3. اصول EKG

5. سیستم هدایتی  SA node  Pacemaker  60-100 bpm  P waves up in I, II, aVF  Internodal Pathways  AVN; RA contraction  Interatrial Pathways  LA to depolarize

6. سیستم هدایتی  AV node  Delays impulse by.1s  PR segment  AV junction  AV node & His  40-60 bpm  Purkinje/bundles  Ventricular depol  20-40 bpm

7. سیستم هدایتی

8.  Repolarization  Direction is same as depolarization  Autonomic Nervous System (ANS)  Sympathetic Nervous System (SNS)  Parasympathetic Nervous System (PNS)

9. اصول EKG

10. اصول EKG: موج P  Normal  Width <.11 secs  Height.5 to 2.5 mm  Morphology  Flat  Biphasic  Absent

11. اصول EKG: موج P  Abnormal  Inversions  Amplitude  P-Pulmonale > 2.5 mm  Duration  P-Mitrale >.1 sec (or 2 ½ boxes)  Absence

12. اصول EKG: موج QRS  Impulse travels quicker down the left bundle branch (LBB) than the right bundle branch (RBB). Septum depolarizes L to R resulting in a downward deflection  Both ventricles are activated simultaneously. Since the RV is smaller, depolarizes quicker resulting in the downward deflection  LV depolarizes resulting in the R wave

14. اصول EKG: موج QRS

15. 6 ویژگی موج QRS 1.Duration:.05 -.12 Secs 2.Amplitude: > 5mm; < 20 mm in limb, < 25 in anterior leads 3.Presence of Q waves < 0.04 msec and < 2 mm normal in I, aVL, aVF, V5 4.Axis 5.Progression: Zone of transition V3-V4 6.Configuration

16. اصول EKG: موج T و U  T waves occur in  Same direction as QRS  Height: < 5 mm in limb leads, <10 mm in anterior leads  U waves  After T wave  Best seen in lead III  Hypothermia/hypokalemia

17. اصول EKG

18. لیدهای قفسه سینه

19. EKG استاندارد EKG استاندارد  12 leads and rhythm strip  Limb leads  I, II, III, aVR, aVL, aVF  Anterior leads  V1-V6  Speed = 25 mm/sec  Height = 10 mm

20. متغیرهای نوار قلب  Source  Age, Sex  Body weight  Chest configuration  Heart position  Food intake  Temperature, Exercise  Smoking, Hyperventilation  Position of precordial leads

21. متغیرهای نوار قلب  Ideal time for EKG  Bayes’ Theorem  Normal hearts have abnl EKGs  Normal EKG does not r/o heart disease

22. رویکرد منظم  Rate  Rhythm  Axis  Wave Morphology  P, T, and U waves and QRS complex  Intervals  PR, QRS, QT  ST Segment

23. تعیین ریت قلب On 6 sec strip, count QRS complexes, X 10 QRS on dark line of tracing, count large boxes, ÷ into 300

24. تعیین ریت قلب

26. دپلاریزاسیون

27. دپلاریزاسیون

28. اصول EKG

29. موج P در لید II

30. دپلاریزاسیون بطن ها در لید قفسه سینه

31. محور قلب  Find the quadrant  Isolate the isoelectric lead  Smallest QRS voltage  Isolate the perpendicular lead  Isolate the vector  Double check your findings

32. پیدا کردن ربع

33. 1.1. 3.

34. پیدا کردن لید ایزوالکتریک

35. پیدا کردن محور

39. ریتم / آریتمی  Sinus  Atrial  Junctional  Ventricular

40. آریتمی سینوسی : معیار و انواع  P waves upright in I, II, aVF  Constant P-P/R-R interval  Rate  Narrow QRS complex  P:QRS ratio 1:1  P-R interval is normal and constant

41. آریتمی سینوسی : معیار و انواع  Normal Sinus Rhythm  Sinus Bradycardia  Sinus Tachycardia  Sinus Arrhythmia

42. Normal Sinus Rhythm Rate is 60 to 100

43. Sinus Bradycardia Can be normal variant Can result from medication Look for underlying cause

44. Sinus Tachycardia May be caused by exercise, fever, hyperthyroidism Look for underlying cause, slow the rate

45. Sinus Arrhythmia Seen in young patients Secondary to breathing Heart beats faster

46. آریتمی دهلیزی : معیار و انواع  P waves inverted in I, II and aVF  Abnormal shape  Notched  Flattened  Biphasic  Narrow QRS complex

47. آریتمی دهلیزی : معیار و انواع  Premature Atrial Contractions  Ectopic Atrial Rhythm  Wandering Atrial Pacemaker  Multifocal Atrial Tachycardia  Atrial Flutter  Atrial Fibrillation

48. Premature Atrial Contraction QRS complex narrow RR interval shorter than sinus QRS complexes P wave shows different morphology than sinus P wave

49. Ectopic Atrial Rhythm Narrow QRS complex P wave inverted

50. Wandering Atrial Pacemaker 3 different P wave morphologies possible with ventricular rate < 100 bpm

51. Multifocal Atrial Tachycardia 3 different P wave morphologies with ventricular rate> 100 bpm

52. Atrial Flutter Regular ventricular rate 150 bpm Varying ratios of F waves to QRS complexes, most common is 4:1 Tracing shows 2:1 conduction

53. Atrial Flutter Tracing shows 6:1 conduction

54. Atrial Fibrillation Tracing shows irregularly irregular rhythm with no P waves Ventricular rate usually > 100 bpm

55. Atrial Fibrillation Tracing shows irregularly irregular rhythm with no P waves Ventricular rate is 40

56. Atrial Tachycardia Tracing shows regular ventricular rate with P waves that are different from sinus P waves Ventricular rate is usually 150 to 250 bpm

57.  P wave  May be absent  Buried in QRS  If present  inverted in leads I, II, and aVF  Inverted after QRS آریتمی جانکشنال : معیار

58.  PR interval < 0.12 Secs  Rate: Varies  Narrow QRS complex آریتمی جانکشنال : معیار و انواع

59. آریتمی جانکشنال : انواع  Premature Junctional Contractions  Junctional Escape Rhythm  Accelerated Junctional Tachycardia  Junctional Tachycardia  Reentrant Tachycardia  AVNRT

60. Premature Junctional Contractions R-R interval is shorter Beat is early, narrow QRS complex Inverted P wave P wave can be buried in QRS complex

61. Junctional Escape Rhythm Junctional origin Rate is 40 to 60

62. Accelerated Junctional Tachycardia Junctional origin Rate is 60 to 100

63. Junctional Tachycardia Junctional origin Rate is > 100

64. Secondary to bypass tract within AV node Premature Atrial Contraction (PAC) depolarizes AV Nodal Reentrant Tachycardia (AVNRT) AV Nodal Reentrant Tachycardia (AVNRT)

65. Rate Summary  Sinus Tachycardia - 100-160 BPM  Atrial Tachycardia - 150-250 BPM  Atrial Flutter - 150-250 BPM  Junctional Tachycardia - 100-180 BPM

66. بلوک های گره AV Delay conduction of impulses from sinus node If AV node does not let impulse through, no QRS complex is seen AV nodal block classes: 1 st, 2 nd, 3 rd degree

67. 1 st Degree AV Block PR interval constant >.2 sec All impulses conducted

68. 2 nd Degree AV Block Type 1 AV node conducted each impulse slower and finally no impulse is conducted Longer PR interval, finally no QRS complex

69. 2 nd Degree AV Block Type 2 Constant PR interval AV node intermittently conducts no impulse

70. AV node conducts no impulse Atria and ventricles beat at intrinsic rate (80 and 40 respectively) No association between P waves and QRS complexes 3 rd Degree AV Block

71. Caused by bypass tract AV node is bypassed, delay EKG shows short PR interval <.11 sec Upsloping to QRS complex (delta wave) Wolfe-Parkinson-White (WPW)

72. Delta wave, short PR interval WPW

73. آریتمی های بطنی : معیار و انواع  Wide QRS complex  Rate : variable  No P waves  Premature Ventricular Contractions  Idioventricular Rhythm  Accelerated IVR  Ventricular Tachycardia  Ventricular Fibrillation

74. Occurs earlier than sinus beat Wide, no P wave Premature Ventricular Contraction

75. Escape rhythm Rate is 20 to 40 bpm Idioventricular Rhythm

76. Rate is 40 to 100 bpm Accelerated Idioventricular Rhythm

77. Rate is > than 100 bpm Ventricular Tachycardia

78. Torsades de Pointes Occurs secondary to prolonged QT interval

79. Unorganized activity of ventricle Ventricular Tachycardia/Fibrillation

80. Ventricular Fibrillation

81. هایپرتروفی بطن ها و دهلیزها

82.  Differential Diagnosis  Hypertension (HTN)  Aortic Stenosis (AS)  Aortic Insufficiency (AI)  Hypertrophic Cardiomyopathy (HCM)  Mitral Regurgitation (MR)  Coarctation of the Aorta (COA)  Physiologic Left Ventricular Hypertrophy (LVH)

83.  False positive  Thin chest wall  Status post mastectomy  Race, Sex, Age  Left Bundle Branch Block (LBBB)  Acute MI  Left Anterior Fascicular Block  Incorrect standardization Left Ventricular Hypertrophy (LVH)

84. Estes Criteria: Diagnosis of LVH

85. Right Ventricular Hypertrophy: Causes  Chronic Obstructive Pulmonary Disease  Pulmonary HTN  Primary  Pulmonary Embolus  Mitral Stenosis  Mitral Regurgitation  Chronic LV failure

86. Right Ventricular Hypertrophy: Causes  Tricuspid Regurgitation  Atrial Septal Defect  Pulmonary Stenosis  Tetralogy of Fallot  Ventricular Septal Defect

87. Right Ventricular Hypertrophy

88.  Reversal of precordial pattern  R waves prominent in V1 and V2  S waves smaller in V1 and V2  S waves become prominent in V5 and V6

89. Strain

90.  Mitral Stenosis  Mitral Regurgitation  Left ventricular hypertrophy  Hypertension  Aortic Stenosis  Aortic Insufficiency  Hypertrophic Cardiomyopathy بزرگی دهلیز چپ : علل

91. بزرگی دهلیز چپ : معیار  P wave  Notch in P wave  Any lead  Peaks > 0.04 secs  V1  Terminal portion of P wave > 1mm deep and > 0.04 sec wide

92. Lead II

93. موج P: بزرگی دهلیز چپ

94. بزرگی دهلیز چپ

95.  CHD  Tricuspid Stenosis  Pulmonary Stenosis  COPD  Pulmonary HTN  Pulmonary Embolus  Mitral Regurgitation  Mitral Stenosis بزرگی دهلیز راست : علل

96.  Tall, peaked P wave > 2.5 mm in any lead  Most prominent P waves in leads I, II and aVF بزرگی دهلیز چپ : معیار

97. بزرگی دهلیز راست

98. Bundle Branch Blocks بلوک شاخه ای دسته ای

99.  Normal variant  Idiopathic degeneration of the conduction system  Cardiomyopathy  Ischemic heart disease  Aortic Stenosis  Hyperkalemia  Left Ventricular Hypertrophy بلوک شاخه ای دسته ای چپ : علل

100. بلوک شاخه ای دسته ای چپ : معیار  Bizarre QRS Morphology  High voltage S wave in V1, V2 & V3  Tall R wave in leads I, aVL and V5-6  Often LAD  QRS Interval  ST depression in leads I, aVL, & V5-V6  T wave inversion in I, aVL, & V5-V6

101. Left Bundle Branch Block

102. بلوک شاخه ای دسته ای راست : علل  Idiopathic degeneration of the conduction system  Ischemic heart disease  Cardiomyopathy  Massive Pulmonary Embolus  Ventricular Hypertrophy  Normal Variant

103. بلوک شاخه ای دسته ای راست : معیار  QRS morphology  Wide S wave in leads I and V4-V6  RSR’ pattern in leads V1, V2 and V3  QRS duration  ST depression in leads V1 and V2  T wave inversion in leads V1 and V2

104. بلوک شاخه ای دسته ای راست

106. ایسکمی و انفارکتوس

107. Normal Complexes and Segments

108. J Point

109. اندازه گیری

110. ایسکمی T wave inversion, ST segment depression Acute injury: ST segment elevation Dead tissue: Q wave

111. EKG Changes: Ischemia → Acute Injury→ Infarction

112. لیدهای قفسه سینه

113. محل لیدهای قدامی  V1  Right 4 th ICS  V2  Left 4 th ICS  V3  Left Sternal border  Between V2 and V4  V4  Left MCL  5 th ICS  V5  Anterior axillary line  5 th ICS  V6  Mid axillary line  5 th ICS

114. خونرسانی به قلب  Left Anterior Descending (LAD) artery  Bulk of LV  Anterior wall  Apex  Part of lateral wall  Part of septum

115. خونرسانی به قلب  Right Coronary Artery (RCA)  Right Ventricle  Sinus Node 60% of the time  Right Atrium  Posterior Descending Artery (PAD) 90% of the time

116. خونرسانی به قلب  Left Circumflex (LCFLX) artery  Lateral Wall & Posterior Wall of LV & LA  SA node 40% of the time  PDA 10% of the time  Posterior Descending Artery (PAD)  Off RCA 90%/LCFLX 40%  AVN, prox BB, IW/PW, basal septum

117. View of the Leads  II, III, aVF  Inferior Wall//RV  RCA distribution  I, aVL  Lateral Wall  LCFLX/distal LAD distribution  aVR  R side of heart  V1 & V2  Intraventricular septum  Proximal LAD  V3 & V4  Anterior wall  Mid LAD  V5 & V6  Lateral wall  Distal LAD

118. Standard EKG

119. Anterior MI

120. Anterior-septal MI

121. Inferior AMI

122. Right Sided Leads

123. Right Ventricular AMI

124. Lateral MI

125. Posterior Leads

126. Posterior AMI

127. Inferior-RV-Posterior AMI

128. تغییرات موج ST-T

129. Strain in Hypertrophy

130. Strain in LVH

131. Strain in RVH

132. Strain vs. Infarction

133. پریکاردیت

134. تغییرات دیوگسین

135. موج T

136. خسته نباشید