Download - Basic of ECG and Easy Interpretation
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BASICS OF ELECTROCARDIOGRAPHY
Dr Mushfiq Newaz Ahmed Medical Officer Department Of Anaesthesia, Comilla Medical College & Hospital
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OUTLINE1. Review of the conduction system & Action Potential2. ECG leads and recording 3. ECG waveforms and intervals4. Normal ECG and its variants5. Basic Interpretation Steps of ECG6. Arrhythmia & ECG7. MI & ECG8. EI & ECG9. Thyroid Disorder & ECG10. Emergency ECG
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ACTION POTENTIAL OF CARDIAC CELL
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BUT THE IRONY OF FATE IS……
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WHAT IS AN ECG?
An ECG is the recording (gram) of the electrical activity(electro) generated by the cells of the heart(cardio) that reaches the body surface.
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USEFUL IN DIAGNOSIS OF…
Cardiac Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances
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ECG LEADS
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ECG LEADSLeads are electrodes which measure the difference in electrical potential between either:
1. Two different points on the body (bipolar leads)
2. One point on the body and a virtual reference point with zero electrical potential, located in
the center of the heart (unipolar leads)
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ECG LEADS
The standard ECG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads
The axis of a particular lead represents the viewpoint from which it looks at the heart
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STANDARD LIMB LEADS
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EINTHOVEN’S TRIANGLE
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PRECORDIAL LEADS
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PRECORDIAL LEADS
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SUMMARY OF LEADS
Limb Leads Precordial Leads
Bipolar I, II, III(standard limb leads)
-
Unipolar aVR, aVL, aVF (aug-mented limb leads)
V1-V6
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ANATOMIC GROUPS(SEPTUM)
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ANATOMIC GROUPS(ANTERIOR WALL)
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ANATOMIC GROUPS(LATERAL WALL)
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ANATOMIC GROUPS(INFERIOR WALL)
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ANATOMIC GROUPS(SUMMARY)
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Localising the arterial territory
InferiorII, III, aVF
LateralI, AVL, V5-V6
Anterior / SeptalV1-V4
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SPECIAL SITUATION Amputation or burns or bandages should be placed
as closely as possible to the standard sites
Dextrocardia right & left arm electrodes should be re-versedpre-cordial leads should be recorded from V1R(V2) to V6
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OTHER PRACTICAL POINTS
Effective contact between electrode and skin is essen-tial.
Electrical Artifacts: external or internal-External can be minimized by straightening the lead
wires-Internal can be due to muscle tremors, shivering ,
hiccups
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ECG PAPER
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ECG PAPER BASICSECG graphs:– Small Square -Height 1 mm and width 0.04 s– Large Square -Height 5 mm and width 0.04X5=0.2s Paper Speed:– 25 mm/s( As 0.2 s=5 mm,1 s=25 mm)Voltage Calibration: – 1 mV= П 10 mm( 10 small square) Half strength 5mm/mV Double strength 20 mm/mV
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ECG PAPER BASICS
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ECG WAVES
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WAVE FORMS
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P WAVE Denotes Atrial depolarization Shape-Rounded, neither peaked nor notched Width/Duration-2.5 small sq Height-2.5 small sq Better seen in Lead II/Lead V1 Upright in every lead except aVR May be Biphasic in lead V1(Equal upward and downward
deflection)
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PR INTERVAL Distance between onset of P wave to the beginning of Q
wave(in absence of Q wave beginning of R wave) Denotes time interval impulse travelling from SA node to
Ventricular muscle through AV node Normal Range:3 to 5 small Sq Short if ‹3 small sq and long if ›5 small sq
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NORMAL QRS COMPLEX Denotes Ventricular depolarization Normal width of QRS-2 to ‹3 small sq Narrow complex if less than 2 small sq and
Broad Complex if more than or equal to 3 small sq
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COMPONENT OF QRS COMPLEXo Q wave-width 1 small sq and depth 2 small sq and ‹25%
of following R wave (Pathological if width›1 small sq,depth›2 small sq and
›25% of following R Wave)o R wave height varies, but must remember the thing that
R wave progresses from V1 to V6(2-3 small square to les than 25 small sq/5 large sq)
(Pathological if height›25 small sq/5 large sq)o S wave follow R wave, depth varies,progressively dimin-
ishes from V1 to V6
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T WAVE Same direction as the preceding QRS complex Blunt apex with asymmetric limbs Height < 5 small sq in limb leads and <10 small square in
precordial leads Smooth contours May be tall in athletes
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ST SEGMENT
Merges smoothly with the proximal limb of the T wave No true horizontality
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QT INTERVAL Distance between beginning of QRS to the end Of T
wave Reciprocal relation with heart rate Normal 8-‹11 small sq If arrhythmia is present( HR less than 60 or more than
100 bpm) then QT interval should be corrected. Corrected QT(QTc)=QT/√RR
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U WAVE Best seen in midprecordial leads Height < 10% of preceding T wave Isoelectric in lead aVL (useful to measure QTc) Rarely exceeds 1 small sq in amplitude May be tall in athletes (2 small sq)
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HEART RATE, RHYTHM AND AXIS
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DETERMINING THE HEART RATE
Rule of 300
10 times/20 times method
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RULE OF 300Take the number of “Large Square” between neighboring QRS complexes, and divide this into 300. More accuracy can be achieved if the number of “small square” between neighboring QRS complexes divided into 1500
Although fast, this method only works for regular rhythms.
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RULE OF 300It may be easiest to memorize the following table:
Number of large square
Rate
1 300
2 150
3 100
4 75
5 60
6 50
7 43
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10 TIMES/20 TIMES RULE
Count the number of R in 30 large square(equivalent to 6 second) and multiply it by 10 would become rate in 60 sec. If small strip-counting the number in 15 large square(equivalent to 3 second) and multiply it by 20
This method works well for irregular rhythms.
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DETERMINING RHYTHM
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AXIS DETERMINATION
The QRS axis represents the net overall direction of the heart’s electrical activity.
Abnormalities of axis can hint at:Ventricular enlargementConduction blocks (i.e. hemiblocks)
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THE QRS AXISBy near-consensus, the nor-mal QRS axis is defined as ranging from -30° to +90°.
-30° to -90° is referred to as a left axis deviation (LAD)
+90° to +180° is referred to as a right axis deviation (RAD)
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DETERMINING THE AXIS
The Quadrant Method
The Degree Method
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THE QUADRANT METHODExamine the QRS complex in lead I/lead aVL and lead III/lead aVF to determine if they are predominantly positive or predominantly negative. The combination should place the axis into one of the 4 quadrants below.
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COMMON CAUSES OF LAD May be normal in the elderly and very obese Due to high diaphragm during pregnancy or ascites Inferior wall MI Left Anterior Hemi block Left Bundle Branch Block Emphysema
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COMMON CAUSES OF RAD Normal variant Right Ventricular Hypertrophy Anterior MI Right Bundle Branch Block Left Posterior Hemiblock
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THE NORMAL ECG & VARIATION WITH RESPIRA-TION
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NORMAL SINUS RHYTHM Originates in the sinus node Rate between 60 and 100 beats per min Monomorphic P waves Normal relationship between P and QRS Some sinus arrhythmia is normal
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APPROACH TO INTERPRET
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STEP-1:LEAD POSITIONNormal-P wave upright in lead I & II and QRS should be
downward in aVR & V1, R wave progresses from V1 to V6(height increases)
Lead Malposition-P wave downward in lead I & II and QRS should be upright in aVR & V1, R wave progresses from V1 to V6(height increases)
Dextrocardia- P wave downward in lead I & II and QRS should be upright in aVR & V1, R wave regresses from V1 to V6(height decreases)
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Lead Malposition
Dextrocardia
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STEP 2: VOLTAGE OR AMPLITUDE Normal ECG paper- voltage or amplitude 10 mV Half Voltage,5 mV used specially when severe LVH causes very
large QRS complex which merges with QRS complexes of above or below leads
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Electrical Alternans-Alternate beat variation in direction, ampli-tude and duration of any component of ECG. It can be found in-Pericardial Effusion, Pericardial Mesothelioma, Pericardial TB, Myocarditis, Hypothermia
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STEP 3:RHYTHM & RATE Rhythm Assessment- By Paper & Pencil Method or
Caliper Method
Rate Measurement-By 300 times method/20 times method
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STEP 4: AXIS Normal- QRS of lead I(+aVL) and QRS of lead II+(III &
aVF) is in the same direction
LAD- QRS of lead I(+aVL) upward and QRS of lead II+(III & aVF) downward
RAD- QRS of lead I(+aVL) downward and QRS of lead II+(III & aVF) upward
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Negative in I, positive in aVF RAD
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Positive in I, negative in aVF LAD
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STEP 5: BUNDLE BRANCH BLOCK(CLUE: WIDE QRS)
RBBB- M pattern in QRS in Lead V1( or V2/V3). May be nor-mal
LBBB-M pattern in QRS in Lead V6( or V4/V5). T inversion can be found. New onset always Alarming
Bifascicular block- RBBB+ Left posterior Hemiblock----›features of
RBBB+RAD(Ostium Secundum ASD) RBBB+ Left anterior Hemiblock ----›features of
RBBB+LAD(Ostium Primum ASD)
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RIGHT MARROW(RBBB) LEFT WILLOW( LBBB)
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STEP 6:CHAMBER ENLARGEMENT Right Atrial Enlargement- Tall peaked P wave
Left Atrial Enlargement-Broad/M Pattern/Wide/Bifid or notched P wave
Right Ventricular Enlargement-Tall R in V1 and deep S in V5/V6
Left Ventricular Enlargement-Unusually tall R in V5/V6 and unusually deep S in V1(R+S>35 mm)
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RIGHT ATRIAL ENLARGEMENT
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LEFT ATRIAL ENLARGEMENT
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RIGHT VENTRICULAR HYPERTRO-PHY
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RIGHT VENTRICULAR HYPERTRO-PHY
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LEFT VENTRICULAR HYPERTRO-PHY
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LEFT VENTRICULAR HYPERTRO-PHY
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7. WAVE & INTERVAL ABNORMALITY
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P WAVE ABNORMALITY Absent- Atrial Fibrillation -Atrial Flutter -Ventricular Tachycardia -SVT -Hyperkalaemia Single for every QRS complex Tall/Peaked-Right Atrial Hypertrophy/Enlargement Wide/Broad/Notched-LA Hypertrophy/Enlargement Multiple-AV Block(Either Partial Or Complete)
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Q WAVE ABNORMALITY Pathological Q wave- Old MI - LVH - LBBB -Cardiomyopathy -Emphysema(due to axis change) -Pulmonary Embolism(lead III)
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R WAVE ABNORMALITY Tall- LVH(in V5/V6) - RVH(in V1/V2) - True Posterior MI Small-Obesity -Emphysema -Pericardial Effusion -Hypothyroidism -Hypothermia Poor Progression of R wave-COPD -PE(left) -Pneumothorax (left) -Cardiomyopathy -Ant/Anteroseptal MI
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QRS COMPLEX ABNORMALITY High Voltage-Thin Chest Wall, Ventricular Hypertrophy Low Voltage-Thick Chest wall, Hypothyroidism, Pericardial Effu-
sion, Emphysema, Hypothermia, Chronic constrictive Pericarditis Wide QRS-BBB -Ventricular Ectopic -VT -Ventricular Enlargement -Hyperkalaemia Narrow QRS-SVT
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T WAVE ABNORMALITY Inversion-MI, Ventricular ectopic, Ventricular Hypertro-
phy with strain, Cardiomyopathy, Acute Pericarditis, BBB Tall Peaked-Hyperkalaemia, Hyper acute MI, Acute True
Post. MI Small- Hypokalaemia, Hypothyroidism, Pericardial Effu-
sion
![Page 86: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/86.jpg)
U WAVE ABNORMALITY Inversion- Ischemic Heart Disease -LVH with strain Prominent-Hypokalaemia -Hypercalcemia -Hyperthyroidism
![Page 87: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/87.jpg)
PR INTERVAL ABNORMALITY Prolonged- First Degree Heart Block(Causes- IHD, Acute
Rheumatic Carditis, Myocarditis, Hypokalaemia, Atrial Dilata-tion or Hypertrophy)
Short- WPW syndrome Variable-Second Degree Block( Type I and Type II) -Third Degree Block
![Page 88: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/88.jpg)
ABNORMALITY OF ST SEGMENT
![Page 89: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/89.jpg)
ST ELEVATION PATTERN
![Page 90: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/90.jpg)
PROLONGED QTC (ABCDE) AntiArrythmic-Amiodarone,Flecainide,Disopyramide AntiBiotic-Macrolides AntiC(Psy)cotic-Chlorpromazine, Haloperidol AntiDepressant-TCAEI-Hypokalaemia, Hypomagnaesemia, Hypocalcemia
![Page 91: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/91.jpg)
SHORTENED QT Digitalis effect Hypercalcemia Hyperthermia Vagal stimulation
![Page 92: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/92.jpg)
ARRHYTHMIA & ECG
![Page 93: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/93.jpg)
SINUS BRADYCARDIA
![Page 94: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/94.jpg)
SINUS TACHYCARDIA
![Page 95: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/95.jpg)
HEART BLOCK SA Block
AV Block -1st degree AV block -2nd degree AV block( Type I & Type II) -3rd degree AV block
BBB -RBBB -LBBB
![Page 96: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/96.jpg)
SA BLOCK
Absence of one P-QRS-T complex Pause is multiple of P-P interval(or R-R interval)
![Page 97: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/97.jpg)
IMPORTANT DIFFERENTIAL IS SA AR-REST…
Absence of one P-QRS-T complex Pause is NOT multiple of P-P interval(or R-R interval)
![Page 98: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/98.jpg)
AV BLOCK
![Page 99: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/99.jpg)
![Page 100: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/100.jpg)
![Page 101: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/101.jpg)
![Page 102: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/102.jpg)
![Page 103: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/103.jpg)
RBBB
![Page 104: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/104.jpg)
LBBB
![Page 105: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/105.jpg)
ATRIAL FIBRILLATION
![Page 106: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/106.jpg)
ATRIAL FLUTTER
![Page 107: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/107.jpg)
ATRIAL TACHYCARDIA/SVT
![Page 108: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/108.jpg)
ATRIAL ECTOPIC/PAC
![Page 109: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/109.jpg)
JUNCTIONAL ECTOPIC/PJC
![Page 110: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/110.jpg)
VENTRICULAR ECTOPIC/PVC
![Page 111: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/111.jpg)
MI & ECG
![Page 112: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/112.jpg)
CHANGE IN INJURY, ISCHEMIA & INFARC-TION
![Page 113: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/113.jpg)
![Page 114: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/114.jpg)
RECIPROCAL LEADS
![Page 115: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/115.jpg)
LATERAL MI
![Page 116: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/116.jpg)
ANTEROSEPTAL MI
![Page 117: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/117.jpg)
EXTENSIVE ANTERIOR MI
![Page 118: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/118.jpg)
INFERIOR MI
![Page 119: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/119.jpg)
POSTERIOR MI
ST depression in V2-V3 Tall, Broad R wave in V2-V3 Dominant R wave in V2(R>S) Upright T wave
![Page 120: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/120.jpg)
Posterior MI confirmed by posterior lead V7, V8, V9V7=Left Post. Axillary line, same plane to V6V8=Tip of the scapulaV9=Left Paraspinal line
![Page 121: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/121.jpg)
Same case with posterior leadST segment elevation in V7-V9
![Page 122: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/122.jpg)
DIFFERENCE BETWEEN MI AND ACUTE PERICARDITIS
ST shape-Convex Up Location of ST change-
Territorial Reciprocal ST change-
Present Q wave change-May be
Present
ST shape-Concave up Location of ST change-
Limb & Precordial Reciprocal ST change-Ab-
sent Q wave change-Absent
Acute MI Acute Pericarditis
![Page 123: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/123.jpg)
![Page 124: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/124.jpg)
EI & ECG
![Page 125: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/125.jpg)
![Page 126: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/126.jpg)
HYPOKALEMIA
![Page 127: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/127.jpg)
HYPERKALEMIA
![Page 128: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/128.jpg)
HYPOCALCAEMIA & HYPERCAL-CEMIA
![Page 129: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/129.jpg)
THYROID DISORDER & ECG
![Page 130: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/130.jpg)
HYPOTHYROIDISM
![Page 131: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/131.jpg)
HYPERTHYROIDISM/ THYROTOXICOSIS
![Page 132: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/132.jpg)
EMERGENCY ECG
![Page 133: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/133.jpg)
VENTRICULAR TACHYCARDIA
![Page 134: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/134.jpg)
VENTRICULAR FIBRILLATION
![Page 135: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/135.jpg)
ASYSTOLE
![Page 136: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/136.jpg)
![Page 137: Basic of ECG and Easy Interpretation](https://reader035.vdocuments.us/reader035/viewer/2022062412/58f9b194760da3da068bc21a/html5/thumbnails/137.jpg)
THANK YOU….