Thirty Papers ECG

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ThirtyPapers

ECG

st 1st Part1 Edition

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Dr.ma7moud@windowslive.com

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.:: CONTENTS ::. BEINGFAMILIARWITHECG: 1. PQRST terminology. 2. Theintervals. 3. Theleads.

BASICKNOWLEDGE: 4. CalculationoftheHeartRate. 5. Axisdeviation.

6. 7. 8. 9.

DISEASEINTERPRETATION: Atrialhypertrophy. Ventricularhypertrophy. BundleBranchBlock Myocardialinfarction

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.:: ABBREVIATIONS ::.Anelectrocardiogram(ECG)is arecordingoftheelectricalactivityofthe heartovertime producedbyanelectrocardiograph, usuallyinanoninvasive recordingviaskinelectrodes. ECG Itsnameismadeofdifferentparts: 1.Electro, becauseitisrelatedtoelectricalactivity. 2.Cardio, Greekforheart. 3.Gram, aGreekrootmeaning"towrite".

aVR AugmentedVoltageof Rightarm. aVF AugmentedVoltageof Foot. aVL AugmentedVoltageof Leftarm.

Lt Left Rt Right RV LeftVentricle LV RightVentricle SV1 Swaveinchestlead1. RV6 Rwaveinchestlead6.

RV1 Rwaveinchestlead1. SV6 Swaveinchestlead6.

LA LeftArm RA RightArm LL LeftLeg RL RightLeg

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Thewiringdiagramoftheheart

Calibration oftheECGrecording

1 Astandardsignalof1millivolt(mV)shouldmovethestylus vertically1cm(2largesquares). Thiscalibrationsignalshouldbeincludedwith everyrecord.

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AgoodrecordofanormalECG

Theupperthreetracesshowthe6limbleads(I,II,III,VR,VL&VF)andthenthesixchestleads. 2 Thebottomtraceisa'rhythmstrip' ,recordedfromleadII(i.e.noleadchanges). Thetrace isclear,withPwaves,QRScomplexesandTwavesarevisibleinallleads.

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PQRST TERMINOLOGY3

4 QRScomplex

Represents

Pwave

Depolarization&contractionof thearia. Depolarization&contractionof theventricles. Repolarizationof theventricles.

Twave

N.B.:1.TheRepolarizationof theatria isnotrecordedontheroutineECG. 2.TheRepolarizationis muchslower thanthedepolarization,sotheTwaveis broader thantheQRS complex.

3.The Qwave mayormaynotbepresent. 4.TheremaybeasmalluprightdeflectionfollowingTwave&iscalled Uwave.

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5.TheremaybeaseconduprightdeflectionfollowingRwave&iscalled Rwave.

6.IfadownwarddeflectionoccursafterR,itiscalled Swave.

SOMEFORMSOFQRS COMPLEXES RSpatterns: o SmallRwave&deepSwave. o TallRwave&deepSwave. o TallRwave&smallSwave.

R pattern: o WithnoQwaveorSwave.

QS complex: o NoRwave.

RRpattern:

RSR:

RSR: WithtallRwave.

RRS pattern:

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Depolarization&theshapeoftheQRScomplex TheECGmachineisarrangessothat: Whenadepolarizationwavespreadstowardsalead thestylusmovesupwards. Whenitspreadsawayfromthelead thestylusmovesdownwards.

Depolarization: (a) Movingtowardsthelead apredominantlyupwardQRScomplex. (b) Movingawayfromthelead apredominantlydownwardQRScomplex. (c) Atrightanglestothe lead equalRandSwaves.

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THE INTERVALS

QRSinterval QTinterval

Represents

5 PRinterval

Theconductiontimefromtheatriumtotheventricles. Thetimetakenbytheimpulsetospreadtothe2ventricles. Thetotalelectricalactivityoftheventricles.

RRinterval IsrelatedtotheHRortherate ofventricularcontractions. PPinterval Indicatestherateofatrialcontractions.

N.B.:1.Undernormalcircumstances,theRRinterval&thePPinterval are equal. 2.InanormalECG,thePR&STsegmentsare atthesamehorizontallevel.

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THE LEADS6 Limbleads(LeadsI,II,III,aVR,aVF&aVL)givedifferentviewsoftheelectricalactivityoftheheartin thefrontalplane. Chestleadsgivedifferentviewsinthehorizontalplane.

7 v 3bipolarleads: (I,II&III) v 3unipolarlimbleads: (aVR,aVF&aVL)

8 Thecardiacaxis&leadangles

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TheECGpatternsrecordedbythe 6 standardleads

v 6unipolarchestleads: (fromV16) Therelationshipbetweenthe6Vleads&theheart

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V1 &V2 V3 V4,V5 &V6 Faces

Therightventricle. Theinterventricularseptum. Theleftventricle.

LeadI&aVLareanteriorleadsdirectedtotheanterior&leftwalloftheLV. LeadII,III&aVFareinferiorwallleadsdirectedtotheinferiorwalloftheLV.

LeadI,aVL,V5 &V6 areleftsidedleads(lookattheleftsideoftheheart). V1 &V2 arerightsidedleads(lookattherightsideoftheheart).

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CALCUTAION OF THE HEART RATEBASIC Smallsquare= 0.04 seconds(40m.sec)oftime& 1mm ofamplitude. KNOWLEDGE Largesquare= 0.2 seconds (200m.sec)oftime& 5mm ofamplitude.

v Incaseofregularrhythm: Rate=1500 N (N=numberofsmallsquaresbetween2successiveRwaves). NormalRRinterval=1525smallsquares= 60100/min. TheRRintervalactually measurestheventricularrate.

Ratesabove 100/min tachycardia. Ratesbelow 60/min bradycardia

v Incaseofirregularrhythm: Rate=20XNumberofRwavesin15largesquares (represent3seconds).

v IntotalHB: ThePwavesdonotcorrespondwiththe QRScomplexes. Theatrialrateshouldbecalculatedseparately:

Atrialrate=1500 numberofsmallsquaresbetween2successivePwaves.

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9 Normalaxis

AXIS DEVIATION

Note: leadsI&III

Lt axisdeviation

Rtaxisdeviation

Amnemonicto remember Left Leaves Right Reaches

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ATRIAL HYPERTROPHYNote:thecontourofPwave, seenbestinleadII (alsoinleadsIII&aVF) The Pwave has2components: BASIC st 1.The initial(1 ) partiscontributedbythe Rt atrium. KNOWLEDGE nd 2.The later(2 ) partiscontributedbythe Lt atrium.

Ltatrialhypertrophynd o The2 componentisdelayed&prominent wide&notched Pwave(wider than2.5small squares).

Rtatrialhypertrophyo The1st componentisprominent tall& peaked Pwave(taller than2.5smallsquares).

o SincethisiscommoninMVdiseases,itiscalled Pmitrale.

o SincethisiscommonwithPH,itiscalled P pulmonale.

o Biatrialhypertrophy: o ThePwaveis wider than2.5smallsquares &taller than2.5smallsquares.

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Ltatrialhypertrophy

Rtatrialhypertrophy

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VENTRICULAR HYPERTROPHYNote: the pattern&amplitudeofQRScomplexesinchestleads(V16)

TheECGpatternsrecordedbythe chest leads

10 Thenormal QRScomplex inchestleads: 1.V1showssmallRwave&deepSwave. BASIC 2.AsweproceedtowardsV6,theheightofRwaveprogressivelyincreases&the KNOWLEDGE depthofSwaveprogressivelydecreases. 11 3.SomewhereinV3&V4,theR&Swavesareequal .

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Lt ventricular hypertrophyo ThepatternofQRScomplexesinchestleads remainsthesamebuttheamplitudeofthe wavesincreases.

Rt ventricular hypertrophy12 o Thepatternchanges: 1.LeadV1&V2showprominentRwave. 2.LeadsV3&V4showequalR&Swaves. 3.LeadsV5&V6showdeepSwave.

o Thecriteriafor diagnosis are: 1.SV1>25,or 2.RV6>25,or 3.SV1+RV6>35.

o Thecriteriafor diagnosis are: 1.RV1>7,or 2.SV6>7,or 3.RV1+SV6>10.

o Itisusually associatedwith: 1.Ltaxis deviation. 2.Pmitrale.

o Itmayormaynotbe associated with: 1.Rtaxisdeviation. 2.Ppulmonale.

STRAIN PATTERN IN VENTRICULAR HYPERTROPHYLtventricularhypertrophyNote:leads V5&V6 o VerytallRwaves. o SlightlydepressedSTsegments. o InvertedTwaves.

RtventricularhypertrophyNote:leads V1 &V2 o R&S waves. o SlightlydepressedSTsegments. o InvertedTwaves.

o Biventricular hypertrophy: o TallRwaveinV1of Rt ventricularhypertrophy. o DeepSwaveinV1&V2withtallRwavesinV5&V6of Lt ventricularhypertrophy. o ThestrainpatterninV5&V6.

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Ltventricularhypertrophy

Rt ventricular hypertrophy

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BUNDLE BRANCH BLOCKNote:thewidthofQRScomplex

The shapeoftheQRScomplexinV1&V2

BASIC Thewidthof QRScomplexorinterval ismeasuredfromthebeginningofQorR KNOWLEDGE wavetotheendofQRScomplex.

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LtBBB

RtBBB

o WideQRScomplex 3smallsquares o WideQRScomplex 3smallsquares o Verydeep&broadSwavewithnoRwaveinV1. o RSRpattern(Mpattern)inV1. o BroadslurredRwaveorRRpatternwithnoQ o BroadslurredSwaveinV5&V6. waveinV5&V6. o Itmaybe associatedwith: Rtaxisdeviation.

o Itisalways associatedwith: Ltaxisdeviation.

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