ECG DR .Allam PDF

ECG revision DR.
Allam
ECG
under graduates

ECG
is the recording of the heart electrical activity
Cardic cycle
action
mechanical force
electrical force
mechanical
contraction
followed by relaxation
electrical
Depolarization
followed by repolarization
Depolarization contraction
repolarization Relaxation
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ECG revision DR. Allam

ECG
atrial contraction
atrial depolarization
ventricular relaxation
ventricular repolarization

introduction ECG

conductive system of the heart Peace maker S.A. node
both atria
A.V. node
bundle branch
Purkinje fibers ventricular wall
S.A. node Both atria A.V. node
bundle branch ventricular wall
A.V. node
A.V. node Point of physiological delay

atrium ventricle
atrium 300
Atrial fibrillation
300 ventricle
ventricle fibrillation
Atrial fibrillation
ventricular fibrillation equal death

A.V. node
to reduce the number

300 120
Atrial fibrillation
line of treatment
Digitalis
digitalis
arrhythmogenic
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A.F. digitalis
300 Atrium
450 400
Atrial fibrillation digitalis
A.V. node block
ventricles numbers reduction
A.V. node conductivity

To protect ventricle from any supra ventricular tachycardia
:
five waves

complex QRS P
T wave
PQRST

Atrial depolarization P wave
ventricular depolarization QRS complex
ventricular repolarization T wave
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Atrial depolarization P wave
atrium P wave
P wave atrium
P wave Atrium
Multiple P waves before QRS ventricle contraction atrium
absent P wave contraction atrium
Atrium P wave
ventricular depolarization QRS complex

ventricle
QRS ventricle
ventricular tachycardia ventricle
ventricle arrhythmia
deformed QRS
QRS ventricle
Ventricular repolarization T wave

:
atrial depolarization Atrial contraction
ventricular contraction ventricular depolarization
ventricular relaxation ventricular repolarization
Atrial repolarization
which is small and masked by QRS complex
QRS
QRS
:
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A.V. node

ECG PR interval
PR interval A.V. nodal conduction
A.V. node
PR interval
PR interval A.V. nodal conduction
heart block A.V. nodal block
Introduction
leads ECG
12 ECG leads
limbic leads
chest wall chest leads

( )

Lead both upper limb L1
Right upper limb left lower limb L2
... Left upper limb Left lower limb L3
Bipolar leads
Bipolar
... standard leads leads

3 Bipolar leads L1, L2 and L3

AVL
AVR
AVF
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AV Augmented voltage
Augmented voltage R Right
AVL Augmented voltage on left
AVF augmented voltage on foot

Bipolar unipolar Unipolar leads

Bipolar Unipolar

Chest wall

, ,
,

AVF
ECG
AVF
L2 Atrium
Atrium

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P, R and T Positive
Q and S Negative
11 leads ECG AVR

Normal
Normally

ECG AVR
AVR
Q
Pathological Q

ECG AVR
AVR
AVR !!!!!!!
chest wall
chest wall

chest wall
V1, V2, V3, V4, V5 and V6

section heart
right ventricle Left ventricle
interventricular septum
Right ventricle V1 and V2
left ventricle V5 and V6
Septum V3 and V4
right ventricle ischemia
ischemia V1 and V2
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V5 and V6 ischemia left ventricle
clinical
most anterior structure of the heart
Right ventricle and septum
anterior wall of the heart V4 V1
12 leads
blood supply of the heart

coronaries
....
Right coronary artery
left coronary artery
Ascending aorta
right coronary right valsulva
Left coronary left valsulva
Left coronary
Two branches
Anterior descending artery
circumflex branch
Inferior wall of the heart Right coronary artery
anterior wall of the heart Anterior descending
lateral wall of the heart circumflex artery
3 arteries 3 walls
3 main vessels
right coronary
circumflex anterior descending
Myocardial infarction
3 arteries
blood supply
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wall

Infarction reversible irreversible Irreversible
Myocardial infarction right coronary artery
Inferior M I

Inferior M I

anterior lateral

anterior descending artery
anterior myocardial infarction

lateral
circumflex artery

wall

... ...

Acute chest pain ECG Myocardial infarction
ECG

Inferior MI anterior MI lateral MI
leads
Leads wall
wall
artery
...

Inferior wall of the heart
....
L2, L3 and AVF
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L2, L3 and AVF
Inferior MI
anterior
V1 V4
acute chest pain
ECG Myocardial infarction
V1, V2, V3 and V4
anterior MI
artery anterior descending artery
Lateral wall
V5, V6 and AVL
chest pain
ECG
MI V5, V6 and AVL
lateral MI
artery circumflex branch
acute sever chest pain
V1, V2, V4, V5, V6 and AVL

anterior Lateral
extensive antero-lateral MI
artery
left coronary artery

Myocardial infarction Leads

wall
anterior MI V1, V2, V3 and V4

V1, V2 and V3

Inferior MI L2 and L3
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ischemic changes in one lead
Myocardial infarction ischemia lead 12

Insignificant
Wall of the heart leads of ECG
topographism

topographism
topographism
Leads artery wall

anterior Inferior Lateral

ECG

5x5

voltage
duration
....
one small square 0.04

one big square 0.04 x 5 0.2

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0.4

3/5

4/5

5/5
One second 5 big squares

One minute 5x60
300
300

300
rate
300
Introduction
calibration

ECG

comment
ECG comment
diagnosis
comment
diagnosis

comment ECG
:
12
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:
.i
rhythm
.ii
rate
.iii
axis
.iv
P wave
.v
PR interval
.vi
QRS complex
.vii
ST segment
.viii
T wave

rhythm ECG
wave ECG
Long strip

R wave
R R RR interval
regular
irregular

Long strip
long strip
Leads Long strip

L2
R R
RR interval

rhythm regular

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Irregular

regular rate
rate 300 RR interval
300
RR interval
rate 300/5 60 beat per min.
RR interval
rate 300/6 50 beats
...
rate
rhythm Irregular

300
( ) RR interval
Mean average

10, 5 and 15
30

30/3
10

RR interval

9
3
14
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9/3 3
rate 300
300/3 100 beats per min.

L 2

:
ECG rate rhythm

rate rhythm

rate
rhythm
rate rhythm

rhythm rate
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Long strip

rhythm
rate
diagnosis
AF

irregular tachycardia
rate
QRS T
AF

diagnosis

Axis

L1 AVF
R wave L1 Positive AVF positive
R wave positive L1 and AVF Normal axis deviation
R wave negative in L1 AVF R wave positive Right axis deviation
RAD
R wave Positive in L1 R wave negative in AVF
Left Axis deviation
RAD LAD

RAD or LAD
ECG segmented
L1, L2 and AVF
ECG long strip
Axis
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Axis AVF L1

P wave

P wave

atrial depolarization
first positive before the complex
L2
long strip L2
P wave
arrhythmia atrial fibrillation
atrial fibrillation absent P wave
P wave L2
long strip
L2

2.5 2.5

2.5
PR interval

P R
A.V. nodal conduction

3 5

...
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A.V. nodal block
heart block
PR interval prolonged Heart block

re excitation syndrome
W.V.W. syndrome
prolonged heart block
QRS complex
ventricular depolarization
V1, V2, V5 and V6

QRS
complex
P T

Q R S
Q wave
Q first negative wave in the complex
negative
Negative

one small square
R wave
one small square

( ) 1/4
R wave
Q

Q
first negative
( Q R
)
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Q R
Q
R wave
P T wave
R, T and P Positive
R
Q
R

( )
absent Q
absent Q
Q

( ) Q
Q
Old MI
pathological Q
old myocardial infraction

R wave
R wave
positive in the complex
voltage criteria
big square
small square
R wave positive complex
the only positive the first positive in the complex
small square

Wide QRS
Tachycardia arrhythmia
ventricular tachycardia
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extra-systole QRS
R
3 small square
big square
voltage criteria

S R

ST segment

S
T
ST segment
normally Iso-electrical line
elevated
elevated ST segment

depressed ST segment
ECG
PR
PR
elevated line PR
depressed Line PR
elevation elevation
depression depression

value
elevation

20
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elevated ST segment
recent MI
variant angina
Pericarditis
elevated ST segment in all leads pericarditis
Leads
MI
chest pain MI
chest pain Pericarditis
ECG
elevated ST segment
12 leads percarditis
topographism MI
elevated ST segment
persistent after recent MI
persistent elevation of ST segment equal Myocardial aneurysm

normal variation

Once elevated ST segment
recent MI


ischemia
angina
angina
angina
clinical
clinical diagnosis
angina
ECG
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angina depressed ST segment variant angina
variant angina
elevated ST segment
ECG angina
Ischemia
angina chest pain
chest pain
T wave
ventricular repolarization
T wave
never absent
absent T
( P wave ) T wave
P T
T wave
P wave P wave is absent
AF
P T wave

T wave
T wave
never absent
ventricle contraction relaxation
ventricle repolarization
comment
rhythm rate
axis p wave
PR interval QRS complex ST segment
T wave

diagnosis

22
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diagnosis

diagnosis

diagnosis

ECG

comment

ECG

comment
abnormal ECG

segmented ECG
chamber enlargement atrial ventricular
atrial P wave
P wave Positive complex
L2 2.5x2.5
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Peaked
P pulmonale
right atrial enlargement
broad
P mitral
left atrial enlargement
( m shaped ) P mitral

P wave L2
Positive complex
2.5 P pulmonale
right atrial enlargement
pulmonale right
... 2.5
P mitral
left atrial enlargement

right atrium
left atrium

ventricular hypertrophy

QRS V1, V2, V5 and V6
normally V1 and V2
S r
normally V5 and V6
R s
S r V1 and V2

normal
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normally V1 and V2
S r
V5 and V6
R s

( S V1
V6 R wave V1 V6

)
left ventricular hypertrophy

exaggeration of normal
V1 or V2

(
S wave r wave
S capital ECG capital
small

S V1 and V2
S wave r wave normal V1 and V2
)

S r

S

S
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Left ventricle

Normal
S r
V1 and V2 S r
S r
S

V1 and V2
V1 V2
Left ventricle V1
Left ventricle V2
V5 and V6
V5 V6

( R s R )
R s
R

...

R

left ventricle
V5 and V6
.... V5 V6
Left ventricle V5
Left ventricle V6
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Exaggeration of normal

Deep S V1 V2
Tall R V5 V6
S V1 V2 R V5 V6
S V1
R V6
S normal normal
R normal Normal

left ventricular hypertrophy

deep S V1 V2
Tall R V5 V6
S wave in V1 or V2
plus
R wave in V5 or V6
More than 7 big squares
Left ventricle

left ventricle
hypertrophy

Strain ischemia
ventricle
strain ischemia
strain ischemia
inverted T wave

Left ventricle

V5 and V6
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Strain ischemia V5 and V6

Left ventricle
left ventricle

( ECG
{ }12 { }13 {}14
{ }10 { }11

)
right ventricle

reversal of normal
reversal of normal
V1 V2
( R wave ) s wave
V1 V2
reversal of normal
R

reversal of normal

left ventricle

Left ventricle

right ventricle
reversal of normal

R wave s wave V1 and V2
V1 V2
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V5 V6
( S wave ) r wave
V5 V6

reversal of normal
S wave r wave
S wave

V5 and V6
V5 V6

I can diagnose right ventricle from V1
V2
V5 V6
Right ventricle

right ventricle
Strain ischemia
strain ischemia depressed ST segment
Inverted T wave
V1 V2
Strain ischemia right ventricle
V1 and V2
left ventricle V5 and V6
Bi ventricular hypertrophy
strain ischemia
V1 and V2
V5 and V6
bi ventricular hypertrophy ECG
S R
reversal of normal
V1 exaggeration of normal
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V2 reversal of normal

chamber enlargement
Bundle branch block

bundle branch block
QRS M
'RSR
V1 V2 right bundle branch block
V5 V6 left bundle branch block
right and left bundle branch block
RSR' pattern V1 V2 Right
' RSR V5 V6 left

QRS
QRS
... shape
... direction
... voltage
QRS

shape direction voltage
shape
M shaped
bundle branch block

direction
direction
V1 and V2
S R
V5 V6
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R S
reversal of normal
direction
right ventricular hypertrophy
shape
Normal
direction
Normal

voltage
voltage

exaggeration of normal ...
Left ventricular hypertrophy

QRS

shape
direction
voltage

abnormality shape
bundle branch block
direction voltage
ventricle

direction
Normal shape
Normal shape
direction
direction

reversal of normal
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voltage

ECG
ischemic heart diseases
: ischemic heart diseases
myocardial infarction
angina ..... ischemia
MI
wall of the heart
central area of necrosis surrounded by an area of tissue damage surrounded by an ischemic
pattern
area of necrosis
pathological Q
tissue damage
Elevated ST segment
ischemia
inverted T wave or peaked T

infarction
necrosis

pathological Q
Once

pathological Q
Old myocardial infarction
pathological Q

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finger print of MI is the pathological Q

Infarction
elevated ST segment
Elevated ST segment recent MI
:
old MI recent MI
topographism
recent MI anterior wall
Inferior wall Lateral wall
old MI

topographism
MI topographism

pathological Q Elevated ST segment
Old Recent
( )

Infarction
artery

Infarction
necrosis
elevated ST segment
recent
ECG
pathological Q
ST
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elevated ST segment pathological Q
Once elevated ST segment
recent MI Q Q

Old inferior MI recent anterior MI
leads Old inferior
leads recent anterior
Lead

artery

Ischemia

Depressed ST segment
topographism
Depressed
Inferior anterior lateral ischemia
topographism

:
Atrial enlargement
ventricular enlargement
ischemia
bundle branch block
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: P wave L 2
: QRS

QRS
V1 V2
V5 V6

shape
Notched V1 V2 ( right bundle branch block )M shaped
Notched V5 V6 ( left bundle branch block )M shaped
direction
Normally V1 V2 S R
S wave r wave
R s wave
V5 V6 S r wave
reversal of normal
reversal of normal right ventricular enlargement
V1 or V2 V5 or V6
voltage
S wave V1 V2
R wave V5 V6

Left ventricular enlargement

shape
direction
voltage


35
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:

: ST segment
normal depressed elevated
topographism recent MI elevated
topographism ischemia Depressed
pathological Q Normal
topographism Old MI
topographism
leads ST segment
heart block

ECG
Mainly hear block
A.V. nodal block
A.V. node
first degree heart block

second degree heart block

ventricle Atrium
third degree heart block
: heart block

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36

A.V. node

Just prolonged PR interval
sinus brady cardia
sinus bradycardia S.A. node

PQRST
sinus brady cardia first degree heart block

definition of first degree heart block
just prolonged PR interval

sinus brady first degree heart block
prolonged PR interval first degree heart block
(

)

A.V. node
A.V. node
:
Mobitz one
Mobitz two
Mobitz one
progressive prolongation of PR interval until dropped QRS

A.V. node

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Long strip RR interval

Mobitz one
irregular

dropped beat

Long strip
Mobitz Two
A.V. node

atrium

system
Mobitz Two regular drop of QRS
P P QRS T ... P P QRS T
P P QRS

A.V. node
:
Irregular Mobitz one
Regular Mobitz Two

Mobitz one
A.V. node

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Mobitz one and Mobitz two Irregular regular
Mobitz one irregular
Mobitz two regualr

A.V. node
Atrium S.A. node
ventricle idioventricular rhythm

ectopic focus
atrium
P wave
QRS
ventricle
QRS ventricle
bizarre shaped
deformed
A.V. node
narrow normal

QRS P P wave


A.V. dissociation
atrio ventricular dissociation
atrium ventricle
P QRS
QRS
deformed
Bizarre shaped
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All type of heart block are regular except....Mobitz one
All types of heart block with normal QRS complex except.... third degree heart block
Mobitz one regular
Third degree normal QRS
complete heart block
long strip
arrhythmia long strip
arrhythmia
rhythm

regular
irregular
irregular
regular
atrial fibrillation
extra systole
Mobitz one
atrial fibrillation

absent P tachy irregular
Normal QRS
Absent P
P wave atrial fibrillation
absent P wave
fibrillation some time
Absent P
AF
rapid
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40

slow AF
: Slow AF
digitalis
Beta blocker
associated Heart block
lone AF
AF slow AF
irregular ECG
With absent P wave
AF
Extra systole

refractory period
stimlus

compensatory pause
irregular

irregular

ventricular extra systole
Mobitz one
Progressive prolongation of PR interval until dropped QRS
so difficult Mobitz one
post graduates
AF
41
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rhythm
regular
rate
regular :
tachycardia
bradycarida
normo cardia tachy cardia
Regular tachycardia :
Sinus tachycardia
Ventricular tachycardia
Supra ventricular tachycardia
Atrial flutter

Sinus tachy cardia
S.A. node Peace maker of the heart

ECG

P followed by QRS T
P QRS T

Ventricular tachycardia
Arrhythmia ventricle
ventricle QRS
deformed

QRS P
T

42
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QRS wide

supra ventricular tachycardia
supra ventricualr

atrium
A.V. node
atrium P deformed
A.V. node P Inverted P
P

P wave Inverted
A.V. node

P absent

Masked by QRS

supra ventricular tachy cardia

deformed P Inverted P absent P
P
Atrial flutter
atrium
A.V. node
reduction Atrial beat in mathematical fashion

atrium

specific Atrial flutter

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Atrial flutter atrial fibrillation
atrial flutter regular
atrial fibrillation regular

regular long strip
rate tachycardia

QRS

deformed
Narrow normal
deformed

ventricular tachycardia
Narrow normal
P
P wave
single
multiple

single sinus tachycardia

P wave QRS T
multiple P

Atrial flutter


deformed QRS

ventricular tachycarida
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sinus tachycardia
multiple P

Atrial flutter
P wave
Supra ventricular tachy cardia
Regular bradycardia

Sinus bradycardia
Mobitz two
Nodal rhythm

regular bradycardia
sinus bradycardia

Mobitz two
regular drop of QRS complex
deformed QRS
AV dissociation
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45

nodal rhythm
peace maker A.V. node
peace maker A.V. node
P
inverted
absent QRS

regular bradycardia
QRS
deformed
Narrow normal
deformed
Narrow normal

P wave
P wave
single
Multiple

first degree heart block sinus bradycardia single

just prolonged PR interval
multiple P wave
Mobitz two
Atrial flutter Mobitz two
bradycardia Mobitz two
tachycardia atrial flutter
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46

Noda rhythm
diagnostic approach long strip
rhythm rate QRS
P

segmented
P
QRS
ST segment
Long strip

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ECG revision DR.

ECG revision DR. Allam

ECG revision DR. Allam

A.V. node conductivity

ECG revision DR. Allam

ventricular depolarization QRS complex

Ventricular repolarization T wave

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

blood supply of the heart

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

one big square 0.04 x 5 0.2

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

prolonged heart block

one small square

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

persistent elevation of ST segment equal Myocardial aneurysm

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

left ventricular hypertrophy

ECG revision DR. Allam

ECG revision DR. Allam

left ventricular hypertrophy

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

Bundle branch block

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

second degree heart block

ECG revision DR. Allam

ECG revision DR. Allam

third degree heart block

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

supra ventricular tachy cardia

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

ECG revision DR. Allam

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