1. f

3. Propagation of cardiac impulse

4. The Normal Conduction System

5. ECG machine

6. Generation of normal ECG complex

7. What is the heart rate? (300 / 6) = 50 bpm www.uptodate.com

8. What is the axis? Normal- QRS up in I and aVF

9. What is the diagnosis? Acute inferior MI with ST elevation in leads II, III, aVF Acute inferior MI with ST elevation in leads II, III, aVF

10. What is this rhythm? First degree AV block First degree AV block

11. What is this rhythm? Type 1 second degree block (Wenckebach)

12. What is this rhythm? Type 2 second degree AV block Dropped QRS

13. What is this rhythm? 3 rd degree heart block (complete)

14. 14 ECTOPIC BEATS

15. 15 ECTOPIC BEATS

16. 16

17. ECG Leads Limb leads: I, II, III, aVR, aVL, aVF, Chest leads: V1-V6 Anterior surface: V1-4. Anterior surface: V1-4. Inferior surface: II, III and aVF. Inferior surface: II, III and aVF. Lateral surface: I, aVL and V5-6. Lateral surface: I, aVL and V5-6.

18. ECG Paper

19. Normal ECG

20. P-wave Normal values 1. Polarity. up in I&II and down in aVR. 2. Duration. < 2.5 mm. 3. Amplitude. < 2.5 mm. < 2.5 mm.Abnormalities 1. Inverted P-wave Junctional rhythm. Junctional rhythm. 2. Wide P-wave (P- mitrale) LAE LAE 3. Peaked P-wave (P-pulmonale) RAE RAE 4. Saw-tooth appearance Atrial flutter Atrial flutter 5. Absent P wave Atrial fibrillation Atrial fibrillation

21. P- mitrale P- pulmonale (LAE) (RAE)

22. PR interval Definition: the time interval between beginning of P-wave to beginning of QRS complex. Normal PR interval 3-5mm (0.12-0.2 sec) Abnormalities 1. Short PR interval WPW syndrome WPW syndrome 2. Long PR interval First degree heart block First degree heart block

23. QRS complex Normal values Duration: < 3 mm. Duration: < 3 mm. Morphology: progression from Short R and deep S (rS) in V1 to tall R and short S in V6 with small Q in V5-6 (qRs). Morphology: progression from Short R and deep S (rS) in V1 to tall R and short S in V6 with small Q in V5-6 (qRs). Abnormalities : 1. Wide QRS complex Bundle branch block. Bundle branch block. Ventricular rhythm. Ventricular rhythm. 2. Tall R in V1 RVH. RVH. RBBB. RBBB. Posterior MI. Posterior MI. WPW syndrome. WPW syndrome. 3. abnormal Q wave [ > 25% of R wave] [ > 25% of R wave] MI. MI. Hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy. Normal variant. Normal variant.

24. Normal Q wave

25. Q wave in MI

26. Q wave in septal hypertrophy

27. ST- segment Normally it's isoelectric. [i.e. at same level of TP segment] [i.e. at same level of TP segment] Abnormalities: 1. ST elevation: Acute MI. Acute MI. Prinzmetal angina. Prinzmetal angina. Acute pericarditis. Acute pericarditis. Early repolarization. Early repolarization. 2. ST depression: Ischemia. Ischemia. Ventricular strain. Ventricular strain. BBB. BBB. Hypokalemia. Hypokalemia. Digoxin effect. Digoxin effect.

28. Abnormalities of ST- segment

29. T-wave Normal values. 1. Polarity: Always up in I,II,V4-6 Always up in I,II,V4-6 Always down in aVR. Always down in aVR. Variable in III, aVL, aVF, V1-3. Variable in III, aVL, aVF, V1-3. 2. amplitude: < 10mm in the chest leads. Abnormalities: 1. Peaked T-wave: Hyper-acute MI. Hyper-acute MI. Hyperkalemia. Hyperkalemia. Normal variant. Normal variant. 2. T- inversion: Ischemia. Ischemia. Myocardial infarction. Myocardial infarction. Myocarditis Myocarditis Ventricular strain Ventricular strain BBB. BBB. Hypokalemia. Hypokalemia. Digoxin effect. Digoxin effect.

30. QT- interval QT- interval Definition: Time interval between beginning of QRS complex to the end of T wave. QRS complex to the end of T wave. Normally: At normal HR: QT ≤ 11mm (0.44 sec) (or ) QTc = QT/ √RR (or ) QTc = QT/ √RR Abnormalities: 1. Prolonged QT interval: hypocalcemia and congenital long QT syndrome. 2. Short QT interval: hypercalcemia.

31. INTERPRETATION OF ECG STANDARD? NAME? DATE? STANDARD? NAME? DATE? P(SR-nonSR ? rate? regular or irregular?) P(SR-nonSR ? rate? regular or irregular?) ORS(wide or narrow? LBBB OR RBBB? rate? regular or irregular?) ORS(wide or narrow? LBBB OR RBBB? rate? regular or irregular?) T(tall? invert? biphasic?) T(tall? invert? biphasic?) P-R(long? short? fixed or no? relation?) P-R(long? short? fixed or no? relation?) ST(elevate? Depressed? ) ST(elevate? Depressed? ) QT(long? short?) QT(long? short?) AXIS? AXIS?

32. Rate Rule of 300- Divide 300 by the number of boxes between each QRS = rate Rule of 300- Divide 300 by the number of boxes between each QRS = rate Number of big boxes Rate 1300 2150 3100 475 560 650

33. Rate HR of 60-100 per minute is normal HR > 100 = tachycardia HR < 60 = bradycardia

34. Interpretation of ECG cont. 4. Axis (mean QRS axis): normally -30 to +100 LAD: LVH LAFB Inf. MI RAD: Normal RVH Lat. MI LPFB 5. Analysis of complete ECG complex in each lead.

35. Calculation of electrical axis depending on QRS polarity in leads I and aVF

36. WPW

37. Long QT syndrome

38. Bundle branch block

39. Left Bundle branch block (LBBB)

40. Right Bundle branch block (RBBB)

41. VT (with RBBB pattern)

42. VT (with LBBB pattern)

43. ECG changes in IHD ECG changes in IHD Signs of ischemia: Signs of ischemia: Reversible ST depression, ST elevation or T inversion. Reversible ST depression, ST elevation or T inversion. Signs of MI: Signs of MI: 1. Hyperacute T wave. 2. ST elevation (STEMI) ST depression(NSTEMI) ST depression(NSTEMI) 1. Q wave (Q or transmural infarction) 2. T inversion.

44. Evolution of ECG changes in MI Evolution of ECG changes in MI

45. Q wave infarction

46. Localization of MI 1. anterior MI

47. Localization of MI 2. lateral MI

48. Localization of MI 3. inferior MI

49. Hyperacute MI

50. Acute anteroseptal MI (STEMI)

51. Acute anterolateral MI (with hyperacute T)

52. Acute anterolateral MI Old inferior MI

53. Acute inferior MI

54. Right ventricular infarction

55. Old ant. MI

56. Old inf. MI

58. Criteria of ventricular enlargement LVH : 1. SV1 + (RV5 or RV6) ≥ 35 mm (or) RV5 or RV6 ≥ 25 mm 2. LV strain 3. LAE RVH : 1. Relatively tall R in V1 2. RV strain 3. RAD

59. LVH

60. LVH

61. RVH with RAE

62. RAE LAE

63. Acute pericarditis

64. SAH

65. Hyperkalemia

66. Sever hyperkalemia

67. PAC

68. PAC bigeminy

69. PVC

70. PVC

71. PVC. bigeminy

72. PVC. trigeminy PVC. trigeminy

73. VT

74. Multifocal PVC

75. PVC. Couplet

76. Sinus tachycardia

77. Paroxysmal supraventricular tachycardia [PSVT]

78. PSVT

79. Atrial fibrillation [fine]

80. Non-sustained VT

81. VT

82. Ventricular fibrillation

83. Sinus bradycardia

84. Junctional rhythm

85. Sinus arrest

87. First degree heart block

88. Second degree heart block Mobitz type I (Wenckebach block)

89. Complete heart block

91. Sinus rhythm (SR), rate 60, normal ECG.

92. SR rate 66, benign early repolarization (BER).

93. SR, rate 91, with first degree AV block.

94. Ectopic atrial rhythm, rate 82, otherwise normal ECG.

95. AV junctional rhythm, rate 50

96. Accelerated idioventricular rhythm (AIVR), rate 65

97. SR, rate 100, right bundle branch block (RBBB)

98. SR, rate 80, first degree AV block, left bundle branch block (LBBB),old inf MI

99. SR, rate 85, RBBB, left posterior fascicular block (LPFB)

100. rate 50, acute anterolateral myocardial infarction rate 50, acute anterolateral myocardial infarction

101. SR with second degree AV block type 1 (Mobitz I, Wenckebach), rate 50, left ventricular hypertrophy (LVH), RBBB.

102. Ventricular tachycardia (VT), rate 140

103. SR, rate 87, Wolff-Parkinson- White syndrome (WPW)

104. ST, rate 155

105. This ECG was recorded from a 25-year-old pregnant woman who complained of an irregular heart beat. Auscultation revealed a soft systolic murmur but her heart was otherwise normal. ^

106. ANSWER 1 The ECG shows: Sinus rhythm Ventricular extrasystoles Normal axis Normal QRS complexes and T waves Clinical interpretation The extrasystoles are fairly frequent but the ECG is otherwise normal. Ventricular extrasystoles are very common in pregnancy, and systolic murmurs are almost universal. Her heart is almost certainly normal. What to do Remember anaemia

125. موفق باشید