1. ECG PRACTICAL APPROACH
Dr. Hossam Hassan
Consultant Emergency Medicine

2. Objectives To emphasize simplicities Practical approach
Interpretation & clinical scenario are inseparable
Systematic approach

4. Conduction System

5. Nomenclature

6. Magic numbers of Dr. Hossam3 5

7. Systematic approach 3 5 Rate Rhythm axis P-wave PR interval
QRS complex
ST segment
T-wave

8. Rate 5 3 The interval between 2 successive R-wave
How many big squares?
Divide 300 / # big squares
Normal 60 – 100/min 5 3

9. Rhythm Sinus Rhythm Every P=wave is followed by QRS complex
P-wave is upright in lead II

10. NSR

11. Types of Sinus Rhythm NSR Sinus Tachycardia Sinus Bradycardia
Sinus arrhythmia

12. Sinus tachycardia

14. Axis
Normal axis
Right axis deviation
Left axis deviation

15. RAD

16. LAD

18. P-wave Atrial depolarization Atrial contraction is a result
Normally a dome-like structure

19. Abnormalities of P-wave
Peaked p-pulmonle
Pulmonary HTN PE
Pulmonary valve stenosis
M-shaped M-mitrale
Mitral valve stenosis
Left atrial hypertrophy
Inverted 2nd atrial / junctional ectopy

20. P-pulmonale

22. PR interval 3 5 Definition From the start of P to beginning of QRS
Represent the delay in transmission in AV node
Normally 0.12 – 0.20 msec 3 5

23. Abnormalities of PR interval5
Prolonged >
1st degree HB
Short <
Pre-excitation syndromes
WPW Syndrome
LGL Syndrome
Junctional rhythm 3

26. QRS Complex
Amplitute
Duration
Shape
Q-wave
R-wave 5

27. QRS AMPLITUTE 35 LVH By voltage criteria
S-wave in V 1 or V 2 + R-wave in V5 or V6 35

28. LVH & STRAIN PATTERN

29. Causes of LVH HTN Aortic stenosis HOCM Aortic regurgitation
Mitral regurgitation

30. QRS DURATION 3 Ventricular depolarization
Ventricular contraction is a result
Normally < 0.12 msec
< small squares 3

31. Causes of wide QRS
Ventricular tachycardia
BBB
Left BBB
Right BBB

32. L BBB

33. LBBB

34. R BBB

35. Shape
Upstroke & downstroke of R-wave
Delta wave

36. Q-wave 1st negative deflection after the P-wave
Normally 1mm wide & 2 mm deep
Lead III , V5 & V6
Pathological Q-wave
Wider & deeper
>1/4 of the ensuing R-wave
Old MI

37. +ve R-wave in V1

38. Causes +ve R-wave in V I
RVH
R BBB
Posterior MI
Type A WPW

39. ST-Segment From the end of S-wave to the beginning of T-wave
Normally iso-electric
Abnormalities
Elevated
depressed

40. Elevated ST segment Acute MI Pericarditis
Early repolarization pattern in the young

41. Infarct localization Inferior Septal Anterior Lead II , III , aVF
V I , V II
Anterior
V3 , V4

42. Lateral Lead I , AVL,V5 , V6 Posterior MI
- Prominent R wave in V1,V2 with depressed ST segment

43. Acute inf MI

44. Anteroseptal MI

45. Anterior MI

46. Lateral MI

47. Depressed ST Segment
Unstable angina
Left ventricular strain pattern

48. LVH & strain pattern

49. T-wave Ventricular repolarization Dome like structure Abnormalities
Peaked / tented t-wave
Hyperkalaemia
Subendocadial ischemia
Inverted
LV Strain pattern
Dynamic t-wave changes of ischemia

50. DYNAMIC T-WAVE CHANGES

66. Hay….. wake up we are done