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14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To determine the electrical axis in the Citations with Sriram & Svirbely 1999 frontal plane for the QRS complex from the documentatio standard limb leads. n. 07.16.01 data enter Do you want to determine the frontal electrical axis for the QRS? (Y or N) y :-):-):-) enter an "x" in the appropriate column for each standard limb lead indicating the wave form (only 1 answer per row) negative isolectric positive I No check data negative isolectric positive II No check data negative isolectric positive III No check data negative isolectric positive aVL No check data negative isolectric positive aVF No check data negative isolectric positive aVR No check data calculate result data complete? No evaluation appropriate? complete data :-):-):-) QRS electrical axis in frontal plane complete data which indicates the the axis complete data 0 check data check data #N/A 113 shows to +239°) -121° to -149° (+211extreme axis deviation 123 -120° (+240°)shows extreme axis deviation 133 shows extreme -91° to -119° (+241 to +269°) axis deviation 143 -150° (+210°)shows extreme axis deviation 163 shows to +209°) -151° to -179° (+181extreme axis deviation 165 -180° (+180°)shows right axis deviation 168 s +151 to +179° hows right axis deviation 268 +150° shows right axis deviation 366 +91 to +119° shows right axis deviation 367 +120° shows right axis deviation 368 s +121 to +149° hows right axis deviation 433 -90° (+270°) shows left axis deviation 566 +90° is borderline normal (vs right axis deviation) 631 -31° to -59° shows left axis deviation 632 -60° shows left axis deviation 633 -61 to -89° shows left axis deviation 731 -30° is borderline normal (vs left axis deviation) 831 -1° to -29° is normal 834 0° is normal 836 +1 to +29° is normal Page 1 14874a99-c5a5-42ca-bb69-939522cb4cff.xls 856 +30° is normal 866 +61 to +89° is normal 876 +60° is normal 886 +31 to +59° is normal 887 check data check data Coding (first and second lead in pairing to table, see documentation) negative-negative 1 I & II: x100 negative-isoelectric 2 III & aVL: x10 negative-positive 3 aVF & aVR: x1 isoelectric-negative 4 isoelectric-positive 5 positive-negative 6 positive-isolectric 7 positive-positive 8 Page 2 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Novosel D, Noll G, Luscher TF. Corrected for Externer Psychiatrischer Dienst, Haselstrasse I II III aVF The calculation of the heart axis in the fronta Net R-S mm ± use of combination of bipolar (I, II, III) and un enter sum of R wave and S wave; eg if R is +5 and S is -8, enter '-3' Calculation of the electrical axis from leads I Arctan (aVF/I) results in lower values (in our that uses leads I and II: EA= Arctan ((2*II axis axis interpretation Bonferroni correction) or with corrected form ECG axis using I and aVF ° northwest axis (axis = 374 degrees, n=48; p<0.005, paired t required because the unipolar and bipolar lea ECG axis using I and II ° right axis deviation clinical significance, our results suggests tha calculation of the electrical axis. ECG axis using I and III ° northwest axis -90° to -29° = left axis deviation 0° -30° to +110° = normal axis +111° to +180° = right axis deviation ±180° to -90° = "northwest axis" ("northwest axis" is commonly seen in congenital heart disease, Singh PN, Athar MS. Simplified [correction of dextrocardia, and sometimes in severe COPD) electrocardiogram. Indian J Physiol Pharmaco Department of Physiology, Faculty of Medicin In clinical practice assessment of the mean Q ventricles or conduction blocks. The method leads has inherent element of subjectivity of a ambiguity about differentiation of left axis dev or complete/hemi block of the left bundle bran correct diagnosis. Though a formula based o for accurate measurement of axis, considerin only method for accurate measurement of the respective axes which is not practicable in cli accurate assessment of MQRSA, some autho ventricular hypertrophy with a broad S correct measurement of MQRSA, we have de and Lead-III. The formula derived is as follow in Lead-I and III, theta = angle subtended wit or the table. In case net voltage of QRS comp 180degrees to find the angle of mean QRS v Page 3 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 4 14874a99-c5a5-42ca-bb69-939522cb4cff.xls G, Luscher TF. Corrected formula for the calculation of the electrical heart axis. Croat Med J. 1999 Mar;40(1):77-9. atrischer Dienst, Haselstrasse 1, CH - 5401 Baden, Switzerland. dragonovosel@hotmail.com of the heart axis in the frontal plane can be performed with the combination of any two leads. The ation of bipolar (I, II, III) and unipolar leads (aVR, aVL and aVF) can produce wrong results. he electrical axis from leads I and aVF without correction (sometimes used in ECG recorders): EA= results in lower values (in our study: 34 4 , n = 48) as compared to the values obtained with formula I and II: EA= Arctan ((2*II-I)/(Sqr(3)*I)) (axis = 33+/-7 degrees, n=48; p<0.005, paired t-test with ection) or with corrected formula which uses leads I and aVF: EA=+/-Arctan ((2*aVF)/(Sqr(3)*I)) grees, n=48; p<0.005, paired t-test with Bonferroni correction). The correction factor 2/Sqr(3) is se the unipolar and bipolar leads have different strengths. Although the difference rarely reach ance, our results suggests that the ECG recorders should be proofed on formulas used for the he electrical axis. r MS. Simplified [correction of Simlified] calculation of mean QRS vector (mean electrical axis of heart) of am. Indian J Physiol Pharmacol. 2003 Apr;47(2):212-6. Physiology, Faculty of Medicine, A.M.U. Aligarh. ce assessment of the mean QRS axis (MQRSA) provides information related either with hypertrophy of the nduction blocks. The method adopted by clinicians i.e. the inspection of the QRS voltage in six of the limb ent element of subjectivity of approximately 10degrees. Moreover, in certain condition, when there is t differentiation of left axis deviation assessed by inspection method in to either hypertrophy of left ventricles mi block of the left bundle branches, accurate measurement of the axis becomes necessary to arrive at the is. Though a formula based on area under R wave and S-wave of the same QRS complex has been derived easurement of axis, considering its use in the computer software, working with ordinary electrocardiograph the r accurate measurement of the QRS axis is plotting method i. e. the net voltages in Lead-I, and III on their s which is not practicable in clinical settings. Although, calculation of MQRSA by area method gives an sment of MQRSA, some authors prefer measurement of axis by voltage method, as in cases of the right ertrophy with a broad S-wave calculation of axis by area method may give erroneous results. Hence, to obtain ement of MQRSA, we have derived a simplified formula based on the net voltage of QRS complexes in Lead-I he formula derived is as follows, Tan(theta) =(I + 2III) divided by sqrt [3I], where I and III represent net voltage I, theta = angle subtended with the axis Lead-I. The value of theta can be found by using scientific calculator case net voltage of QRS complex in Lead-I being negative, the value of the theta should be subtracted from find the angle of mean QRS vector. Page 5 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 6 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Mar;40(1):77-9. Page 7 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 8 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To determine the electrical axis of Citations with the QRS complex in the horizontal plane by documentatio examining the precordial leads (V1 through n. 07.16.02 V6). data Are you trying to determine the enter electrical axis for the QRS complex in the horizontal plane? of the N) Are all (Y or precordial leads Y :-):-):-) predominantly negative? (Y or N) all of the precordial leads Are n :-):-):-) predominantly positive? (Y or N) n :-):-):-) enter an 'x' in the appropriate column for the most isoelectric lead (give only 1 answer) V1 V2 V3 V4 V5 V6 most isolectric precordial lead x calculate result data complete? Yes evaluation appropriate? Yes :-):-):-) The electrical axis for the QRS complex is normal Page 9 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Sriram & Svirbely 1999 Yes 4 Page 10 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To correct the Q-T interval for various Citations with Sriram & heart rates. documentation Svirbely 1997 . 07.26.01 conversion enter duration in msec 350 msec equals 0.35 seconds data enter heart rate per minute 50 beats/min Q-T interval in seconds 0.39 seconds calculate results data complete? Yes R-R interval (in seconds) 1.21 seconds Q-T corrected 0.35 seconds Page 11 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To identify the location of atrioventricular Citations with Sriram & (AV) block by examining the changes in the ECG. documentation Svirbely 1999 . 07.15.01 data enter Does the patient have evidence of AV block? (Y or N) Y :-):-):-) QRS duration in seconds seconds Are conducted beats present? (Y or N) enter Y or N Is the PR interval constant? (Y or N) enter Y or N Are RP intervals variable? (Y or N) enter Y or N calculate result data complete? No evaluation appropriate? complete data :-):-):-) block located in AV node? complete data block in common bundle? complete data block located in bundle branches? complete data block cannot be localized? complete data Should a temporary pacemaker be inserted into the patient? complete data Page 12 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To diagnose left ventricular hypertrophy Citations with Sriram & from electrocardiographic changes using the criteria documentation Svirbely 1998 of Casale et al. . 07.05.03 conversion enter peak height in mV mV equals 0 mm data enter gender of the patient (M or F) enter M or F check data Is the patient in normal sinus rhythm? (Y or N) enter Y or N :-):-):-) :-):-):-) QRS wave duration in seconds seconds P terminal force in V1 in mm•sec mm•sec peak height in mm R wave S wave T wave V1 mm V3 mm aVL mm calculate result data complete? No value of voltage equation complete data mm which indicates LVH iscomplete data multiple logistic regression equation complete data which indicates LVH iscomplete data Page 13 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To identify changes in the electrocardiogram associated with altered Citations with documentation. concentrations of potassium. 07.23.01 data Are you evaluating an ECG for enter changes associated with potassium levels? (Y or N) Y :-):-):-) enter an "x" in the appropriate column for each finding (give only 1 answer per row) increased amplitude absent flattened normal and/or width P wave x Yes 1 normal prolonged PR interval x Yes 0 normal prolonged AV block QRS interval x Yes 0 depressed normal increased ST segment x Yes 2 increased amplitude and/or width normal flattened inverted T wave x Yes 2 normal prominent U wave x Yes 0 ventricular premature tachy- normal fibrillation beats arrhythmias rate and rhythm x Yes 0 calculate result data complete? Yes evaluation appropriate? Yes :-):-):-) number of findings associated with hyperkalemia 1 number of findings associated with hypokalemia 2 Page 14 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 15 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 16 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Purpose: To diagnose myocardial injury from the patterns of cardiac markers seen over time. data enter age of patient in years 55 years gender of patient (enter M or F) M :-):-):-) Test enter laboratory findings over time Initial 3 hour 6 hour 12 hour 18 hour 24 hour 48 hour total CK (U/L) 200 210 220 250 230 225 199 CK-MB (ng/mL) 25 26 30 35 32 30 20 myoglobulin in µg/L 90 100 100 80 70 60 50 troponin T in µg/L 0.05 0.15 0.2 0.3 0.2 0.25 0.3 troponin I in µg/L 3 4 6 8 7 5 6 total LD (U/L) 400 410 420 450 475 500 600 LD1 as percent total of LD (enter from 0 to 100) 30 30 31 32 34 36 40 LD2 as percent of total LD (enter from 0 to 100) 36 36 37 38 38 39 40 intermediate calculation Initial 3 hour 6 hour 12 hour 18 hour 24 hour 48 hour CK-MB index 12.50 12.38 13.64 14.00 13.91 13.33 10.05 troponin T as multiple of upper limit of normal 0.50 1.50 2.00 3.00 2.00 2.50 3.00 troponin I as multiple of upper limit of normal 0.97 1.29 1.94 2.58 2.26 1.61 1.94 amount LD1 in U/L 120 123 130.2 144 161.5 180 240 amount LD2 in U/L 144 147.6 155.4 171 180.5 195 240 LD1-to-LD2 ratio 0.83 0.83 0.84 0.84 0.89 0.92 1.00 intermediate evaluation Initial 3 hour 6 hour 12 hour 18 hour 24 hour 48 hour total CK normal increasedincreased increased normal increased increased CK-MB is:increasedincreasedincreasedincreasedincreasedincreasedincreased CK-MB index is:increasedincreasedincreasedincreasedincreasedincreasedincreased myoglobulin is: normalincreasedincreased normal normal normal normal troponin T is: normalincreasedincreasedincreasedincreasedincreasedincreased troponin I is: normalincreasedincreasedincreasedincreasedincreasedincreased LD1 is:increasedincreasedincreasedincreasedincreasedincreasedincreased LD2 is:increasedincreasedincreasedincreasedincreasedincreasedincreased LD1-to-LD2 ratio is:increasedincreasedincreasedincreasedincreasedincreasedincreased peak value seen at: peak after infarct injury relative to initial • CK-MB 12 hours 12-24 hours 0-12 hours before • troponin T 12 hours 10-24 hours 12 hours before to 2 after • troponin I 12 hours 10-24 hours 12 hours before to 2 after • LD1 48 hours 48-72 hours 0-24 hours before interpretation c/w normal? minor myocardial suspicious for No injury? No c/w myocardial infarction? Yes Page 17 14874a99-c5a5-42ca-bb69-939522cb4cff.xls c/w late presentation of MI? No c/w skeletal muscle injury? No Reference Range LD total low normal high normal 297 537 Ref Range LD Isoenzymes low normal high normal high in LD units LD1 0.156 0.278 149 LD2 0.318 0.407 219 LD3 0.176 0.26 140 LD4 0.071 0.127 68 LD5 0.062 0.156 84 Reference Range Markers high normal troponin T 0.1 µg/L troponin I 3.1 µg/L myoglobin 90 µg/L total CK upper limit normal male female 20 200 165 60 203 99 CK-MB upper limit normal 5 ng/mL upper limit borderline 10 ng/mL time of infarct CK-MB initial 12-24 hours before 3 9-21 hours before 6 6-18 hours before 9 3-15 hours before 12 0-12 hours before 18 6 hours before to after 24 0-12 hours after 48 24-36 hours after trop T initial 10-24 hours before 3 7-21 hours before 6 4-18 hours before 9 1-15 hours before 12 12 hours before to 2 after 18 6 hours before to 8 after 24 0-14 hours after 48 24-38 hours after LD1 initial 48-72 hours before 3 45-69 hours before 6 42-66 hours before 9 39-63 hours before Page 18 14874a99-c5a5-42ca-bb69-939522cb4cff.xls 12 36-60 hours before 18 30-54 hours before 24 24-48 hours before 48 0-24 hours before Page 19 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Citations with Sriram & documentation Svirbely 1997 . 06.07.01-.05 U/L ng/mL µg/L µg/L µg/L U/L per cent per cent U/L U/L # increased # borderline 5 7 0 7 2 6 6 7 7 7 Page 20 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 21 14874a99-c5a5-42ca-bb69-939522cb4cff.xls Page 22