Thirty Papers ECG

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<p>ThirtyPapersECG Ma7moudSho3eb</p> <p>1</p> <p>ThirtyPapers</p> <p>ECG</p> <p>st 1st Part1 Edition</p> <p>Esnips.com/user/ma7moud</p> <p>. ( </p> <p>. </p> <p>: ) </p> <p>: : : </p> <p>. </p> <p>Dr.ma7moud@windowslive.com</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>695</p> <p>Esnips.com/user/ma7moud</p> <p>2</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>3</p> <p>.:: CONTENTS ::. BEINGFAMILIARWITHECG: 1. PQRST terminology. 2. Theintervals. 3. Theleads.</p> <p>BASICKNOWLEDGE: 4. CalculationoftheHeartRate. 5. Axisdeviation.</p> <p>6. 7. 8. 9.</p> <p>DISEASEINTERPRETATION: Atrialhypertrophy. Ventricularhypertrophy. BundleBranchBlock Myocardialinfarction</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>4</p> <p>.:: ABBREVIATIONS ::.Anelectrocardiogram(ECG)is arecordingoftheelectricalactivityofthe heartovertime producedbyanelectrocardiograph, usuallyinanoninvasive recordingviaskinelectrodes. ECG Itsnameismadeofdifferentparts: 1.Electro, becauseitisrelatedtoelectricalactivity. 2.Cardio, Greekforheart. 3.Gram, aGreekrootmeaning"towrite".</p> <p>aVR AugmentedVoltageof Rightarm. aVF AugmentedVoltageof Foot. aVL AugmentedVoltageof Leftarm.</p> <p>Lt Left Rt Right RV LeftVentricle LV RightVentricle SV1 Swaveinchestlead1. RV6 Rwaveinchestlead6.</p> <p>RV1 Rwaveinchestlead1. SV6 Swaveinchestlead6.</p> <p>LA LeftArm RA RightArm LL LeftLeg RL RightLeg</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>5</p> <p> Thewiringdiagramoftheheart </p> <p> Calibration oftheECGrecording </p> <p>1 Astandardsignalof1millivolt(mV)shouldmovethestylus vertically1cm(2largesquares). Thiscalibrationsignalshouldbeincludedwith everyrecord.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>6</p> <p> AgoodrecordofanormalECG </p> <p> Theupperthreetracesshowthe6limbleads(I,II,III,VR,VL&amp;VF)andthenthesixchestleads. 2 Thebottomtraceisa'rhythmstrip' ,recordedfromleadII(i.e.noleadchanges). Thetrace isclear,withPwaves,QRScomplexesandTwavesarevisibleinallleads.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>7</p> <p>PQRST TERMINOLOGY3</p> <p>4 QRScomplex</p> <p>Represents</p> <p>Pwave</p> <p>Depolarization&amp;contractionof thearia. Depolarization&amp;contractionof theventricles. Repolarizationof theventricles.</p> <p>Twave</p> <p>N.B.:1.TheRepolarizationof theatria isnotrecordedontheroutineECG. 2.TheRepolarizationis muchslower thanthedepolarization,sotheTwaveis broader thantheQRS complex.</p> <p>3.The Qwave mayormaynotbepresent. 4.TheremaybeasmalluprightdeflectionfollowingTwave&amp;iscalled Uwave.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>8</p> <p>5.TheremaybeaseconduprightdeflectionfollowingRwave&amp;iscalled Rwave.</p> <p>6.IfadownwarddeflectionoccursafterR,itiscalled Swave.</p> <p> SOMEFORMSOFQRS COMPLEXES RSpatterns: o SmallRwave&amp;deepSwave. o TallRwave&amp;deepSwave. o TallRwave&amp;smallSwave.</p> <p> R pattern: o WithnoQwaveorSwave.</p> <p> QS complex: o NoRwave.</p> <p> RRpattern:</p> <p> RSR:</p> <p> RSR: WithtallRwave.</p> <p> RRS pattern:</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>9</p> <p> Depolarization&amp;theshapeoftheQRScomplex TheECGmachineisarrangessothat: Whenadepolarizationwavespreadstowardsalead thestylusmovesupwards. Whenitspreadsawayfromthelead thestylusmovesdownwards.</p> <p> Depolarization: (a) Movingtowardsthelead apredominantlyupwardQRScomplex. (b) Movingawayfromthelead apredominantlydownwardQRScomplex. (c) Atrightanglestothe lead equalRandSwaves.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>10</p> <p>THE INTERVALS</p> <p>QRSinterval QTinterval</p> <p>Represents</p> <p>5 PRinterval</p> <p>Theconductiontimefromtheatriumtotheventricles. Thetimetakenbytheimpulsetospreadtothe2ventricles. Thetotalelectricalactivityoftheventricles.</p> <p>RRinterval IsrelatedtotheHRortherate ofventricularcontractions. PPinterval Indicatestherateofatrialcontractions.</p> <p>N.B.:1.Undernormalcircumstances,theRRinterval&amp;thePPinterval are equal. 2.InanormalECG,thePR&amp;STsegmentsare atthesamehorizontallevel.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>11</p> <p>THE LEADS6 Limbleads(LeadsI,II,III,aVR,aVF&amp;aVL)givedifferentviewsoftheelectricalactivityoftheheartin thefrontalplane. Chestleadsgivedifferentviewsinthehorizontalplane.</p> <p>7 v 3bipolarleads: (I,II&amp;III) v 3unipolarlimbleads: (aVR,aVF&amp;aVL)</p> <p>8 Thecardiacaxis&amp;leadangles </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>12</p> <p> TheECGpatternsrecordedbythe 6 standardleads </p> <p>v 6unipolarchestleads: (fromV16) Therelationshipbetweenthe6Vleads&amp;theheart </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>13</p> <p>V1 &amp;V2 V3 V4,V5 &amp;V6 Faces</p> <p>Therightventricle. Theinterventricularseptum. Theleftventricle.</p> <p> LeadI&amp;aVLareanteriorleadsdirectedtotheanterior&amp;leftwalloftheLV. LeadII,III&amp;aVFareinferiorwallleadsdirectedtotheinferiorwalloftheLV.</p> <p> LeadI,aVL,V5 &amp;V6 areleftsidedleads(lookattheleftsideoftheheart). V1 &amp;V2 arerightsidedleads(lookattherightsideoftheheart).</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>14</p> <p>CALCUTAION OF THE HEART RATEBASIC Smallsquare= 0.04 seconds(40m.sec)oftime&amp; 1mm ofamplitude. KNOWLEDGE Largesquare= 0.2 seconds (200m.sec)oftime&amp; 5mm ofamplitude.</p> <p>v Incaseofregularrhythm: Rate=1500 N (N=numberofsmallsquaresbetween2successiveRwaves). NormalRRinterval=1525smallsquares= 60100/min. TheRRintervalactually measurestheventricularrate.</p> <p> Ratesabove 100/min tachycardia. Ratesbelow 60/min bradycardia</p> <p>v Incaseofirregularrhythm: Rate=20XNumberofRwavesin15largesquares (represent3seconds).</p> <p>v IntotalHB: ThePwavesdonotcorrespondwiththe QRScomplexes. Theatrialrateshouldbecalculatedseparately:</p> <p>Atrialrate=1500 numberofsmallsquaresbetween2successivePwaves.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>15</p> <p>9 Normalaxis</p> <p>AXIS DEVIATION</p> <p>Note: leadsI&amp;III</p> <p>Lt axisdeviation</p> <p>Rtaxisdeviation</p> <p>Amnemonicto remember Left Leaves Right Reaches</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>16</p> <p>ATRIAL HYPERTROPHYNote:thecontourofPwave, seenbestinleadII (alsoinleadsIII&amp;aVF) The Pwave has2components: BASIC st 1.The initial(1 ) partiscontributedbythe Rt atrium. KNOWLEDGE nd 2.The later(2 ) partiscontributedbythe Lt atrium.</p> <p>Ltatrialhypertrophynd o The2 componentisdelayed&amp;prominent wide&amp;notched Pwave(wider than2.5small squares).</p> <p>Rtatrialhypertrophyo The1st componentisprominent tall&amp; peaked Pwave(taller than2.5smallsquares).</p> <p>o SincethisiscommoninMVdiseases,itiscalled Pmitrale.</p> <p>o SincethisiscommonwithPH,itiscalled P pulmonale.</p> <p>o Biatrialhypertrophy: o ThePwaveis wider than2.5smallsquares &amp;taller than2.5smallsquares.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>17</p> <p> Ltatrialhypertrophy </p> <p> Rtatrialhypertrophy </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>18</p> <p>VENTRICULAR HYPERTROPHYNote: the pattern&amp;amplitudeofQRScomplexesinchestleads(V16)</p> <p> TheECGpatternsrecordedbythe chest leads </p> <p>10 Thenormal QRScomplex inchestleads: 1.V1showssmallRwave&amp;deepSwave. BASIC 2.AsweproceedtowardsV6,theheightofRwaveprogressivelyincreases&amp;the KNOWLEDGE depthofSwaveprogressivelydecreases. 11 3.SomewhereinV3&amp;V4,theR&amp;Swavesareequal .</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>19</p> <p>Lt ventricular hypertrophyo ThepatternofQRScomplexesinchestleads remainsthesamebuttheamplitudeofthe wavesincreases.</p> <p>Rt ventricular hypertrophy12 o Thepatternchanges: 1.LeadV1&amp;V2showprominentRwave. 2.LeadsV3&amp;V4showequalR&amp;Swaves. 3.LeadsV5&amp;V6showdeepSwave.</p> <p>o Thecriteriafor diagnosis are: 1.SV1&gt;25,or 2.RV6&gt;25,or 3.SV1+RV6&gt;35.</p> <p>o Thecriteriafor diagnosis are: 1.RV1&gt;7,or 2.SV6&gt;7,or 3.RV1+SV6&gt;10.</p> <p>o Itisusually associatedwith: 1.Ltaxis deviation. 2.Pmitrale.</p> <p>o Itmayormaynotbe associated with: 1.Rtaxisdeviation. 2.Ppulmonale.</p> <p>STRAIN PATTERN IN VENTRICULAR HYPERTROPHYLtventricularhypertrophyNote:leads V5&amp;V6 o VerytallRwaves. o SlightlydepressedSTsegments. o InvertedTwaves.</p> <p>RtventricularhypertrophyNote:leads V1 &amp;V2 o R&amp;S waves. o SlightlydepressedSTsegments. o InvertedTwaves.</p> <p>o Biventricular hypertrophy: o TallRwaveinV1of Rt ventricularhypertrophy. o DeepSwaveinV1&amp;V2withtallRwavesinV5&amp;V6of Lt ventricularhypertrophy. o ThestrainpatterninV5&amp;V6.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>20</p> <p> Ltventricularhypertrophy </p> <p> Rt ventricular hypertrophy </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>21</p> <p>BUNDLE BRANCH BLOCKNote:thewidthofQRScomplex</p> <p> The shapeoftheQRScomplexinV1&amp;V2</p> <p>BASIC Thewidthof QRScomplexorinterval ismeasuredfromthebeginningofQorR KNOWLEDGE wavetotheendofQRScomplex.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>22</p> <p>LtBBB</p> <p>RtBBB</p> <p>o WideQRScomplex 3smallsquares o WideQRScomplex 3smallsquares o Verydeep&amp;broadSwavewithnoRwaveinV1. o RSRpattern(Mpattern)inV1. o BroadslurredRwaveorRRpatternwithnoQ o BroadslurredSwaveinV5&amp;V6. waveinV5&amp;V6. o Itmaybe associatedwith: Rtaxisdeviation.</p> <p>o Itisalways associatedwith: Ltaxisdeviation.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>23</p> <p>v LtanteriorhemiblockLAHB=PureLt axisdeviation: 1.QRpatterninleadI. 2.RSpatterninleadIII.</p> <p>v RBBBwithLAHB: (commonbecausebothbundleshavecommonbloodsupply) =RBBBwithLtaxisdeviation.RBBB RSRpatterninV1&amp;broadshallowSwaveinV5&amp;V6. LAHB Ltaxisdeviation(Left Leaves).</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>24</p> <p> LBBB </p> <p> RBBB </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>25</p> <p>MYOCARDIAL ISCHEMIA (ACUTE)Note:STsegment</p> <p>During angina (&amp;Duringstressorexercise test)</p> <p>Aftertheattack</p> <p>infarction</p> <p> PlaneordownwardslopingST normal ECG. segment depression (temporary).</p> <p> STsegment elevation.</p> <p>o Thecriteriafor diagnosis of acute myocardialischemia are: 1.DepressionofJpoint&gt;1mm. 2.PlaneordownwardslopingSTsegmentdepression.</p> <p> TypesofSTsegmentdepression myocardialischemia Plane (horizontal) depression withsharpanglewiththeTwave. earlymanifestationof AbsolutelyHorizontal(isoelectrical)withsharpanglewiththeT wave. ischemia severeischemiaor Downwardsloping depression. digitalistoxicity</p> <p>Suggestingofischemia Sagging&amp; concaveupwards. variantofnormal Upwardslopingdepression. Significant ischemia UpwardslopingdepressionwithJpointdepression 2mm.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>26</p> <p>MYOCARDIAL ISCHEMIA (NON ACUTE)Note:STsegment</p> <p>Duringangina (&amp;Duringstressorexercise test) STsegment depression &amp; symmetricalTwaveinversion.</p> <p>Afterthe attack normalECG. butmaybe: 1.Slight ST segment depression. 2.Twaveinversion or flattening. (likestrainpatterninLV hypertrophy).</p> <p>o Thecriteriafor diagnosis of nonacutemyocardialischemia are: 1.STsegmentdepressioninV5&amp;V6. 2.Twaveinversionorflattening(especiallyinlimbleads).</p> <p>MYOCARDIAL INFARCTION</p> <p>2.Inversion ofTwave13 3.Deep&amp;wideQwave</p> <p>Indicating</p> <p> MIproduces3basicchangesintheleadsfacingtheinfractedwall: 1.ElevationofSTsegment zoneofinjury. Theeffectofsurroundingischemiczone. Thezoneofinfarctordeadmuscle.</p> <p> Diagnosisissupportedbyreciprocalchangesintheleadsfacingtheoppositewalls. Thesesleadswillshow: 1.Depression ofSTsegment. 2.Tall uprightTwave.</p> <p>14 Thefirstchangestoappearare : 1.ElevationofSTsegment. 2.TalluprightTwave.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>27</p> <p>Qwave Onthe4 day Overthenext2daysth</p> <p>STsegment</p> <p>TwaveTall&amp;upright. Graduallybecome inverted. Deeplyinverted. Graduallybecomeflat&amp; startsreturningto normal.</p> <p>No.</p> <p>Elevated. Startsreturning tonormal.</p> <p>st By theendofthe1 Startsappearing. week rd Inthe3 week Fullyapparent.</p> <p>15 rd Bytheendofthe3 Remainpermenant . month</p> <p>Returntonormal.</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>28</p> <p>LOCALIZATION OF THE ISCEMIC AREA OR INFARCT</p> <p>v ANTERIORINFARCTION:o LeadsI,aVL&amp;chestleads(V1 6). &amp;alsoshowreciprocalchanges (STsegmentdepression) ininferiorinfarction.</p> <p>v INFERIORINFARCTION:o LeadsII,III&amp;aVF. &amp;alsoshowreciprocalchanges (STsegmentdepression) inanteriorinfarction.</p> <p>STsegmentelevation V24. V46. V16.</p> <p>Siteofinfarctiono Anteroseptalinfarction. o Anterolateralinfarction. o Extensiveanteriorinfarction.</p> <p> Anteroseptalmyocardialinfarction </p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>29</p> <p>THE REFERENCES1. VideoAtlasECG Cassetteclinics, Dr. GhanashyamVaidya.th 2. TheECGmadeeasy 7 edition,JohnR.Hampton.</p> <p>3. ABCofclinicalelectrocardiography.</p> <p>USEFUL WEB SITES1. emedu.org/ecg/index.htm 2. ecglibrary.com 3. nobelprize.org/educational_games/medicine/ecg/</p> <p>Esnips.com/user/ma7moud</p> <p>ThirtyPapersECG Ma7moudSho3eb</p> <p>30</p> <p>1 ( ) ThepenoftheECGmachine. 2 ( )Rhythmstrip: Asingleleadisrecordedsimplytoshow therhythm. 3 ( )ThelettersP,Q,R,S&amp;TwereselectedintheearlydaysofECGhistory,&amp;werechosenarbitrarily (notbasedonobjectivefacts,reasons,orprinciples). 4 ( )IfthefirstdeflectionisdownwarditisaQwave. Anyupwarddeflectionisan Rwave. AdownwarddeflectionafteranRwaveisanSwave. 5 ( )logically,itshouldbecalledPQintervalbutcommonusageisPRinterval. 6 ( )ThewordleadissometimesusedtomeanthepiecesofwirethatconnectthepatienttotheECG recorder. Properly,aleadisanelectricalpictureoftheheart. 7 ( )LeadIrecordsthepotentialdifferencebetweenLA&amp;RA,LeadIIbetweenLL&amp;RA&amp;LeadIII betweenLL&amp;LA. 8 ( )Thecardiacaxisissometimesmeasuredindegrees,thoughthisisnotclinicallyuseful: o LeadIistakenaslookingattheheartfrom0 ,LeadIIfrom+60o &amp;soon Minordegreesofright&amp;leftaxisdeviationsoccurintall,thinindividuals&amp;inshort,fatindividuals respectively. 9 ( )Thenormaldepolarizationwavespreadsthroughtheventriclesfrom11oclockto5oclock. 10 ( )Notethat: Theseptumisdepolarizedfromthelefttotherightside. TheLVexertsmoreinfluenceontheECGthantheRV. 11 ( )Thisiscalledthetransitionpointwhichindicatesthepositionof theinterventricularseptum. IftheRVisenlarged,thetransitionpointwillmovefromitsnormalpositionofleadsV3&amp;V4toleads V4&amp;V5orsometimesV5&amp;V6. Thisclockwiserotationischaracteristicofchroniclungdisease. 12 ( ) Tosummarize: ProminentRwaveinV1&amp;deepSwaveinV6. 13 ( ) Qwavemaybenormallypresentduetoahighdiaphragm,sorepeatECGduringdeepinspiration. 14 ( ) AnECGtakenimmediatelyaftertheonsetofchestpainmaybenormal&amp;itmustberepeated afterafewhoursifMIissuspectedclinically. 15 ( ) Itssizeisproportionatetothesizeofinfarct. Ofcourse, ifthesizeoftheinfarctisverysmalltheQwavemaycompletelydisappear.</p> <p>Esnips.com/user/ma7moud</p>