. 170 00:13:59.700 --> 00:14:06.510 It is also positive so we know huge somewhere in this wire and now the 171 00:14:06.520 --> 00:14:12.710 most ever isolator lead is. Well it's kind of the you want 172 00:14:13.480 --> 00:14:14.360 to pick a b.l.t. 173 00:14:14.370 --> 00:14:19.120 Will get in there you can kind of figure why so it's about the most positive and 174 00:14:19.130 --> 00:14:24.550 the most isolated from the ones will be it's going to be somewhere it here now is 175 00:14:24.560 --> 00:14:29.250 it's like dating he's not exactly actual African We want you to see if you write 176 00:14:29.260 --> 00:14:34.710 slowly. So it's going to be a little bit more industry. Now another 177 00:14:35.170 --> 00:14:38.710 a little bit more confusing what I'm doing is look at lead a.b.l. 178 00:14:38.720 --> 00:14:45.590 That's also kind of on the left. Side. All that. Right away yells 179 00:14:45.600 --> 00:14:51.880 over here so we crawl out. A 90 degree angle 180 00:14:52.510 --> 00:14:56.920 then leave the algae is also kind of nice a left or well it's 181 00:14:56.930 --> 00:15:02.670 a right about here isn't it but it's slightly negative in that isolator slightly 182 00:15:02.680 --> 00:15:05.110 negative So again it's 183 00:15:05.120 --> 00:15:12.020 a data. Wall and that we get about Aboriginal 184 00:15:12.030 --> 00:15:18.320 and we just estimated the axis as being about $75.00 well the computers. Same. 185 00:15:19.510 --> 00:15:24.330 So that and that's when you do the electrical axis and as we go through will start 186 00:15:24.640 --> 00:15:30.460 I sort of pick more and we'll see how to put the axis is. I want to say it's only 187 00:15:30.950 --> 00:15:34.390 because it does help you because that it will give you information in terms of 188 00:15:34.990 --> 00:15:38.840 various diagnosis went into the sick the bottom post your physical block which 189 00:15:38.850 --> 00:15:44.570 we're getting through and no this is. Ok let's go to the next one now. 190 00:15:46.430 --> 00:15:50.650 Looking down at the root script is ropy way with every Q r s n a Q 191 00:15:50.660 --> 00:15:56.550 r s what everybody wants the answer is. To go to the. 192 00:15:57.830 --> 00:16:04.770 Start. Looking down to the bottom. User 193 00:16:04.780 --> 00:16:07.460 of the way with every q.r.s. And if you are as with every p. 194 00:16:07.470 --> 00:16:12.740 Way of looking down at the bottom the answer is yes yes let's look at the rate now 195 00:16:13.430 --> 00:16:19.770 we figure out this rain. 301517560 about 196 00:16:19.780 --> 00:16:26.370 5056 so by definition this is the British foreign secretary 197 00:16:27.020 --> 00:16:27.720 and it is 198 00:16:27.730 --> 00:16:32.530 a sinus mechanism so this is sinus bridge party and let's look at our internal 199 00:16:32.540 --> 00:16:34.890 balls now. P.r. 200 00:16:34.900 --> 00:16:41.770 Or will. We get in here point to something I point to maybe about soup. 201 00:16:42.140 --> 00:16:48.210 Point 24 so we know that's not normal right point 34 and by the way obviously you 202 00:16:48.220 --> 00:16:51.090 mean becoming more facile to diagnosis as you know you do have to do 203 00:16:51.100 --> 00:16:57.270 a certain amount of memorization of the normal of the normals if you get better and 204 00:16:57.280 --> 00:16:59.930 say Ok I have a prolonged p.r. 205 00:16:59.940 --> 00:17:05.660 Intervals when I know that some parents are going to talk about that so looking now 206 00:17:05.670 --> 00:17:11.570 at our own rules and not going on those $6.00 that's normal are cuties normal so 207 00:17:11.580 --> 00:17:16.850 our findings are a the way that every few are as secure as of every every key 208 00:17:17.090 --> 00:17:18.510 a prolonged p.r.n. 209 00:17:18.520 --> 00:17:22.710 Revolt and everything else is normal so far since this is the right diagnosis is. 210 00:17:23.910 --> 00:17:27.070 Sinus rated Cardia and. First 211 00:17:27.080 --> 00:17:33.460 a great people otherwise normal after Congress I did not mention yet that after you 212 00:17:33.470 --> 00:17:38.810 do your Since this is named I omitted from the handout after you look at the 213 00:17:38.820 --> 00:17:42.990 current and what I said in terms of taking the history most important part of the 214 00:17:43.000 --> 00:17:47.830 current history is the old history most important part of the well but it is an 215 00:17:47.840 --> 00:17:53.280 important part of the current the letter cardiogram it's the previous record so 216 00:17:53.290 --> 00:17:57.640 I've not given you comparisons so what you are interpreting it yourself or I'm 217 00:17:57.650 --> 00:18:02.670 interviewing and I will always say compared with previous There is no significant 218 00:18:02.680 --> 00:18:04.280 change or 1st degree 219 00:18:04.290 --> 00:18:09.170 a blot is now present or if you doubt my is now present or something has changed 220 00:18:09.480 --> 00:18:16.380 while always give you compared with the previous. Next. Now. They 221 00:18:16.390 --> 00:18:22.300 will focus looking down into the rhythm strip down the bottom rather his European 222 00:18:22.310 --> 00:18:25.850 way with every q.r.s. And if you are as with every p. Way 1st of either any p. 223 00:18:25.860 --> 00:18:29.920 Works no there's applause Ok so we've got 224 00:18:29.930 --> 00:18:32.930 a rhythm abnormality right out of that and the q. 225 00:18:32.940 --> 00:18:39.000 Are asked is irregular. And in fact it's irregularly irregular. 226 00:18:40.150 --> 00:18:43.110 Which gives us a clue that we have a diagnosis right off the bat of 227 00:18:43.700 --> 00:18:49.310 a filter on your back so that we've got our rhythm here are intervals can we 228 00:18:49.320 --> 00:18:50.000 measure a p.r. 229 00:18:50.010 --> 00:18:56.290 Interval here and they drop their relation. Now you can the result here is there is 230 00:18:56.300 --> 00:19:01.110 no people people it's organs if you are as we can measure our purest something's 231 00:19:01.120 --> 00:19:02.100 wrong with this q.r.s. 232 00:19:02.110 --> 00:19:09.050 Right it's it does will prolong prolong about point 16 or so so we have 233 00:19:09.060 --> 00:19:14.400 some sort of conduction an analogy right off the bat. Now we're going to we're 234 00:19:14.410 --> 00:19:18.820 going to skip the axis here generally when you turn the left of the electrical axis 235 00:19:18.830 --> 00:19:24.600 you know with the right button it's. Well let's give the electrical axis here and 236 00:19:25.030 --> 00:19:31.800 in this case for for the moment. Well. Actually Ok let's talk about it now look at 237 00:19:31.970 --> 00:19:35.460 is it this is positively what's the answer is yes it's 238 00:19:35.470 --> 00:19:40.080 a positive lead and the answer is yes so we're going to be in the hole is going to 239 00:19:40.090 --> 00:19:43.930 be. Now those are the s.e.p. 240 00:19:43.940 --> 00:19:48.580 Within the valleys something is wrong we know that this or prolonged here as to be 241 00:19:48.590 --> 00:19:50.300 sure and there's 242 00:19:50.310 --> 00:19:56.720 a clue to the pre Korea leaves now I try not to put this on pattern recognition but 243 00:19:56.730 --> 00:19:57.850 it is helpful in 244 00:19:57.860 --> 00:20:02.400 a later lecture we're going to talk about the whole nectar concept interpretations 245 00:20:02.410 --> 00:20:06.630 electrocardiogram this is the introduction but right now we can say all right 246 00:20:06.640 --> 00:20:09.310 there's something wrong with the pattern here we have 247 00:20:09.320 --> 00:20:16.140 a delayed delayed and why isn't terminal works here the end of the curative found. 248 00:20:17.300 --> 00:20:19.110 In the leaves the one b. 249 00:20:19.120 --> 00:20:25.260 2 v 3. We've got rabbit ears right it looks like rabbit ears and remember this so 250 00:20:25.270 --> 00:20:27.270 the diagnosis of this is going to be 251 00:20:27.370 --> 00:20:31.990 a wreck on the range one you can see. It is so our interpretation of this 252 00:20:32.000 --> 00:20:38.930 electrocardiogram is the result is. We took her life and we compute the weight now 253 00:20:38.940 --> 00:20:43.250 the rate you can't use used to complexes generally this kind of thing you are 254 00:20:43.260 --> 00:20:50.070 averaging you might take 6 seconds. One to 5 on 5 big boxes one 255 00:20:50.080 --> 00:20:55.740 second one second to 2nd reason or 2nd time 2nd get your average heart rate over 256 00:20:55.750 --> 00:21:01.550 that 6 seconds and multiply at least 3 times 10 for 60 seconds so you can go 257 00:21:01.560 --> 00:21:07.280 through this in the average rate in the sixty's. And you go through the entire 258 00:21:07.290 --> 00:21:14.150 journey. It's like it. Doesn't because it varies so are pursued this is 259 00:21:14.160 --> 00:21:16.840 about a diagnosis is a tool for relation with 260 00:21:16.850 --> 00:21:23.850 a control the trigger the response. Rate below gradual. Turn diagnosis 261 00:21:24.280 --> 00:21:31.250 and now to the. Next Ok. Is 262 00:21:31.260 --> 00:21:35.780 there a p. Way to do the 9th European way with every q.r.s. 263 00:21:35.790 --> 00:21:41.600 In a furious with everybody where. There is exactly or one account 264 00:21:41.610 --> 00:21:47.920 a complex. Open in general the answer is yes but we're going to take notice that 265 00:21:47.970 --> 00:21:50.120 there is one complex that has a q.r. 266 00:21:50.130 --> 00:21:56.860 As with milky way. Right now so let's just go through this tracing our in our 267 00:21:57.010 --> 00:22:01.510 rate here is our rate is now we're going to be again in the interest of time you 268 00:22:01.520 --> 00:22:06.580 all can do the rate we can all count the boxes 301756050. 269 00:22:12.400 --> 00:22:15.820 Account the rate there and again we will go over things in much more detail we're 270 00:22:15.830 --> 00:22:17.520 going to have electronic rhythms 271 00:22:17.530 --> 00:22:22.450 a lot of electronic cardiac vectors and patterns that this is going to sort of sort 272 00:22:22.460 --> 00:22:27.950 of go be repetitive here today and I'm going over the general corruption so we have 273 00:22:27.960 --> 00:22:31.070 a good measure intervals and it's p.r. 274 00:22:31.080 --> 00:22:35.970 Interval looks pretty good right it's about point $16.00 secure rest is also normal 275 00:22:36.010 --> 00:22:42.200 or. Asked about point 08 or so the cutie interval is normal. The axis is 276 00:22:42.210 --> 00:22:43.940 a positive delete look at lead one is 277 00:22:43.950 --> 00:22:48.580 a positive or negative it's obviously positive is it positive immediately after the 278 00:22:48.590 --> 00:22:52.890 answer is yes and the Axis 279 00:22:52.930 --> 00:22:56.490 b I most I selected lead is lead 3. 280 00:23:00.630 --> 00:23:05.570 Approximately the 3 years over the year this is something to serve if you do your 281 00:23:05.580 --> 00:23:12.140 hand I will instruct race so 90 degrees only 3 is actually plus 282 00:23:12.180 --> 00:23:18.740 30. Now it's likely. They did so instead of either the negative 283 00:23:19.710 --> 00:23:25.600 of that event or. Close 30 so it's going to be about all of us. 284 00:23:26.990 --> 00:23:27.680 But it is just 285 00:23:27.690 --> 00:23:34.460 a normal random He is in the same. Again I'm 286 00:23:34.470 --> 00:23:38.930 very big on no matter what you do in medicine it's very important to be systematic 287 00:23:39.530 --> 00:23:44.410 or very poor and again if you don't know it you seem to just don't know something's 288 00:23:44.420 --> 00:23:49.850 wrong but you've been analyzed It's just now so what we have here the rhythm is. 289 00:23:52.550 --> 00:23:55.880 Returning to the sinus rhythm Exactly and I would interpret this with 290 00:23:55.890 --> 00:24:01.120 a sinus rhythm with that topic complex it's why the bizarre we know it's 291 00:24:01.130 --> 00:24:06.010 a premature complex writing team really writes number not every Have topic complex 292 00:24:06.020 --> 00:24:11.900 is an early complex but this one is you have your calipers out. And you're looking 293 00:24:11.910 --> 00:24:16.660 along or your fingers you know to get your fingers and that's an account the beat 294 00:24:16.670 --> 00:24:21.920 is it been trigger or Superman trick it's of interest there's no p. 295 00:24:21.930 --> 00:24:27.980 Waves it's why didn't bizarre. When we talk about contributor do appear you will 296 00:24:27.990 --> 00:24:34.230 talk about the compensatory pause basically if you had your calipers out they wind 297 00:24:34.240 --> 00:24:35.550 up the 2 p. 298 00:24:35.560 --> 00:24:39.280 Waves go. Right they fall right on right on the money right next there's 299 00:24:39.290 --> 00:24:43.540 a mist peel away and it comes right back. There. 300 00:24:46.400 --> 00:24:49.420 And we will this when we talk ever lecture about contributor arrhythmias we're 301 00:24:49.430 --> 00:24:53.220 going to over that we talk about letter diagrams we're going to go with this 302 00:24:53.230 --> 00:24:58.040 interpretation therefore it is sinus rhythm with occasional b.b.c. 303 00:24:58.690 --> 00:25:01.040 I'm curious if he sees the b.b.c. 304 00:25:01.460 --> 00:25:06.730 Contributor in by the way to see here's a here's a little different. B.b.c. 305 00:25:06.740 --> 00:25:11.790 As they used it when I 1st train moves and even trickier premature contractions and 306 00:25:11.800 --> 00:25:17.550 what's not you don't even know if you don't know our contract. Is more accurate 307 00:25:17.560 --> 00:25:23.950 ways to call it premature which it is contributor complex you never wrong by 308 00:25:23.960 --> 00:25:29.950 calling it. From what I've. Read you're never wrong very calling it 309 00:25:29.960 --> 00:25:36.240 a social scientists rhythm contributor premature complex algo otherwise within all 310 00:25:36.250 --> 00:25:41.950 of them it's next. To. 311 00:25:43.140 --> 00:25:44.030 Ok this one's 312 00:25:44.040 --> 00:25:49.340 a little bit of fun. Looking at the rhythm strip is really the way with 313 00:25:49.350 --> 00:25:51.300 a Rick you were asking if you were us with every t. 314 00:25:51.310 --> 00:25:56.961 Wave most of the time except. Some of the stronger work out look at the 4th company 315 00:25:57.201 --> 00:26:02.631 complex. See this some stuff we're out of the way looks like it should be you know 316 00:26:03.151 --> 00:26:07.181 sometimes in America well that will think about that it took a so there is 317 00:26:07.191 --> 00:26:08.711 a sound there is a rhythm there is 318 00:26:08.721 --> 00:26:13.441 a deal with every few arrests and curiously there and he waved except for one 319 00:26:13.451 --> 00:26:18.321 complex will come back and determine what that is the intervals. 320 00:26:22.241 --> 00:26:29.101 The Army of all get out to calibers. 4 boxes point 16 The Curious 321 00:26:29.151 --> 00:26:29.291 is 322 00:26:29.301 --> 00:26:36.341 a little bit long actually. It's 323 00:26:36.351 --> 00:26:40.621 all would come on this is some curious Croatian they're not going to want to or so 324 00:26:41.581 --> 00:26:44.571 even the q. T. Interval of salute of the line is sometimes a cutie 325 00:26:44.581 --> 00:26:51.491 a little bit hard to find these but so let's go to over I would go over to say. B. 326 00:26:51.501 --> 00:26:56.071 3 you can measure it in any lead generally cutey interval is measured in the 327 00:26:56.611 --> 00:27:03.581 standard Linley's But if you can't see it it's Ok to go in one of the other. Cutie 328 00:27:03.591 --> 00:27:10.531 interval using your calibers is about. 4 329 00:27:10.541 --> 00:27:14.391 or something. And actually it's 330 00:27:14.401 --> 00:27:20.591 a little. Computer is actually in this measure. About you 331 00:27:20.801 --> 00:27:25.071 4.42. The axis is 332 00:27:25.081 --> 00:27:31.501 a positive in lead one. Yes Is it positive in leading abs 333 00:27:31.891 --> 00:27:37.771 no negative so we know this is the 1st time you'll be back here. 334 00:27:39.771 --> 00:27:42.851 This time why. So race. 335 00:27:51.861 --> 00:27:57.571 So it's actually some really good positive. One Nation the soul is actually 336 00:27:57.581 --> 00:28:02.311 somewhere right here let's look at our most I feel that we really don't have 337 00:28:02.321 --> 00:28:07.491 running our selectively here. Maybe they added some o. 338 00:28:07.501 --> 00:28:14.021 Psychologically to actually put it slightly so this is going to be about. Minus 339 00:28:14.031 --> 00:28:20.641 15 or so somewhere around June is yet. Positively one nay the 340 00:28:20.651 --> 00:28:27.321 day as we know is here this air year day and the most I feel as a leader is 341 00:28:27.331 --> 00:28:33.101 a yeah but it's like the making of that something on my 60 Ok. 342 00:28:34.491 --> 00:28:39.681 As you get if you do more and more of these this will become much much easier to 343 00:28:39.691 --> 00:28:45.101 determine electrical acts All right so now let's look at the age of g. 344 00:28:45.111 --> 00:28:47.301 In general for most of tracing the a.b. 345 00:28:47.341 --> 00:28:52.821 Relationship is intact but we've got some we can have some sort of funny be in the 346 00:28:52.831 --> 00:28:55.711 4th be really at the end of the end of the board b. 347 00:28:56.501 --> 00:28:59.501 And what does anybody think that little flip 348 00:28:59.511 --> 00:29:05.771 a symbol Square has. Is it a p. 349 00:29:05.781 --> 00:29:10.081 Wave is a Q r s. There's 350 00:29:10.091 --> 00:29:15.151 a look like any of the other complexes. It's a little bit like a p. 351 00:29:15.161 --> 00:29:21.421 Way. And in fact with this is that you've got Peewee if you were an s.p. 352 00:29:21.431 --> 00:29:27.001 What if you're s p weights you're asked people if you are asked atrial premature 353 00:29:27.011 --> 00:29:33.651 complex block is not conductive the Your That's a blast a piece. Of writing 354 00:29:33.731 --> 00:29:40.681 a lot he suggested. Well it would be very into right now 355 00:29:40.691 --> 00:29:44.761 with the way it is sitting right on the t what we hear is we're getting 356 00:29:44.771 --> 00:29:50.971 a little experience why was he waiting to weigh some change one bit of it. So it 357 00:29:50.981 --> 00:29:56.631 would be very unlikely 2 waves are reflecting. Of the polarization what could 358 00:29:56.641 --> 00:30:03.371 possibly repolish rise individual purists you know the individual herby for one b. 359 00:30:03.681 --> 00:30:06.771 You can change it 2 ways can change a lot but every t. 360 00:30:06.781 --> 00:30:07.321 Way is going to be 361 00:30:07.331 --> 00:30:13.311 a thing that's the answer so that's an ectopic complex but it didn't conduct you 362 00:30:13.321 --> 00:30:18.041 did not conduct it doesn't look like a b p c You know I don't see a q.r.s. 363 00:30:18.051 --> 00:30:22.321 There and it kind of looks like the other he weighs Why doesn't it look identical 364 00:30:22.331 --> 00:30:26.331 to the other p waves because it's coming from a power poles have 365 00:30:26.341 --> 00:30:30.011 a different spot in a tree. And sometimes the p. 366 00:30:30.021 --> 00:30:33.731 Wears are actually inverted in Bertie because they're way down again when I know 367 00:30:33.911 --> 00:30:39.111 all our teaching materials and we do another lecture on this. Will be going on so 368 00:30:39.911 --> 00:30:41.401 now let's look at the q.r. 369 00:30:41.411 --> 00:30:43.701 At the well list let's look at let's look at our Q 370 00:30:43.711 --> 00:30:49.331 r s cap let's start with us do we see any curious in this electrocardiogram of 371 00:30:49.341 --> 00:30:56.001 starting the record Uli's. See any curious here. We're going to do something no 372 00:30:56.011 --> 00:31:00.801 doesn't look normal There are only 23 Navia. We have some deep q. 373 00:31:00.811 --> 00:31:02.441 Ways and there's a q. 374 00:31:02.451 --> 00:31:06.931 Where there's a small queue waiting lead to deep he wave and leave 3 x. 375 00:31:06.991 --> 00:31:09.411 3 and a deep q. Waving lead a.v.f. 376 00:31:09.411 --> 00:31:14.691 . Well again as you become more experienced here remember that's the infidels and 377 00:31:14.701 --> 00:31:19.201 girlies let's keep looking no we're not done looks we could be recording believes 378 00:31:19.391 --> 00:31:20.041 any q.h. 379 00:31:20.051 --> 00:31:25.811 In the pic or deletes are significant Actually no. So there's Right now we're 380 00:31:25.821 --> 00:31:29.691 thinking I hear my We're writing this out and said he waves to 3 an a.t.m. 381 00:31:29.731 --> 00:31:33.981 We haven't done our diagnosis yet but we're going to get there in my mind I'm going 382 00:31:33.991 --> 00:31:37.851 to he waves into 3 Yeah which are not under side looking into 383 00:31:37.861 --> 00:31:43.911 a triangle and later I'm going to draw pictures of our over live there for that but 384 00:31:44.041 --> 00:31:48.611 for now for today 2 ways and 23 in the air in the inferior leaves we are in 385 00:31:48.621 --> 00:31:52.171 a fury one. Let's look at our s.t.t. 386 00:31:52.181 --> 00:31:59.081 Way of sense now. We've got some funny looking Misty 2 387 00:31:59.091 --> 00:32:04.301 ways theories are kind of flat or even by face or current burden and lead why media 388 00:32:04.311 --> 00:32:10.831 all. 3 And again as you were saying look at ab out the correct 389 00:32:10.901 --> 00:32:13.831 complex and maybe it's the 1st complex to look at the t.v. 390 00:32:13.841 --> 00:32:15.561 Ways you were looking if you had 391 00:32:15.571 --> 00:32:17.721 a whole run of the ways in the 2nd when you said wait 392 00:32:17.731 --> 00:32:24.321 a minute what's wrong with that the way the 2nd complex in the media. Is the 393 00:32:24.471 --> 00:32:30.641 static topic Peewit they're looking at the humorous pattern and so get into who 394 00:32:30.651 --> 00:32:36.931 leaves nothing really to be exciting maybe in the 6 I will point out on one thing 395 00:32:36.941 --> 00:32:38.691 again a nuance look at the p. 396 00:32:38.701 --> 00:32:40.951 Wave and leave the one that's 397 00:32:40.961 --> 00:32:45.491 a little wide and deep that's actually left atrial abnormality very good with data 398 00:32:45.501 --> 00:32:47.921 around the so this is a little bit more of 399 00:32:47.931 --> 00:32:53.511 a complex rhythm complex electrocardiogram Here's how I would interpret this the 400 00:32:53.521 --> 00:32:57.091 rhythm is. That sinus or not it's 401 00:32:57.101 --> 00:33:03.911 a sinus rhythm where. A blocks meaning to not conduct or 402 00:33:03.921 --> 00:33:09.681 non-conductive is the more precise term we have sinus rhythm with in the trill 403 00:33:09.691 --> 00:33:15.781 Prima. Sure complex comma non-conductive or block the p.c. . Q. 404 00:33:15.791 --> 00:33:17.271 Weighs into 3 a b. F. 405 00:33:17.281 --> 00:33:17.811 Indicative of 406 00:33:17.821 --> 00:33:22.361 a prior of the indicative of inferior Walmart in Parchin of indeterminate 407 00:33:22.371 --> 00:33:27.011 a Why do I cite you say indeterminate age I don't have a previous e.k.g. 408 00:33:27.421 --> 00:33:34.381 I don't know in this her. Now if I have and so the correct term is 3 Wal-Mart kind 409 00:33:34.391 --> 00:33:39.551 of far from the indeterminate page Now we did not I did not focus on this but 410 00:33:39.561 --> 00:33:40.411 because it's a little bit of 411 00:33:40.421 --> 00:33:44.931 a nuance in terms of the voltage we are talking about hold the voltages 412 00:33:44.941 --> 00:33:50.381 a little enlarged and leads one to me Don't focus on that today I miss the small I 413 00:33:50.391 --> 00:33:55.421 would comment personally on Consider of my future who I purge of being increased 414 00:33:55.431 --> 00:33:56.491 voltage because that a.v. 415 00:33:56.501 --> 00:34:01.092 Else will all but. Again to continue sinus rhythm to 416 00:34:01.102 --> 00:34:06.352 a premature complex Kummel block to inferior Walmart no function in term and age 417 00:34:07.402 --> 00:34:09.082 prolonging q.r.s. 418 00:34:09.182 --> 00:34:14.872 Or my quality of interview trigger look induction delay. Left atrial lead to malady 419 00:34:14.872 --> 00:34:17.672 . Non-specific s.t.t. 420 00:34:17.682 --> 00:34:19.432 Way better now please this is 421 00:34:19.442 --> 00:34:24.372 a pretty complicated one but I want to show you one with the way. Next. 422 00:34:27.762 --> 00:34:32.702 To the rhythm script. Is there any way with every Q r s n a cure us with 423 00:34:32.712 --> 00:34:38.872 a repeat wave the answer is yes it's real and the relationship is most likely the 424 00:34:38.882 --> 00:34:44.542 sinus mechanism here let's look at our interval. P.r. 425 00:34:44.552 --> 00:34:48.610 Interval. Looks normal. This is 426 00:34:48.620 --> 00:34:54.820 a curious interval normal now things. We have some purist role in the nation about 427 00:34:54.830 --> 00:35:01.680 point $16.00 and sprawl on top of it was a normal point $12.00. And a cutie was 428 00:35:01.690 --> 00:35:08.680 a little tough to find and it's there but it is also. Normal. 429 00:35:10.640 --> 00:35:15.060 Now so going to our interview look our relationship between the piece and accuse 430 00:35:15.070 --> 00:35:21.760 their mind are axis are axis it's positive lead one and negative in lead 431 00:35:21.770 --> 00:35:23.250 abs so we have 432 00:35:23.260 --> 00:35:30.160 a left axis not in the normal range we're. Let's look at our curious pattern well 433 00:35:30.170 --> 00:35:35.800 something's wrong or right. Away then sure what's wrong with this we have 434 00:35:35.810 --> 00:35:39.380 a wide complex the most prominent needs one e.t.l. 435 00:35:39.950 --> 00:35:44.110 V 6 which on the left we're looking leaves. So we have 436 00:35:44.120 --> 00:35:46.560 a conduction area malady that is likely to be 437 00:35:46.570 --> 00:35:53.180 a. Left on the right. Level so the interpretation of this 438 00:35:53.650 --> 00:35:59.590 is the sinus rhythm left over from. The. 439 00:36:02.340 --> 00:36:07.070 Next. Ones are all in this one on. 440 00:36:09.900 --> 00:36:15.190 The 1st while there are other he wears. No no there's something wrong with that 441 00:36:15.430 --> 00:36:20.100 name Next I would call those waves. And always 442 00:36:20.110 --> 00:36:26.440 a lot of ways around the circle other ways and it's tough to do but be interesting 443 00:36:26.450 --> 00:36:32.310 Lee There does seem to be a relationship between the flatter ways and the u.r.s. 444 00:36:32.320 --> 00:36:37.181 Ways because they're really very regular. There is some sort of relationship there 445 00:36:37.931 --> 00:36:39.121 so looking at b. 446 00:36:39.121 --> 00:36:42.981 . Atrial rate. This is 447 00:36:42.991 --> 00:36:48.751 a tough one because it's actually about. $300.00 or even 448 00:36:48.761 --> 00:36:54.081 a little bit more pretty close to $300.00 and the q.r.s. 449 00:36:54.091 --> 00:37:00.870 Ray is about. 75. So 450 00:37:00.880 --> 00:37:03.620 that's you go wait a minute we have a relationship it's an it's 451 00:37:03.630 --> 00:37:10.580 a mathematical relationship there. And if you. Sort of put it to him 452 00:37:10.590 --> 00:37:10.910 We have 453 00:37:10.920 --> 00:37:15.890 a guy who exactly what they're doing does seem to be relationship $375.00 and those 454 00:37:15.960 --> 00:37:21.870 is me going to change. Our axis our axis is actually kind of tough to see because 455 00:37:21.880 --> 00:37:22.930 the floor ways are going in 456 00:37:22.940 --> 00:37:25.800 a way that it is positively one way and it is kind of I saw 457 00:37:25.810 --> 00:37:28.660 a letter can lead to worse luck in the lead a.v.f. 458 00:37:28.670 --> 00:37:33.160 Or slightly negative close in the slightly negative point in the s.t.t. 459 00:37:33.170 --> 00:37:37.420 Way segments you really can't interpret their stuff you're stuck in 460 00:37:37.430 --> 00:37:43.920 a spiral so why are it does look if you look in lead the one there might be an iris 461 00:37:43.930 --> 00:37:47.700 our prime what we call in ours our claim there might be some sort of the notion 462 00:37:47.710 --> 00:37:53.360 around either in there or in there but if you're looking through this tracing. The 463 00:37:53.370 --> 00:37:57.670 key route to keep finding it we can do it comprehensively in the world so I would 464 00:37:57.680 --> 00:38:04.460 interpret this rhythm as atrial flutter with 413-0007 warning 465 00:38:04.470 --> 00:38:10.880 one ab conduction it's not really heart block it's for conduction. Atrial flutter 466 00:38:11.290 --> 00:38:17.430 with 4 to one maybe conduction. And there's actually what we call an incomplete 467 00:38:17.440 --> 00:38:18.790 right ball branch where there is 468 00:38:18.800 --> 00:38:24.820 a little rabbit of yours you leave the one. Cell again you cannot interpret the 469 00:38:25.420 --> 00:38:29.900 history you are saying and so. Next. 470 00:38:35.560 --> 00:38:38.660 Looking down the rhythm to serve you with every cue or resecure rest with 471 00:38:38.670 --> 00:38:44.560 everything you wave the answer is yes. The relationship between each one living 472 00:38:44.570 --> 00:38:48.920 trigger lire they consist that the answer is yes that we're going to we know in our 473 00:38:48.970 --> 00:38:50.590 in our mind's eye here that we've got 474 00:38:50.600 --> 00:38:56.990 a science with the intervals look pretty good here 21 me me me. 475 00:38:59.410 --> 00:39:04.430 Point 06. Cuti intervals Ok let's look at the s.-t. Are there any q. 476 00:39:04.440 --> 00:39:06.160 Ways in the pathological q. 477 00:39:06.170 --> 00:39:11.510 Ways. Now looks pretty good. The s.t.t. 478 00:39:11.520 --> 00:39:17.650 Way segments. Here the pretty good. I see a little bit of an inverted t. 479 00:39:17.660 --> 00:39:18.450 Way to Navy l. 480 00:39:18.460 --> 00:39:22.630 But it's really it's really kind of in the normal limits listen to the voltage now 481 00:39:22.640 --> 00:39:27.320 we're looking for scanning the voltage in the record of the unit just in the limits 482 00:39:27.330 --> 00:39:27.670 give me 483 00:39:28.110 --> 00:39:35.840 a little east now looks pretty good what about over in the record feelings. They 484 00:39:35.850 --> 00:39:41.080 look pretty tall right so if we were to count now you take your calipers or disk 485 00:39:41.090 --> 00:39:45.330 with their fingernails here if you want to look at make sure that there could be 486 00:39:45.340 --> 00:39:46.250 increased voltage or 487 00:39:46.260 --> 00:39:50.460 a high perch of you there and in fact if you want to take the simplest criteria. 488 00:39:51.510 --> 00:39:52.580 And see one plus r 489 00:39:52.590 --> 00:40:00.400 b 5 grid $35.00 I think we've got so we counted up 510-152-0258 490 00:40:00.410 --> 00:40:07.380 little bit more than $25.00 almost 30. $3540.00 so we got 491 00:40:07.390 --> 00:40:10.000 plenty of room there and we've got just the one plus our bit by 492 00:40:10.010 --> 00:40:15.190 a greater than $35.00 so we're going to increase voltage for 11 trick America. 493 00:40:17.060 --> 00:40:23.940 So we need to get that far. To be. The our way be biased the one 494 00:40:24.410 --> 00:40:31.070 those are the 5 or 6 so the Us wave in the one is about $10000000.00 495 00:40:31.080 --> 00:40:33.090 illegals and the r.v. 496 00:40:33.100 --> 00:40:34.850 5 really almost 497 00:40:34.860 --> 00:40:41.720 a 3rd rate there 510152030. Or so so we've got more 498 00:40:41.730 --> 00:40:46.370 than you so the city resold for less than trickle are actually enlarging I should 499 00:40:46.380 --> 00:40:50.460 state that the term is less term that's often utilized as well contributory 500 00:40:50.470 --> 00:40:54.840 purchase be the correct term is actually left in tricking the market is all you 501 00:40:54.850 --> 00:40:59.560 know is it the ventricles that you don't know his perjury by definition is that you 502 00:40:59.570 --> 00:41:04.690 may have been in. In large part due to Valve insufficiency Carty myopic the it may 503 00:41:04.700 --> 00:41:09.000 not be thick so the correct term is actually increased voltage for less than 3 504 00:41:09.010 --> 00:41:13.350 killer enlargement and you will see it in the computerized interpretation I 505 00:41:13.360 --> 00:41:16.970 purchased and it's not matricular enlargement the ventricle has 506 00:41:16.980 --> 00:41:23.740 a lock in making dilated or maybe hyper The or all. So let me 507 00:41:23.750 --> 00:41:26.940 trickle in larger just because. You get 508 00:41:26.950 --> 00:41:34.420 a. Good answer. Yes 509 00:41:34.550 --> 00:41:41.260 indeed. You know I do use them and use kind of more than one and you use the old 510 00:41:41.270 --> 00:41:45.300 voltage criteria I do use the Cornell criteria which is 511 00:41:45.310 --> 00:41:50.990 a. Little more complicated and there is also something chordal be prepared to 512 00:41:51.000 --> 00:41:57.140 realize. They are very sensitive B.'s unspecified specificities I do look at the 513 00:41:57.150 --> 00:42:01.870 wall and now they are all in your hand Ok the curve right here is your own in my 514 00:42:01.880 --> 00:42:07.200 book the correct be corny all criteria are there are probably the most sensitive in 515 00:42:07.210 --> 00:42:13.100 specific Indeed but they do vary between male and female center and you have to 516 00:42:13.110 --> 00:42:13.850 consider that they're 517 00:42:13.860 --> 00:42:18.930 a little more complicated. I actually here's where the electrocardiogram is 518 00:42:18.940 --> 00:42:23.310 a little weak compared to other move down it's sort of it's not 519 00:42:23.320 --> 00:42:27.240 a sensitive and specific is it is as other move down it's but when you see this 520 00:42:27.250 --> 00:42:31.280 this is where Ok And you know get an echocardiogram and get some more information 521 00:42:31.290 --> 00:42:36.770 which is much more accurate it's actually you know it's obviously imaging. I guess 522 00:42:36.780 --> 00:42:43.760 on top of that. You could be. A. Little on the day 523 00:42:43.810 --> 00:42:50.720 before you buy. It Right. It looks. The 524 00:42:50.730 --> 00:42:55.600 same in. A year you're exactly right that as light as the depression is within home 525 00:42:56.430 --> 00:43:02.380 so would not be you know normal. Well. 526 00:43:06.690 --> 00:43:08.730 You shouldn't have more than a sort of 527 00:43:08.740 --> 00:43:11.940 a couple of small boxes here and you know also it's a it's 528 00:43:11.950 --> 00:43:13.780 a reason I'm hedging it's not 529 00:43:13.790 --> 00:43:19.530 a yes or no answer. Because it also depends on the configuration of it the 530 00:43:19.650 --> 00:43:25.890 slightest the depression that it's absolutely horizontal or certainly maybe it is 531 00:43:25.960 --> 00:43:29.790 you know inverted is not unknown compared to 532 00:43:29.800 --> 00:43:33.880 a slightest even pressure net up sloping that isn't all that is 533 00:43:33.890 --> 00:43:37.430 a normal again if you look in your hand out there I get 534 00:43:37.440 --> 00:43:41.880 a little bit more precise definition center and again this is my criteria My 535 00:43:41.890 --> 00:43:46.020 current theory have been implemented schools across the country but in India and I 536 00:43:46.070 --> 00:43:51.390 didn't invent or I did see of designs of the many many other resources but you're 537 00:43:51.400 --> 00:43:53.060 right you're right it's 538 00:43:53.070 --> 00:43:57.260 a little bit different but I would not the interpreter also has a little bit of 539 00:43:57.270 --> 00:44:04.150 a responsibility in saying. Little bit of responsibility in 540 00:44:04.450 --> 00:44:08.080 alerting the observer that things that I'm 541 00:44:08.090 --> 00:44:12.960 a little worried about this or I'm not worried about I don't want to be an alarmist 542 00:44:13.190 --> 00:44:17.410 and that is nuance and nuance is difficult in medicine sometimes but you're right 543 00:44:17.880 --> 00:44:24.550 it's looking and that it actually. It's not an owner as you might be thinking in 544 00:44:24.560 --> 00:44:28.760 patients with lead contributor and larger than average associated s.t.t. 545 00:44:28.770 --> 00:44:32.670 Where they don't work like Mark Carney in the scheme where you don't know where to 546 00:44:32.720 --> 00:44:36.310 start so you're right you have to take a look at the no spin this is 547 00:44:36.320 --> 00:44:41.660 a perfect segue excellent. The next let's look at the big big key point in the next 548 00:44:41.670 --> 00:44:43.470 20 something to do with s.p.t. 549 00:44:43.480 --> 00:44:49.580 What to do the next. Minute and if I can. Get. 550 00:44:51.450 --> 00:44:52.940 We got the wave before every 2 or 551 00:44:52.950 --> 00:44:58.690 a secure us before every few where the answer is yes we have this measure are. 552 00:44:59.800 --> 00:45:06.370 We're going to assume the rates Ok here are the intervals let's look down our p.r. 553 00:45:06.380 --> 00:45:12.750 Interval is a little generous. To 554 00:45:12.760 --> 00:45:18.560 a. Student going to $1.00 to some advance or think that there's some sort of a b. 555 00:45:18.570 --> 00:45:24.000 Conduction amount of you there are certainly you know if you block now let's focus 556 00:45:24.010 --> 00:45:27.040 on that you shouldn't just be again for this purpose of this lecture we're going to 557 00:45:27.050 --> 00:45:31.710 focus on the Animal Farm and we're not being told the system that time is short 558 00:45:32.621 --> 00:45:38.151 lived so get out of your ass is an hour to you wait Are there any 2 ways here. Now 559 00:45:38.151 --> 00:45:41.811 . To raise other some s. T. And t. 560 00:45:41.821 --> 00:45:48.481 Wave them now these. Verses or give us the segment that is the 2nd arrest of the 561 00:45:48.491 --> 00:45:52.971 normal as the segment is slightly up sloping But if this one is 562 00:45:52.981 --> 00:45:57.931 a little bit or slightly depressed and up sloping this one looks like 563 00:45:57.941 --> 00:45:59.871 a look at lead to it's a little bit 564 00:45:59.881 --> 00:46:06.371 a little bit above the baseline and straight across. We see that in more than one 565 00:46:06.381 --> 00:46:12.051 leaves. Something's wrong with this and we look at the t. Waves and the t. 566 00:46:12.061 --> 00:46:16.251 Ways certainly those are not normal to you when it's right the waves are heard of 567 00:46:16.261 --> 00:46:19.281 the usually one to a.b.l. 568 00:46:19.391 --> 00:46:19.891 Abs 569 00:46:20.361 --> 00:46:27.461 b 3 through v 6. And Target patient of this is going to be. Scientists 570 00:46:27.471 --> 00:46:29.251 rhythm. We have 571 00:46:29.261 --> 00:46:35.792 a prolonged period of also we have. First degree of the block and we have I would 572 00:46:35.802 --> 00:46:38.572 call this abnormal s.t.t. 573 00:46:38.582 --> 00:46:43.330 Way findings is opposed to nonspecific. You'll see that 574 00:46:43.340 --> 00:46:47.610 a lot by the way guys using the because the catch all term is not specific I want 575 00:46:47.620 --> 00:46:53.980 to help the observer by telling them this is an abnormal after cardiogram s.t.t. 576 00:46:53.990 --> 00:46:59.890 Waiver maladies and frankly this is indicative of either is the elevation Mark kind 577 00:46:59.900 --> 00:47:02.610 of harsh and possibly acute angle or even there is 578 00:47:02.620 --> 00:47:09.360 a little asking. And even this may be an acute enough. So you've got I would say 579 00:47:09.400 --> 00:47:10.540 admirable s.t.t. 580 00:47:10.550 --> 00:47:15.130 Way about the maladies consider acute scheme to process something. 581 00:47:17.490 --> 00:47:20.830 And what's the most important part of this electrocardiogram is the all over your 582 00:47:20.840 --> 00:47:22.900 career as an hour earlier and made him 583 00:47:22.910 --> 00:47:29.770 a normal patient would be on his way to use our army. Well this well I would 584 00:47:29.780 --> 00:47:35.560 call this this would be a good question this would be in for all lateral s.t.t. 585 00:47:35.570 --> 00:47:41.760 We're going to analyse inferior because the president and 3 Navy and and Latin all 586 00:47:41.770 --> 00:47:48.220 because it's one. Almost Banjul isn't the starts and be 3 in burrow into role 587 00:47:48.230 --> 00:47:54.820 lateral the way around are now. Ok We're going down the 588 00:47:54.830 --> 00:47:56.530 homestretch here running 589 00:47:56.540 --> 00:47:59.460 a little bit over we're going to be our ass off against this time you see this now 590 00:47:59.990 --> 00:48:03.040 these are the way with every curiosity cure as with every piece where you could 591 00:48:03.050 --> 00:48:09.080 lead to. The answer is yes to something spicy they're right all right so we're 592 00:48:09.120 --> 00:48:13.920 coming right off the balcony and you go do not interpret the axis in the presence 593 00:48:13.930 --> 00:48:14.080 of 594 00:48:14.090 --> 00:48:21.410 a where we got pacing or. So in fact the computer interpreted as incorrectly 595 00:48:21.870 --> 00:48:22.370 we have 596 00:48:22.380 --> 00:48:28.780 a dual chamber pacemaker here why don't we know it's dual chamber because the 597 00:48:29.340 --> 00:48:33.130 there is a relationship between the p. Wave and b. 598 00:48:33.170 --> 00:48:38.070 Pacemaker the polarization so the pacemaker must be listening to the ways I think 599 00:48:38.080 --> 00:48:41.550 it's not pacing the atrium with this at least is 600 00:48:41.560 --> 00:48:46.580 a dual chamber. Based maker because we have real sensing in sensing that the waves 601 00:48:46.940 --> 00:48:53.720 and ventricular pacing so I would be interpret this as a. Sinus rhythm is 602 00:48:53.730 --> 00:48:59.550 a sinus rhythm sinus rhythm with. Sensing been treated or. 603 00:49:01.950 --> 00:49:02.190 See 604 00:49:02.200 --> 00:49:10.960 a big ole spike there see the big line this little I don't want. Sorry 605 00:49:10.960 --> 00:49:16.810 . Now compare that to the very next 606 00:49:17.140 --> 00:49:23.060 electrocardiogram these are the way we have read through our Ras and exterior as 607 00:49:23.070 --> 00:49:23.670 with every p. 608 00:49:23.680 --> 00:49:30.660 Way No Are there even where there are people down there in the rhythm strip so the 609 00:49:30.670 --> 00:49:35.920 way so we're actually we're going to we're going to go faster than. We actually 610 00:49:35.930 --> 00:49:39.010 have a sinus rhythm here we have a sinus rhythm it's not 611 00:49:39.020 --> 00:49:40.250 a jewel verbalization right there's 612 00:49:40.260 --> 00:49:43.650 a sinus rhythm but there is no relationship with 613 00:49:43.660 --> 00:49:48.040 a mate of your Rasul right off the van I'm going to say this sinus rhythm with. 614 00:49:50.180 --> 00:49:52.590 We'll call it a high grade were complete a.v. 615 00:49:52.600 --> 00:49:56.200 Block there is no relationship between a new wave and a native Q 616 00:49:56.210 --> 00:50:02.410 r s so I will interpret this letter cardiogram in sinus rhythm with high graded 617 00:50:02.420 --> 00:50:07.470 work complete right here and that's completely 80 blocks been triggered there 618 00:50:07.480 --> 00:50:13.690 pacemaker rules Norman trigger pacing. And I put them just in just 619 00:50:13.700 --> 00:50:16.140 a position to the previous letter cardiogram where there was 620 00:50:16.150 --> 00:50:20.850 a relationship between the atrium and the Pacemakers like this one does not so this 621 00:50:20.860 --> 00:50:21.970 patient and a.b. 622 00:50:21.980 --> 00:50:23.260 Block it's actually 623 00:50:23.270 --> 00:50:28.260 a patient mine aren't complete are glop you know I'll also not you know passing out 624 00:50:28.450 --> 00:50:30.690 he's got a pacemaker pacing at 625 00:50:30.700 --> 00:50:37.360 a rate of 50 and the by the way to be precise the atrial rein I would put them into 626 00:50:37.370 --> 00:50:44.270 agreeing the atrial rate is. The actual rape. It was about 60 something and 627 00:50:44.310 --> 00:50:47.730 the pacemaker rate was in the fifty's so we had 628 00:50:47.740 --> 00:50:53.840 a sinus rhythm rate of $65.00 when I heard you not to be with complete ab block 629 00:50:54.830 --> 00:51:01.480 the trigger of the rest. Were just given to me. It 630 00:51:02.050 --> 00:51:08.660 was. Just in the present time all right let's look down at the bottom and then we 631 00:51:08.670 --> 00:51:12.210 have one more. Is there a look at the rhythms tribute is there 632 00:51:12.220 --> 00:51:17.220 a you were there if you were actually curious would there be way the answer is yes 633 00:51:17.810 --> 00:51:19.800 the p.r. Animal would go away and that's 634 00:51:19.810 --> 00:51:25.930 a toughie are you know what's going on at that interval. Interval is really sure 635 00:51:25.970 --> 00:51:32.950 right. When you want to or something like that so even lower you can small point 10 636 00:51:32.960 --> 00:51:34.710 mm q.r.s. 637 00:51:34.720 --> 00:51:41.590 The little good wine with some sort of funny looking months will mean. To 638 00:51:41.600 --> 00:51:45.430 wipe your ass now we're looking at the s.t.c. S.t.t. 639 00:51:45.440 --> 00:51:47.430 Website and so it's a connect your to q. 640 00:51:47.440 --> 00:51:52.470 Waves in a species that's the same that's. Your body I want to venture 641 00:51:52.480 --> 00:51:54.550 a song with something's wrong with the sea k.g. 642 00:51:54.590 --> 00:51:58.920 Do we use it in some sort of can why you are asked and it's got 643 00:51:58.930 --> 00:52:03.300 a certain pattern. It's got a Delta where very good the Delta wave is 644 00:52:03.310 --> 00:52:07.840 a little off sloping right in front right after that interval we have a short p.r. 645 00:52:07.850 --> 00:52:13.390 Interval with the Delta wave and all sloping Delta way and this is pretty exciting 646 00:52:13.430 --> 00:52:20.410 if you got me. There last one Ok and I actually don't hear this in front of 647 00:52:20.420 --> 00:52:24.500 you to get rest what is are you doing with every q.r.s. 648 00:52:24.510 --> 00:52:28.690 But I know this one is your new way with everything your rest and if your as with 649 00:52:28.700 --> 00:52:34.210 everything away. Wait a minute to someone this guy and looks pretty bad on 650 00:52:34.220 --> 00:52:35.780 a dead end street signs in 651 00:52:35.790 --> 00:52:40.550 a bad day right pretty flat iron right but look at the other leads it's flat lining 652 00:52:40.560 --> 00:52:46.380 madly Now let's look. It leave one is leaving one positive or negative negative you 653 00:52:46.390 --> 00:52:50.260 know when I'm that's a kind of a really negative and looking in a.t.m. 654 00:52:50.260 --> 00:52:54.950 . There's something but now look at wait a minute you go wait 655 00:52:54.960 --> 00:52:56.910 a minute there's something really wrong with us I got 656 00:52:56.920 --> 00:53:02.450 a flat line and we need to and they would just say. This is mine and get you all 657 00:53:02.460 --> 00:53:06.700 right all business manager card is a leader Ok this is 658 00:53:06.710 --> 00:53:12.700 a complex legal versus. It's actually the most how liberals are right and left the 659 00:53:12.710 --> 00:53:16.370 right arm and the left arm reversed you look at leave when it's maybe the word 660 00:53:16.380 --> 00:53:18.320 should be the d.v.r. 661 00:53:18.370 --> 00:53:22.910 Which is the right word leave which should never be positive as positive you look 662 00:53:22.920 --> 00:53:26.560 at it that this is a very complex e.k.g. 663 00:53:26.570 --> 00:53:31.240 Where the right eye reversed everything just birthparents all of these I screwed it 664 00:53:31.250 --> 00:53:38.070 up and this is my mentor So Ok now when I did teaching point is if you look 665 00:53:38.470 --> 00:53:42.440 I don't want her to get around and be cagey leading the c.c. In the i.c.u. 666 00:53:42.450 --> 00:53:47.070 Or c c u n u c a flatline out there or you're in the middle of 667 00:53:47.080 --> 00:53:53.660 a cardiac arrest situation make sure the leads are I'm right make sure because I 668 00:53:53.670 --> 00:53:57.760 have seen this happen where you say Larry we're going to hear I feel 669 00:53:57.770 --> 00:54:01.830 a pulse and so our leads are either off or they're in 670 00:54:01.840 --> 00:54:05.650 a complex reversal picks the lead picks 671 00:54:05.660 --> 00:54:09.990 a lead to make sure hope they're not going to play very hostile All right if you 672 00:54:10.000 --> 00:54:10.700 will learn to love 673 00:54:10.710 --> 00:54:14.910 a good use We're going to do this again and we'll do it we're going to basically In 674 00:54:14.920 --> 00:54:20.310 fact I will you list your age because I am writing this book and as you know with 675 00:54:20.320 --> 00:54:23.910 your permission with the chapter I really would like your opinion I would like to 676 00:54:23.950 --> 00:54:26.960 forward you a you know to see what you guys think about it is 677 00:54:26.970 --> 00:54:32.260 a readability doesn't make sense it's written from very basic. To start from the 678 00:54:32.270 --> 00:54:33.410 beginning to gives 679 00:54:33.420 --> 00:54:37.530 a very very complex and I love the forward now the chapters for your comments and 680 00:54:37.540 --> 00:54:43.040 critique but it's written for you that will be in the next book no way. For this is 681 00:54:43.260 --> 00:54:47.410 yet to be this is clinical letter party are to be reviewed study guide you there 682 00:54:47.540 --> 00:54:54.370 don't leap to the movie and. So what if at Peter's mirror you write and 683 00:54:54.380 --> 00:55:00.800 scam All right guys under one goes he's a patient. He's very nice man.