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I aVR V1 V4
HIGH LATERAL
II aVL V2 SEPTAL STRICT V5
INFERIOR
III aVF V3 ANTERIOR V6 LOW
II LATERAL
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Summary of ECG 2
Step II
II.1. Atrial enlargement:
Look at
V1
II
Biatrial
For diagnosis of atrial enlargement, a change in ONE lead is ENOUGH
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Summary of ECG 3
Step III
III.1. Axis:
Look at:
I
III aVF
III or
aVF
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Summary of ECG 4
Pathological Q:
- Wide (>/+ 1mm) & deep (>/= 2mm or >/= ¼ R)
- In 2 successive lead of the same wall
Poor progression of R: in anterolateral infarction
- R is NOT >S in V4
ST elevation:
- First mm after J point is elevated than isoelectric line
- Isoelectric lines (baseline) are P-R segment or T-P segment
- Considered elevated if:
>/= 1mm in limb leads
>/= 2mm in chest leads
- Determine straightened or coved according to T wave & J point elevation
- These changes MUST be IN 2 SUCCESSIVE LEADS of the SAME WALL
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Summary of ECG 5
If:
ST elevation (+/- ST depression in other walls) ST elevation Myocardial
Infarction (+/- reciprocal ST depression)
ST depression ONLY Myocardial ischemia
If ST Elevation Myocardial Infarction, determine age & site:
1. Age:
Scheme for age of STEMI
Age of STEMI How to know
ST segment Q wave T wave
Hyperacute ST elevation NO pathological Q +/- Hyperacute T wave
Spot diagnosis
2. Site:
I aVR V1 V4 I aVR V1 V4
HIGHLATERAL II aVL V2 V5
II aVL SEPTAL
V2 V5
STRICT
LOW
III aVF V3 V6
IIIINFERIOR aVF V3 ANTERIOR
V6LATERA
II
L
Anterolateral
II Extensive anterior
Anteroseptal
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Summary of ECG 6
Step V
V.1. Low voltage:
Look at
I
II
III
How to know
QRS in I + II + III < 15mm
QRS small and P & T waves large
NB Electrical alternans in pericardial effusion:
- LOW voltage
+
V.2. Digitalis effect: in ALL LEADs
Digitalis effect: NB Normal QT = ½ RR
Short QT i.e. QT < ½ RR
Sagging ST depression:
- J point is isoelectric (unlike ischemia)
- ST depression + T inversion
- Fused ST + T
V.3. Hyperkalemia: in ALL LEADs
How to know:
Hyperacute T wave alone (tall, narrow & peaked)
V.4. Preexcitation syndrome: in ALL LEADs
Scheme for prexcitation syndromes
WPW-Wolf Parkinson White LGL-Lawn Ganong Levine
Short PR interval Short PR interval
Delta wave
Wide QRS
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Summary of ECG 7
Step I
I.2. Arrhythmia:
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Summary of ECG 8
I.Sinus pacemaker:
Scheme for Sinus Pacemaker
1.pacemaker 2. decide arrhythmia
Regularity Rate Lead II (Strip) Rhythm (Diagnosis)
60-100 Normal sinus rhythm
II.Atrial pacemaker:
Scheme for Atrial Pacemaker
1.pacemaker 2.deciding arrhythmia
Pacemaker Regularity Rate Lead II (Strip) Rhythm (Diagnosis)
Small P waves Regular >150 Supraventricular
tachycardia
Fibrillatory Irregular Any Coarse Atrial
waves
Fine fibrillation
Atrial Regular Atrial flutter 4:1
pacemaker Flutter
NO sinus P waves Irregular Any
(Saw teeth) Atrial flutter with
wave variable block
Tachycardia Multifocal atrial
>/= 3 tachycardia (MAT)
Irregular
different Ps Bradycardia Wandering atrial
pacemaker
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Summary of ECG 9
III.Junctional pacemaker:
Scheme for Junctional Pacemaker
1.pacemaker 2.decide arrhythmia
Regularity Rate Lead II (Strip) Rhythm (Diagnosis)
>150 Supraventricular tachycardia
(>100) (PAVNRT)
Junctional
Pacemaker 40-60 Escape Junctional rhythm
Regular
P absent or
retrograde 60-100 Accelerated Junctional rhythm
IV.Ventricular pacemaker:
Scheme for ventricular Pacemaker
1.pacemaker 2.decide arrhythmia
Pacemaker Regularity Rate Lead II (Strip) Rhythm (Diagnosis)
>150 Ventricular tachycardia
Bidirectional
Ventricular tachycardia
NO QRS Vent. Irregular Any Ventricular fibrillation
fibrillatory
waves
Ventricular Regular 300- Ventricular flutter
flutter waves 400
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Summary of ECG 10
V.Ectopic beats
Scheme for Ectopic Beats
If ,so If ,So diagnosis
1. Decide whether ectopic beat
Escape beat
beat
is escape or premature
Sinus rhythm
Junctional or ventricular
Retrograde P Escape
pause wave
ectopic beat Junctional beat
sinus rhythm Wide QRS Escape
T wave
opposite QRS ventricular beat
Small (atrial) P Premature atrial
Premature beat
wave
Premature Pause beat
Sinus rhythm Retrograde P Premature
ectopic beat wave 2 Normal cycles
pause
Junctional beat
Wide QRS Premature
sinus rhythm T wave
Premature Pause
wave
premature
beats
Atrial trigeminy
Monofocal premature beat
Atrial quadrigeminy
Wide QRS Ventricular bigeminy
ventricular
sinus beats
premature beat
T wave
Ventricular
opposite
QRS
Ventricular trigeminy
Ventricular quadrigeminy
P wave
beats
Junctional trigeminy
Junctional quadrigeminy
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Summary of ECG 11
2.Couplet:
Scheme for Couplet
How to know If Lead II (Strip) ,So diagnosis
Couplet
Small P wave Atrial couplet
Sinus rhythm
premature beat Retrograde P wave Junctional couplet
premature beat
Wide QRS Ventricular couplet
sinus rhythm
T wave opposite QRS
premature beat
sinus beat (NO pause) Retrograde P wave Interpolated PJB
Premature cycle + return cycle Wide QRS Interpolated PVB
= ONE normal sinus cycle T wave opposite QRS
Collected Arrhythmias
PM Rhythm Lead II Pacemaker Regularity Rate
1.1. Normal sinus rhythm Sinus Regular 60-100
1.2. Sinus tachycardia Sinus Regular 100-180
Sinus
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