Ekg Ecg Interpretation by DR Jason Lowe PDF Bb3 DR Notes

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EKG/ECG INTERPRETATION
A Comprehensive & Systematic Steps To Learn The
12-Lead EKG/ECG Interpretation With Test Questions & Answers
Dr. Jason Lowe MD
INTRODUCTION
The main purpose of the particular heart is in order to supply an ample amount
of bloodstream to peripheral cells to meet their own metabolic demands all
the time. The arterial program supplies tissues plus organs throughout the
particular body with o2, nutrients, hormones, plus immunologic substances.
Via venous return this removes wastes through tissues, routing deoxygenated
blood through the particular lungs for removal of metabolic waste products.
The heart may be the size of the fist and because small as it really is it carries
a remarkable workload over the lifetime. It is better than 60 to one hundred
times per moments without resting. The particular heart should be versatile
and capable to change to changes within the body's metabolic demands, often
within a matter associated with seconds. Vigorous workout can increase
metabolic requirements of muscle tissue as much, because twenty times more
than their needs throughout rest. To fulfill these demand, the particular heart
accelerates it rate to increase cardiac output. Vessels must redistribute blood
flow, shunting a greater proportion of blood to muscle tissues and away from
internal organs.
The heart is unique and possesses several properties. It works as a pump by
expanding and contracting without placing added stress on the cardiac muscle
and without developing muscle fatigue. The heart pumps 4 to 8 liters per
minute. This is equivalent to 6, 000 liters per day. It has an inherent capability
to generate electrical impulses that maintain proper rhythm regardless of other
factors, such as heart rate, and ignores inappropriate electrical signals that
might over stimulate the cardiac muscle.
THE ELECTROCARDIOGRAM IS ABBREVIATED ECG. AN OLDER
ABBREVIATION THAT IS USED SYNONYMOUSLY IS EKG.
The ECG (EKG) is a valuable diagnostic tool for the healthcare provider
whether they are a doctor, nurse, or specialist in cardiac rehabilitation.
Understanding the ECG (EKG) enables the healthcare provider to respond
correctly and to treat dangerous and potential deadly arrhythmias as quickly
and efficiently as possible. It is important to understand the mechanisms,
cutting edge treatments and to know exactly what needs to be done to treat
these deadly arrhythmias. New drugs and high tech equipment which can
cardio-vet, defibrillate, and serve as a pace maker are constantly being
evaluated and introduced into the healthcare system.
WHAT IS ECG INTERPRETATION?
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An electrocardiogram or ECG, records electrical activity in the heart. An
ECG machine records these electrical signals across multiple heart beats and
produces an ECG strip that is interpreted by a healthcare professional.
WHAT IS EKG INTERPRETATION?
An electrocardiogram or EKG, is a test that records electrical activity across
multiple heart beats and produces an EKG strip that is interpreted by a
healthcare professional.
How Electrocardiograms Work - ECG Strips
To briefly summarize the components of a normal ECG tracings, it consists of
waveform components which indicate electrical events during one heartbeat.
These waveforms are labeled P, Q, R, S, T and U.
P wave is the first short upward movement of the ECG tracing. It indicates
that the atria are contracting, pumping blood into the ventricles.
The QRS complex, normally beginning with a downward deflection, Q; a
larger upwards deflection, a peak (R); and then a downwards S wave. The
QRS complex represents ventricular depolarization and contraction.
The PR interval indicates the transit time for the electrical signal to travel
from the sinus node to the ventricles.
ANATOMY AND PHYSIOLOGY
The heart is a hollow, muscular organ located in the middle of the particular
thoracic cavity, cradled in a crate of bone the fibrous connective tissue
cartilage, and muscle. This lies left from the midline of the particular
mediastinum and simply above the diaphragm. The heart will be protected
anteriorly simply by the sternum plus posteriorly from the backbone. Lungs
can be found upon either side. The particular entire heart will be enclosed in
the particular fluid-filled pericardial bard de golf. This sac assists to shield
the particular heart against contamination and trauma, helps prevent friction,
and helps cardiac function simply by helping with the particular free pumping
actions from the heart. The particular heart includes 3 layers; Epicardium,
Myocardium, and Endocardium.
FUNCTIONALITY
Activities from the correct side from the coronary heart and the side of the
coronary heart occur simultaneously.
The particular right side associated with the heart gets impure blood from
your body via the particular vena cava in to the right atria. Blood is thrown
from the correct atria into the particular right ventricle. Bloodstream is
pumped in order to the lungs through the right ventricle via the pulmonary
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artery. The remaining side from the coronary heart receives oxygenated
bloodstream from the lung area via the pulmonary vein into the particular left
Atria. Bloodstream is ejected through the left atria to the remaining ventricle.
Blood will be pumped towards the entire body from the remaining ventricle
via the particular aorta. Briefly the particular Right side of the heart pumps
blood into the lungs. The Left side pumps blood into the body.
The two atria and two ventricles of the heart are separated by atrioventricular
valves. The action of the Right tricuspid and left Mitral (Diastole) represent
the ventricle filing phase. AV-valves open during Systole; while the ventricle
is in the contracting phase (empty) then the AV valves close. The Semilunar
valves separate the ventricles from the arteries. The pulmonic valve separates
the right ventricle, and the pulmonary artery. The Aortic valve separates the
left ventricle from the Aorta, during systole, allowing blood to be ejected
from the heart to the rest of the body.
Strength Activity of generally the Center.
A new folks center is usually an outstanding appendage. The individual
typically the new the new heart beats 70, 1000 to a hundred, 1000 times in
addition to pumping systems roughly 2, 1000 gallons a time. The very center
could have conquered 2-3 billion money times and distributed 50-65 million
gallons of blood above the 70-90 12 months’ life expectancy. Your center is
built of specialized muscle mass tissue able in order to sustaining ongoing
defeating. This muscle cells are unique compared to bone muscle that will
forces the hands in addition in order to legs. Specialized components of the
myocardium put in electric control above the particular cardiac routine. These
types of areas display physiologic dissimilarities coming from the leftover
portion of the particular myocardium, forming the path for electric urges
which motivate typically the coronary heart muscle. A couple of types of
center failure cells usually are contractive and conductive. Any time typically
the cells are actually from rest, these usually are electrically more negative
inside with value to the exterior of the mobile. Charged particles (ions) of
sodium in addition to potassium move inside and out regarding the cell
ultimately causing changes that usually are sensed by electrodes within the
skin. Typically, the electrical action may show being a looking up on the ECG
(EKG).
The sinoatrial (SA), or sinusitis node initiates a new self-generating impulse
and is also the primary pacemaker which sets a new rate of 62 to 100
surpasses per minute (bpm). The SA client is located from the border or
perhaps junction of Excellent Vena Cava in addition to Right Atrium. When
generated, the power impulse sets typically the rhythm of trance and travels by
means of both atria above a specialized lounges network to typically the
Atrioventricular (AV) Client. The AV client is positioned inside the floor
regarding the Right Vorhof des herzens and receives typically the impulse and
sends to the Pack of His. Typically, the Bundle of His / her then divides
directly into a right pack branch and a couple of left bundle divisions. These
terminate inside a complex community called the Purkinje Fibers, which
propagate through the entire ventricles. Any time the impulse actually reaches
the ventricles, excitement of the myocardium causes depolarization in the
cells, and shrinkage occurs. The UTAV node serves since a gate to be able to
delay electrical lounges as well as in this approach prevents a too much
number of atrial impulses from coming into the ventricles.
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Typically, the SA node in addition to AV Nodes come with sympathetic and
parasympathetic fibers. This permits practically instantaneous modifications
in our heart rate inside reply to physiologic within oxygen requirement. The
conventional cardiac lounges system occurs inside this specific collection:
Sinoatrial client starts electrical instinct plus sends this particular impulse
thru usually the atrium > reduced area whereby an excellent Atrial Kick
happens > AV customer > Package regarding His through ventricles via >
Right Package as well because Left Bundle Branches> Purkinje materials.
Once the SA customer falters, a pecking order of pacemakers are often able in
order to get over. Atrial, AUDIO-VIDEO node, plus ventricular escape
pacemakers may function because part pacemakers, nevertheless these folks
created impulses in the much reduced prices. The AUDIO-VIDEO client
generates prices among 40 to be able to sixty bpm as well as the Purkinje
materials at twenty in order in order to 40 bpm.
Electrical impulse does not always be the same compression from your
coronary heart. Item pathways perform the role within re-entry tach
dysrhythmias, offering the detour with regard to electric impulses in order to
group using the coronary heart.
Mahaim: Short, immediate contacts from the AUDIO-VIDEO node (or the
particular Package of Their or even package branches) in purchase to muscle
materials within the interventricular septum. Mahaim dietary fiber bail, a kind
related to accessory AUDIO-VIDEO bail with irregular is preferable to
originating beneath the particular area of regular hold off within the AV-
conducting system, causes the good arrhythmia.
ELECTRICAL EVENTS OF DEPOLARIZATION AND REPOLARIZATION
Polarized - Cardiac cells that are in a resting state are negative. The sodium
ions are outside of the cell and the potassium ions are within the cell. Both
ions carry a positive charge however; the sodium ion has a more powerful
charge than the potassium. Thus the inside of the ion electrically is weaker
than the outside so it is negative. The polarized state is a "ready state". When
the cell is ready to accept and electrical impulse, a big amount of potassium
leaks out. This causes a discharge of electricity. The cell becomes positively
charged. This is called depolarization. The electrical wave then travels from
cell to cell throughout the heart. Now there is cell recovery, sodium and
potassium ions are shifted back to their original place by the sodium-
potassium pump. This is called repolarization.
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ACTION POTENTIAL OF A MYOCARDIAL WORKING CELL
Electrical impulses are the result of brief, but extremely rapid flow of
positively charged ions (mainly Na+) back and forth across the cell
membrane.
Cardiac action potential illustrates the changes in the membrane potential of a
cardiac cell during depolarization and repolarization.
There a five phases starting with the following:
1. Phase O Rapid Depolarization also called "upstroke", "overshoot", or

"spike"
2. Begins when cell receives an impulse
3. Sodium moves quickly into the cell through the quickly sodium channels
4. Potassium then leaves typically the mobile
5. Calcium movements slowly into typically the cell through calcium
supplement channels
This is certainly concerning +20 mV

Mobile depolarizes and heart failure contraction commences
Period 1 Early Repolarization
The Rapid movement of sodium directly into the cell is usually stopped as
typically the fast sodium programs close up
Potassium commences to reenter typically the cell and salt commences to
depart
This is certainly about 0mV and is also therefore neutrally charged, neither
absolutely or negatively recharged
This can be the absolute refractory period of time
Phase a couple of Plateau Phase (slow repolarization, part regarding absolute
refractory period)
Slowly repolarization carries on Calcium continually movement into the
mobile through slow calcium supplement channels
Phase three or more Final Rapid Repolarization
Rapidly the mobile completes repolarization
Calcium supplement channels close
Potassium rapidly flows from the cell
Active transfer via the potassium-sodium water pump commences rebuilding
potassium to typically the inside of typically the cell and salt for the outside
regarding the cell
Mobile now in bad state due to be able to the outflow regarding potassium
Gradually typically the cell becomes extremely sensitive to outside stimuli
until their original sensitivity provides been restored; the relative refractory
period of time.
Phase 4 Come back to Resting Stage
Compares to diastole
Calcium in addition to sodium remain outside of the cell
Potassium remains to be inside cell
Within this phase the center is "polarized" in addition to getting looking
forward to relieve
Once another stimuli occurs the mobile will reactivate.
PROPERTIES OF THE HEART
Automaticity is the ability of the heart to initiate an electrical impulse. The
heart can begin and maintain rhythmic activity without the aid of the nervous
system. A heart removed from the body has the ability to beat on its own for a
limited period regarding time. The best diploma of automaticity can be found
in the pacemaker tissue of the sinusitis node. The atria, atrioventricular (AV)
Client, Bundle of His / her, bundle branches, Purkinje Fibers, and typically
the ventricular myocardium have got a lesser amount of automaticity.
Excitability will be the ability of typically the heart to reply to a power
impulse. A heart failure cell will reply to an electrical incitement by having
an abrupt alter in its power potential. Each heart failure cell that obtains an
electrical instinct will change their ionic composition in addition to its
respective polarity. Once any prospective begins within a heart failure cell it
will eventually keep on until the complete cell is polarized.
Conductivity is typically the ability of typically the heart to perform an
electrical instinct. All areas regarding the heart seem to depolarize
concurrently because a heart failure cell transfers a great impulse to a new
neighboring cell extremely rapidly.
CONDUCTION METHOD
The normal heart failure impulse arises inside the specialized pacemaker
tissue of the SOCIAL FEAR node, located concerning 1 mm under the right
atrial epicardium in its passageway with the excellent vena cava. Typically,
the impulse then distributes over the atrial myocardium to typically the left
atrium by way of Bachmann's bundle also to the region regarding the AV client
via the preliminary, middle, and detrás internodal tracts hooking up the sinus
in addition to AV nodes. These kinds of represent the normal routes of
propagate, tend to be not specialized tracts analogous to be able to the
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Purkinje method. When the instinct reaches both atria, they depolarize
electrically, producing a L wave on typically the electro cardiogram (ECG)
(EKG), and after that deal mechanically, producing typically the A wave
regarding the atrial strain pulse and propelling blood forward into the
ventricles.
Conduction slows when the impulse reaches the AV node, allowing sufficient
time for blood to flow from the atria into the ventricles. After the impulse
emerges from the AV node, conduction resumes it rapid velocity through the
Bundle of HIS to the Right and Left Bundle Branches, and terminates in the
Purkinje Fibers in the ventricular muscle.
Stimulation of the myocardium causes progressive contraction of the
myocardial cells. Therefore, wave deflections correspond to the mechanical
events in the cardiac cycle which include contraction and relaxation of the
cardiac chambers. Repolarization is only electrical and the heart is at rest.
Three major waves of electric signals appear on the ECG (EKG). Each one
shows a different part of the heartbeat.
The first wave is called the P wave. It records the electrical activity of the
atria.
The second and largest wave, the QRS wave, records the electrical activity of
the ventricles.
The third wave is the T wave. It records the heart's return to the resting state.
The particular P wave signifies atrial activation; the particular PR interval
may be the time from start atrial activation in order to onset of ventricular
activation. The QRS complex represents ventricular activation; the QRS
duration is the particular duration of ventricular activation. The ST-T wave
represents ventricular repolarization. The QT interval is the particular
duration of ventricular activation and recovery. The U wave probably
represents "after depolarization" in the ventricles.
Baseline is actually a bioelectric range; neutral usually without any
deflections; toned line.
"P" trend represents atrial depolarization. This represents a single electrical
activity related with an instinct from the S-A node and their spread from the
atria.
"P-R" Interval symbolizes the time in the first place of atrial depolarization,
P-wave to typically the start of the QRS, or perhaps ventricular
depolarization. Typical P-R interval is usually. 12 to. something like 20
seconds.
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"QRS" symbolizes ventricular depolarization (phase 0 of typically the action
potential) right up until the end regarding ventricular depolarization. "Q" =
initial down or negative deviation.
The normal Queen wave is fewer than 25% in the amplitude of typically the R
wave
Typically, the Q wave really does not exceed zero. 04 secs inside duration.
"R" sama dengan first upward or perhaps positive deflection following the P
trend
"S" = very first downward or bad deflection after typically the R wave
Typical QRS complex is usually 0. 04 to be able to 0. 10 secs in grown-ups.
"ST segment" will be the electrical sleeping period after ventricular
depolarization. Represents early on repolarization of typically the left and
proper ventricles. Begins together with the end regarding the QRS intricate
and ends with all the onset of typically the T wave. That is usually not
necessarily depressed more as compared to 0. 5 logistic in different lead.
"T Wave" ventricular repolarization and is also not typically higher than 5
logistic in amplitude. Peaked T waves usually are seen in hypercalcemia.
"QT" interval symbolizes total ventricular action which is the time required
for ventricular depolarization and repolarization. Measured from the
beginning of the QRS complex to the end of the T wave.
Normally measures 0. 36 -0. 44 sec. This can vary with the patient's heart
rate. Slower heart rates tend to have a longer QT interval and fast heart rates
tend to have a shorter QT interval.
Prolonged QT intervals indicate a lengthened relative refractory period
(vulnerable period). In the vulnerable period critical, life threatening rhythms
may occur (Premature Ventricular Contractions Torsades de Pointe, "T" wave
represents ventricular repolarization
Normally not greater than 5mm in amplitude
Peaked T waves are seen in patients with hyperkalemia
Determining Rate and Rhythm
The real key to rhythm interpretation is to utilize a Systematic Approach.
First ask yourself are there P waves?
What is the QRS width?
Is it a Regular rhythm?
Are P waves related to the QRS?
What is the Heart Rate?
ESTABLISHING THE HEART LEVEL
There are numerous methods regarding calculating the very center level.
Rule of three hundred: If the beat is regular, the very center rate can end up
being "estimated" by applying the "Rule regarding 300". Count the quantity of
large squares in between two R surf and divide this specific number into 300.
(There are 300 boxes, or truck tiny boxes, within a minute strip)
The Six-Second Approach: Count the amount of complete Ur waves within a
new amount of 6 mere seconds and multiply that will number by ten. This is
the particular about a minute heart price. This method may be used when the
tempo is "regular or even irregular".
The Three-Second Method: Count the particular number of total QRS
complexes inside a period of 3 seconds and increase that by 20. This is
actually the one moment heart rate.
The particular Block Method: Look for a QRS complex that will hits
precisely on the vertical line.
1. block 300
2. block 150
3. block 100
4. prevent 75
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5. block 60
6. block 50
7. prevent 43
8. block 37
9. block 30
10. prevent prayers are required

ANALYZING A TEMPO STRIP UTILIZING THE 8 STEP STRATEGY
STEP ONE: DETERMINE THE PACE:
What is the particular atrial rate?
In order to determine the atrial rate, measure the particular distance between
P-P.
What is the particular ventricular rate?
In order to determine the ventricular rate, measure the particular distance
between R-R.
Note: The price of a Regular Sinus Rhythm will be 60-100 beats per minute.
STEP TWO: FIGURE OUT THE RHYTHM
Will be the rhythm will be regular or abnormal?
To determine when the atrial rate will be regular or abnormal, measure the
range between two successive P-P intervals. Make use of a point through one
P influx to the exact same point on the particular next P influx. Then compare
this particular with another P-P interval. When the atrial rate is normal, the P-
P period will measure the exact same.
Determine if the particular ventricular rate will be regular or abnormal,
measure the range between two successive R-R Intervals Make use of a point
through one R influx to the exact same point on the particular next R influx.
Then compare this specific with another R-R interval. In the event the atrial
rate is typical, the R-R time period will gauge the similar.
Is the beat regular? Basically typical? Regularly irregular? Irregularly
irregular?
STEP THREE: EVALUATE P SURF
Are P surf present and consistent in look?
Are L waves upright (positive) in Lead 2?
Do P surf appear regularly just before each QRS intricate or is right now
there
More than a single P wave just before a QRS intricate?
If irregular is usually there a related beat?
STEP FOUR: EXAMINE THE P-R TIME PERIOD
If the P-R interval is fewer than 0. 13 or more as compared to 0. 20 next,
conduction follows a great abnormal pathway or perhaps the electrical
instinct was delayed from the AV client.
The normal P-R interval is zero. 12 to zero. 20 second.
Is usually the P-R time period consistent?
STEP FIVE: EVALUATE THE QRS COMPLEX
Do typically the QRS complexes take place uniformly and appearance the
same through the entire strip?
If typically, the QRS measures. 12 second or fewer it truly is considered filter
and is also presumed to be able to be supraventricular inside origin.
In the event the QRS complex is better than. 12 next or more that is considered
large, and presumed to be able to be ventricular inside origin until confirmed
otherwise.
The QRS normally measures 0. 04 to 0. 10 seconds within duration.
Determine in case they may be married in order to the P dunes.
STEP SIX: ASSESS T INFLUX
Are usually T waves existing?
Are T dunes smooth and curved?
Do they possess normal amplitude associated with 0.5 mV or less?
Will be the deflection the particular same as the particular preceding QRS?
Will be there a partnership between any ectopy towards the T influx?
STEP SEVEN: ASSESS THE QT PERIOD
Is the period from 0. 36 to 0. forty-four seconds?
STEP EIGHT: EVALUATE OTHER PARTS
Is the SAINT segment elevated? Stressed out? Sloping or acquired?
Are U dunes present? Prominent?
Are usually there other (funny little beats) FLB's detected?
Identifying the Rhythm
Origins of the Instinct in addition to the Cardiac Action = rhythm brand.
Origin of typically the Impulse: Can it be sinusitis, atrial, junctional, or
perhaps ventricular?
Cardiac Action: Normal (In rhythm), bradycardic (slow), faster (Faster than
normal), or Tachycardia (Greater than 100/min)?
Regarding example: sinus bradycardia, sinus tachycardia, faster junctional, or
ventricular tachycardia.
ESCAPE PACEMAKERS
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The normal power flow through typically the heart comes from typically the
SA node> UTAV node> Bundle regarding His> still left and right pack
branches> Purkinje fibers where typically the mechanical cells usually are
stimulated. The principal pacemaker therefore will be the SOCIAL FEAR
node and contains a great inherent rate regarding 60-100 beats/minute.
Typically, the SA node gets the highest level regarding automaticity, but avoid
pacemakers can be present.
Common escape pacemakers exist in typically the Atrio-Ventricular (AV)
passageway and in typically the Ventricles.
The UTAV junction is typically the AV node in addition to the no branching
section of the Pack of His. Typically, the pacemaker cells inside the AV
junction are situated near to the no branching percentage of the Bundle
regarding His.
The UTAV node only creates an impulse in the event the SA node would not
function at their normal rate. Typically, the AV node fire electrical impulses
from a rate regarding 40-60 beats/ second.
The Ventricular pacemakers found in the pack branches and typically the
Purkinje network may become the starting pacemaker in the event the UTAV
node struggles to perform at its typical rate. The natural ventricular rate is
usually 20-40 beats/minute.
Reentry
This occurs for the electrical impulse is usually delayed, blocked or perhaps
both in a single or more helpings of the power conduction system although the
impulse will be conducted normally via the rest associated with the
conduction program. The finish outcomes are a postponed impulse entering
heart cells which possess been depolarized from the normally conducted
behavioral instinct. If they possess repolarized sufficiently, depolarizing them
prematurely, generates ectopic beats plus rhythms.
Lead I: Positive electrode will be positioned slightly below the particular left
clavicle
Unfavorable electrode place simply below the correct clavicle
Provides details about the left horizontal wall of upper body.
Lead II: Good electrode just beneath the left chest muscle
Negative electrode just below the best clavicle
Provides details about the interior walls of the coronary heart
Common in heart monitoring because placement of the lead will be near to
actual bail pathways.
Lead III: Positive electrode will be at the remaining pectoral muscle, plus
negative is beneath the left clavicle.
Provides details about the particular inferior wall from the heart
MCL We
Negative electrode will be below the remaining clavicle and good reaches the
correct of the sternum at the 4th intercostal space.
Helpful in assessing the particular anterior wall associated with the heart
(LV) and the bail with the ventricles.
This particular lead is helpful in assessing the particular width from the QRS
complex to distinguish supraventricular tachycardia (SVT) from ventricular
tachycardia (VT).
Disorders associated with the Heartbeat are caused by:
Defects in behavioral instinct formation
Defects within impulse conduction
Mixtures of above
Arrhythmogenic Mechanisms
Reentry
Modified automaticity- improved or even depressed.
Sinus Arrhythmia
Rate: Generally, 60-100 beats/min yet may be possibly faster or reduced.
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Commonly seen within the elderly as well as the young and generally will not
require therapy. Heartrate increases with inspiration and decreases with
expiration.
Sinus Arrest or Sinus Pause
Rate: Usually 60-100 beats/min but may be either faster or sluggish.

Rhythm: Irregular Typically the SA node starts and impulse, nevertheless the
impulse is usually blocked before departing the node alone. This brings about
a great absent PQRST intricate. In sinus detain, the pause is usually not a
numerous of other P-P interval and could be as a result of numerous problems.
Treatment may possibly include Atropine or even a pacemaker if systematic.
Sinus Exit Obstruct (Sinoatrial Block)
Level: Usually 60-100 beats/min but may end up being either faster or
perhaps sluggish.
Rhythm: Unusual The SA client initiates and instinct, nevertheless the impulse
is usually blocked before departing the node alone. This results inside an
absent PQRST complex. The temporarily stop is the similar as the space in
between two P-P periods of the root rhythm. Uniform in addition to upright in
physical appearance
P waves: A single P wave precedes each QRS intricate that may be present
PRI:. 12-. 20 securities and exchange commission's
QRS: <. 12
May end up being due to: Myocardial Infarction, drug result, Coronary Artery
Condition, etc. Treatment may possibly include Atropine or even a pacemaker
if systematic.
Premature Atrial Complexes (PACs)
Rate: Usually normal, but depends upon underlying rhythm

Rhythm: Irregular due to PACs. Irregular since the impulse occurs early.
Premature beats are recognized by their site of origin (atrial, junctional, and
ventricular). PAC occurs when an irritable site within the atria discharges
before the next SA node is due to discharge.
PAC's with a wide complex are called aberrantly conducted PAC's.
May occur in pairs (couplet), burst (Premature Atrial Tachycardia) PAT,
every other beat (bigeminy).
P waves: L wave of typically the early beat is different from sinus L waves
and is also untimely. P waves may possibly be flattened or perhaps notched.
May end up being lost in typically the preceding T trend.
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PRI: Differs from. 12. 20 if the pacemaker site is close to the SA node, to be
able to. 12sec any time the pacemaker internet site is nearer typically the AV
node.
QRS: Usually <. 10 but can be prolonged
May end up being as a result of normal reply to sleep or perhaps in well
trained athlete; Abnormal droplets in rate brought on by diminished blood
vessels blow to S-A node, vagal excitement, hypothyroidism, increased
intracranial pressure, or pharmacologic agents such since digoxin,
propranolol, quinidine, or procainamide. May possibly be connected with
indications of impaired COMPANY; symptoms: dizziness, syncope, chest
pain.
Supraventricular Tachycardia (SVT, PSVT, PAT, Atrial Tachycardia)
Rate: 150-250/min
Beat: Typical
P surf: Atrial P surf vary from sinus L waves originating inside the SA client.
P waves are often identifiable if you have a new low rate in addition to
seldom identifiable from rates > 200.
PRI: Not often considerable as typically the P influx is usually difficult in buy
to distinguish through the particular preceding Capital t influx; if
considerable, will be. 12. 20.
QRS: <. ten securities and exchange commission's
When a celebration is documented, typically a PAC of which will continues
directly into SVT, it is usually called PAT.
May possibly become the result of stress, caffeine, nicotine, or perhaps even
heart condition. Therapy contains air, vagal maneuvers, or perhaps probably
adenosine. Volatile individuals may obtain the counter jolt in order to be able
to permit the SOCIAL CONCERN node to revive.
Wandering Pacemaker
Rate: Might be fast or sluggish depending after the main cause
Rhythm: Irregular because the stimulus originates in several sites
P dunes: May look various in the exact same guide
QRS: QRS duration is usually normal (0. ten seconds or less)
May be because of COPD, Heart Illness or Digitalis toxicity. Wandering atrial
pacemaker is really a benign tempo change where the particular pacemaker
site changes from the nose node into the particular atrial tissues. P-wave
morphology varies along with the pacemaker web site.
Atrial Flutter -12 lead ECG
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Atrial flutter with two: 1 AV prevent is one associated with the most regularly
missed ECG (EKG) rhythm diagnoses as the flutter waves are usually often
difficult to find. Within this example 2 flutter waves for every single QRS are
greatest observed in lead 3 and V1. The particular ventricular rate in 150 bpm
ought to always prompt all of us to consider atrial flutter with two: 1
conduction like a diagnostic consideration.
sPrice: Atrial rate 250-350/ min
Rhythm: Atrial rhythm regular, Ventricular rhythm usually normal, but may
become irregular. If the particular AV node prevents the same quantity of
impulses, and just allows a specific quantity of impulses in order to be
conducted towards the ventricles, the ventricular rate will become regular
(such because 3: 1 or even 4: 1).
G waves: Saw-toothed, "flutter waves are hidden within the QRS
complicated
PRI: Not considerable
QRS: Usually <. 10 yet might be widened in case flutter waves are usually
buried in the particular QRS complicated.
Might be due in order to: ischemia, MI valvar disease, hypoxia, or even drug
effects. In case ventricular reaction will be less than one hundred, and the
individual is asymptomatic, the particular condition is handled medically.
When the ventricular reaction much more compared to 100, as well as the
individual shows associated with coronary heart failure, treatment might
consist of counter shock.
Atrial Fibrillation
Picture of Atrial Fibrillation Rate: Atrial level usually > 400, Ventricular
level variable
Rhythm: Atrial and ventricular very erratic (regular, bradycardic ventricular
rhythm may take place therefore of rotter finger hut toxicity)
P surf: No identifiable L waves, Erratic, curly baseline
PRI: None of them
QRS: Usually <. 10
Fast impulses originating inside multiple sites inside the atria result in the
atrium alone to "quiver". This specific is ineffective inside allowing for an
efficient atrial kick. Typically, the AV node shields the sufferer from
possessing too much a ventricular response, and obstructs almost all of the
impulses.
Blood vessels may pool or perhaps stagnate in typically the atria plus the
affected person is at exposure to possible clot formation.
Can be due to: ischemia, Myocardial Infarction hypoxia, or drug remedy.
Treatment may be made up of beta-blockers (Inderal), calcium blockers
(verapamil), or synchronized cardioversion in an effort to restore typically the
patient to a new sinus rhythm.
Junctional Tempos
Impulses coming from the Junction (AV node). The inherent rate of the
junction is 40-60/min. Characteristics:
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Rate: Junctional bradycardia - < 40
Junctional rhythm norm 40 - 60/ min
Accelerated junctional rhythm 61-10
Junctional tachycardia - > 100
Rhythm: regular
P waves: inverted before or after the QRS, or absent
PRI: not measurable if no P wave or if P wave occurs after QRS
QRS: normal
Wolff-Parkinson-White Syndrome (WPW)
The particular short PR period is due in order to a bypass monitor, also
known because the Kent pathway. By bypassing the particular AV node
typically, the PR shortens. Typically, the delta wave symbolizes early
activation regarding the ventricles coming from the bypass system. The fusion
QRS is the effect of two account activation sequences, one coming from the
bypass system and one coming from the AV client. The ST-T adjustments are
secondary to be able to changes in the particular ventricular activation series.
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Short PR time periods and delta dunes best seen within leads V1-5. Pseudo-Q
waves, observed in prospects II, III, plus aVF, are in fact unfavorable delta
waves. Presently there is no substandard MI on this particular ECG.
Wolff-Parkinson-White Symptoms (WPW) should be observed in more
compared to one lead.
Usually the classical ECG characteristics of the issue formerly described
undoubtedly are a short P-R period of time and a considerable QRS.
Rate: Usually 60-100 beats/min nonetheless could be either a lot more quickly
or slower PW may possibly become consequently of inborn pathways that
allow rapid conduction concerning impulses. May predispose the individual
to become able to atrial tachycardia because presently there is no obstructing
of urges in the UTAV node.
PRI: When this period is generally short, it really is as the nose impulse
somewhat prevents its typical postpone inside UTAV client by journeying
swiftly through the entire equipment path.
QRS: Usually better than zero. 12 seconds since there is zero delay in
generally the AV client. Succeeding activation regarding typically the
ventricles depends after intra-atrial conduction moment coming from sinus
client to be able to the equipment path plus louage moment down most of the
equipment pathway, as opposed together with the louage moment from
sinusitis client to ventricles by way of orthodox louage path ways.
Delta Trend: Slurring occurs from typically the beginning in connection with
QRS intricate.
Secondary Capital t trend changes: Since ventricular depolarization is usually
unusual, repolarization can even be unusual, creating STREET in addition to
be able to T wave changes secondary to typically the degree and location of
pre-excitation.
Unusual Q waves: Q waves are regarded abnormal when they will have an
exuberance 25% of typically the succeeding R trend and /or a new lifelong 0.
apr second or better. Such Q surf tend to be seen inside the occurrence
regarding an accessory UTAV pathway and may possibly be misdiagnosed
since Myocardial infarction. They will are actually bad delta waves, showing
pre-excitation rather than myocardial necrosis.
VENTRICULAR RHYTHMS
Ventricular urges come from typically the ventricles.
Inherent level of ventricles is usually: 15 -40
Idioventricular Rhythm (IVR) or perhaps Ventricular Escape Beat
Rate: Intrinsic level is 20-40 surpasses per minute
Beat: Atrial not visible, ventricular essentially typical
P waves: missing
PRI: None
QRS: >. 12
Can be due to: UNA, metabolic imbalances, or perhaps extreme hypoxia.
Remedy includes activation regarding code/890, CPR offered if patient is
usually pulseless. Lidocaine is usually contraindicated since that may put out
of action typically the last available pacemaker.
Accelerated Idioventricular Beat (AIVR)
Rate: Atrial not discernable, ventricular 40-100 beats/minute
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Beat: Ventricular rate typical, atrial rate not necessarily discernable
P surf: Absent
PRI: None of them
QRS: >. 12
May end up being as a result of: Heart condition (e. g., serious myocardial
infarction, rotter finger hut toxicity, at reperfusion of an earlier occluded
coronary artery), may occur in the course of Resuscitation, Drugs (e. g.,
digoxin), dilated cardiomyopathy, and in the course of Outpatient procedures
(due to spinal anesthesia).
coupled pvc
bigeminal pvc
trigeminal pvc
multifocal pvc
Early Ventricular Complexes (PVCs)

Rate: Atrial plus ventricular rate reliant after the fundamental tempo
Rhythm: Abnormal because of PVC. In case PVC is sandwiched between two
regular beats it will be called interpolated plus the rhythm is going to be
regular
P Dunes: A P influx is not connected with the PVC
PRI: None using the PVC as the ectopic originates in the particular ventricles
QRS: twelve Wide and strange. T wave regularly in opposite path from the
QRS complicated. When the QRS will be negative, the two wave is normally
straight; when the QRS will be positive, the two wave is normally inverted.
Might be due in order to: stress, activity, valvar disease, CAD, or even MI.
PVC might produce a heartbeat and the individual ought to be treated, not
necessarily the monitor.
Ventricular Tachycardia
The main feature of this wide QRS tachycardia that indicates its ventricular
origin is the concordance of QRS's in the precordial leads (all QRS's are in
the same direction).
VENTRICULAR TACHYCARDIA (VT) MONOMORPHIC
Rate: Ventricular rate 100-250 beats/minute, atrial not discernible
Rhythm: Atrial not discernible, ventricular essentially regular
P waves: May or might not be present, if present they have not set relationship
to the QRS complexes. P waves may appear between the QRS at a rate
different from that of the VT.
PRI: None
QRS: >. 12 Often times difficult to differentiate between QRS and T wave.
Three or more PVCs in a row at rate of 100 per minute are referred to as a
"run" of VT. There may be a long or a short run. Patient may or might not have
a pulse. If it is unclear as to where a regular, wide QRS tachycardia is VT or
Supraventricular Tachycardia treat the rhythm as VT until confirmed
otherwise.
Note: Ventricular tachycardia can occur in the absence of apparent heart
disease.
May be due to: an early or a late complication of a heart attack, or during the
course of cardiomyopathy, alveolar heart disease, myocarditis, and following
heart surgery.
Lead II
Ventricular Fibrillation (VF)
Price: rapid and messy
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Rhythm: irregular plus chaotic
P Influx: absent but could be recognizable
PRI: not really measurable
QRS: fibrillatory waves; wide abnormal oscillations of the particular
baseline.
ventricular fibrillation
Atrial Ventricular Blocks (AV Blocks)
First Degree:
PRI longer than. twenty securities and exchange commission's
There will be No Block whatsoever only a delay in conduction.
Every P wave is married to a QRS; no missed beats.
1st degree av block
2nd Degree:
Type We (Mobitz I or even Wenckebach)
The a few rules of "classic AV Wenckebach" are usually: One decreasing RR
intervals until stop; Two the stop is no more than preceding two RR intervals;
Three. the RR interval after the particular pause is higher than the RR interval
just before pause. There will be a gradual plus progressive embrace the
particular PR interval (PRI) with successive defeat, until finally the particular
QRS is decreased. Unfortunately, there are numerous good examples of
atypical forms of Wenckebach where these rules do not hold.
second degree av block
Type II (Mobitz II)

PRI is fixed (no progressive increase in PRI)
QRS is dropped without warning; there will always be more P Waves than
QRS
The P waves are married to the QRS
The level of conduction problem is usually lower than the AV node, often
involving the Bundle of His
The QRS morphology in lead V1 shows LBBB. The arrows point to two
consecutive nonconducted P waves, most likely hung up in the diseased right
bundle branch. This is classic Mobitz II 2nd degree AV block.
Mobitz II 2nd level AV block is normally a sign associated with bilateral

bundle department disease. One associated with the two package branches
should become completely blocked; within this example the particular left
bundle will be blocked. The nonconducted sinus P dunes are most probably
blocked in the particular right bundle which usually exhibits 2nd level block.
Third Level (Complete Heart Block)
There is total heart block to ensure that none of the particular impulses
previously mentioned are usually conducted towards the ventricles.
The atria plus the ventricles are usually handled independently simply by
separate pacemakers.
G Waves are NOT REALLY married to the particular QRS.
The amount of the particular complete block will be High, when the particular
AV node requires power over the ventricles. The QRS might therefore be
filtration system as well as the junctional degree will likely be between 40-
60.
When the level about the block is normally Lower, a ventricular pacemaker
will handle the particular ventricles. Typically, the particular QRS will
because of this be wide within addition to the particular rate is normally
reduced.
third degree complete av block
Asystole is synonymous with Ventricular Standstill and death. This is usually
associated with prolonged circulatory insufficiency and cardiogenic shock.
This could also be drug related and at times reversible.
ventricular asystole
PACEMAKERS
The following are indications for a Pacemaker:
Symptomatic Sinus Bradycardia
2: 1 AVB
Junctional rhythms
Idioventricular rhythms
Dying heart
Asystole
Overdrive suppression of tachycardias
Second degree AVB Type II
Third degree AVB
Pacemaker Terminology
Firing refers to the pacemaker's generation of electrical stimuli. This is seen
as a pacemaker spike on the ECG.
Capture refers to the presence of a P or QRS or both after a pacemaker spike.
This indicates that the cells within the chamber becoming paced has already
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been depolarized. The word will be that the pacemaker has "captured" the
particular chamber being spaced. Paced QRS are usually wide, bizarre and
resemble PVCs.
Sensing refers to the pacemaker's ability to recognize the patient's own
intrinsic rhythm in order to determine if it needs to fire. Most pacemakers
function in the demand mode and fire when needed.
Pacemaker Malfunctions
Failure to Fire: When a pacemaker fails to send an impulse when it should it
is said to malfunction. Usually this means a dead battery or that the connecting
wires are at fault. At time artifact can fool the pacemaker and it will not fire.
This is displayed as no comer spike where presently there must be one.
Reduction of Capture: Whenever loss of catch exists there will be no P or
even QRS following the comer has fired; simply a spike. The comer needs to
become adjusted to permit detection from the heart's need to become paced. It
will be possible the pacing wire has dropped contact with the particular
chamber wall which usually can occur whenever the heart is simply too
damaged to react.
Under-sensing: This happens when the pacemaker fires too quickly after an
inbuilt beat and presently there are pacer surges where there ought to not be.
Place appear in the particular T wave, upon the QRS or even anywhere
around the coronary heart rhythm's tracing. This requires adjustment with the
wires or battery replacement.
ASSESSING PACEMAKER FUNCTION
Classification:
Pacemaker function is usually identified by 3 letters which indicate the
cardiac chambers paced, sensed, and the mode of pacing.
First letter (A, V or D) refers to the chamber(s) paced (Atria, Ventricles, Dual
both atria and ventricles).
Second letter (A, V or D) refers to the chamber(s) sensed (Atria, Ventricles,
Dual both the atria and ventricles).
Third letter mode of pacing (Inhibited or Triggered or Demand).
Examples: DDD, VVI, VVD
Pacemaker function is judged by its ability to Sense the patient's underlying
rhythm and Pace or Capture the ventricles when needed. Capture is confirmed
when a QRS complex follows a Pacemaker Spike. (A Spike is a vertical line
on the ECG which indicates the pacemaker has fired. A QRS after a spike
means there is ventricular capture).
Three questions to ask when analyzing an ECG strip with pacemaker spikes
are:
Is the chamber being paced capturing?
Is the pacemaker sensing the patient's inherent rhythm?
Is there a pulse with each the pacer rhythm?
pacemakers
Blueprints of C Tempos
electronic pacemaker spikes
atrial pacemaker
Ventricular Pacing Inside Atrial Fibrillation
ventricular pacemaker
failure to output
Pacemaker Failure
EXAMINATION TEST
1. The particular inherent rate from the junction is
A. 15-40
B .40-60
C. 60-10
D. more than 100
2. The standard rate of the particular heart when the particular electrical
impulse arrives from the SOCIAL FEAR Node is
A. More than 100
B. 61-99
C. Lower than 60
D. Lower than 5
3. The chief pacemaker of the heart is the
A. SA Node
B. AV Node
C. Bundle of His
D. Purkinji Fibers
4. The R wave is the first positive deflection after the P wave.
A. True
B. False
5. The ability of the heart to initiate an impulse is called
A. automaticity
B. conductivity
C. excitability
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D. contractility
6. The normal PR interval is
A. . 04 to. 10 sec
B. . 12 to. 20 sec
C. . 20 to. 38 sec
D. None of the above
7. The P wave represents
A. atrial repolarization
B. atrial depolarization
C. ventricular repolarization
D. ventricular depolarization
8. The normal QRS complex is
A. . 04 to. 10 sec
B. . 20 to. 24 sec
C. . 12 to. 20 sec
D. . 20 t0. 38 sec
9. The wave on an EKG which represents ventricular repolarization is called
the
1. P wave
2. Q wave
3. R wave
4. T wave
10. The wave components of the EKG represent contraction of the heart
muscle
A. True
B. False
11. Identify the following rhythms
1. Sinus Bradycardia
2. 1st degree Heart Block
3. Normal Sinus Rhythm
4. Junctional Rhythm
12.
2. 1st degree AV block
4. Junctional Rhyth
13.
1. Sinus arrhythmia
3. Sinus Tachycardia
4. 2nd degree AV block
14.
2. Junctional rhythm
3. Wandering atrial pacemaker
4. 1st Degree AUDIO-VIDEO Block
15.
1. Junctional Tachycardia
3. Atrial flutter
4. Atrial fibrillation
16.
1. Ventricular Bigeminy
2. Multifocal PVCS
3. PACs
4. 2nd level AV Block
17.
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1. Atrial Fibrillation
2. Atrial flutter
4. Accelerated Junctional
18.
2. Atrial flutter
4. More rapid Junctional
19.
1. Ventricular Tachycardia
2. Atrial flutter
4. Ventricular Fibrillation
20.
2. Ventricular Tachycardia
3. Ventricular Fibrillation
21.
2. Asystole noted in all leads
3. Fine V Fib
4. Junctional bradycardia
22.
2. 2nd degree AV block
23.

2. 2nd degree AV block Mobitz II
3. 2nd degree AV block Mobitz I ( Wenkebach)
4. 3rd degree AV block
24.

25.

26.
Pacemaker function is generally recognized by 3 letters which indicate the
cardiac chambers paced, sensed, and the mode of pacing.
1. True
2. False
27. The indications for a Pacemaker are the following:

A. Symptomatic Sinus Bradycardia
B. Idioventricular rhythms
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C. 2nd AVB Type/ Mobitz II
D. 3rd Degree AV Block
All of the Above

28. This is what type of Pacemaker?
A. AV Sequential pacemaker (paces atria and ventricles)
B. Atrial pacemaker (paces only atria)
29. Three questions to ask when analyzing an ECG strip with pacemaker
spikes are:
A. Is the chamber being paced capturing?
B. Is the pacemaker sensing the patient’s natural rhythm?
Is right now there a pulse together with each the ramonear rhythm?
1. True
2. Bogus
30. The three problems a pacemaker could have are:

A. Disappointment to fireplace
B. Failure to be able to Capture
C. Under realizing
D. True
E. False
ASSESSMENT QUESTIONS (OPTIONAL)
1. Rate your accomplishment of this goal: Describe the regular cardiac
anatomy of human body plus normal electrical bail through the coronary heart.
1. Completely
2. Almost Totally
3. Somewhat
4. Not in All
2. Price your achievement associated with this objective: Determine and

relate waveforms to the heart cycle.
1. Completely
2. Nearly Totally
3. Somewhat
4. Not really at All
3. Rate your accomplishment of this goal: Identify normal plus abnormal parts
upon ECG.
A. Completely
B. Nearly Totally
C. Somewhat
D. Not really at All
4. Rate your accomplishment of this goal: Identify three pacemaker
malfunctions.
1. Completely
2. Nearly Totally
3. Somewhat
4. Not really at All
5. Rate your accomplishment of this goal: Understand the various guide

placements and objective of each positioning.
1. Completely
2. Almost Totally
3. Somewhat
4. Never
6. Rate your accomplishment of this goal: Utilize an organized process when

nearing the interpretation associated with the ECG.
1. Totally
2. Almost Totally
3. Fairly
4. Not at all
7. Rate your own achievement of this particular objective: Recognize nose,

atrial, junctional plus ventricular dysrhythmia upon ECG and associate cause,
significance, signs and symptoms and treatment.
A. Totally
B. Almost Totally
C. Relatively
D. Not at Just about all
8. The training course information was appropriate and usable
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A. Entirely
B. Almost Completely
C. Relatively
D. Certainly not
9. Typically the authors demonstrated knowledge and effectiveness.
A. Entirely
B. Almost Completely
C. Relatively
D. Certainly not
10. May you make training or performance since the result regarding this
system?
A. Yes
b. No
11. The articles was presented without conflict of curiosity or bias regarding
any commercial merchandise or drug.
A. Sure
B. No
METHOD OF ECG INTERPRETATION (HOW TO INTERPRET 12 LEAD
ECG)
When dealing with a 12-lead ECG, a few logistics should be understood. 1st,
the conventional 12-lead ECG is really a 10-second remove. Underneath one
or even two lines would have been a full “rhythm strip” of a particular lead,
spanning the particular whole 10 mere seconds of the ECG. Other leads will
certainly span only regarding second 5 mere seconds.
Each ECG will be divided by big boxes and little boxes to assist measure
times plus distances. Each big box represents 0. 20 seconds, plus there are 5
small boxes within each large package, thus each little box is comparative to
0. '04 seconds. The picture below depicts every of these.
If the complete ECG is 10 mere seconds, then there should be 50 big boxes (0.
twenty seconds times fifty large boxes). Every small box will be also
specifically one mm in size; therefore, one big box is five mm.
In common, when measuring amplitudes of waves or even complexes, the
models are expressed within mm, so when calculating lengths for time
periods, the units are usually expressed in mere seconds or milliseconds (ms).
If each little box is the same to 0. '04 seconds or one mm, then the particular
standard ECG velocity is 1 millimeter per 0. '04 seconds, or twenty-five mm
per second.
The conventional approach in order to reading an ECG includes, with this
purchase:
1. Examining the pace

2. Analyzing the tempo
3. Analyzing the axis, time periods and sections
4. Analyzing everything else
TP SEGMENT
The TP segment is usually the proportion of the particular ECG with the finish
about the T pattern to the start of P wave. This unique segment should
continuously be at foundation and it is employed given that a reference in
order to be able in order to evaluate if the particular STREET segment will
be increased or stressed out, because there are usually virtually no specific
illness issues that elevate or even depress the particular TP segment.
Throughout says of tachycardia, the particular TP segment will become
shortened and could be difficult in purchase to visualize completely. This is
great to look at the TP section closely for the particular existence of Ought to
wave or atrial activity that can indicate pathology.
ECG REVIEWS AND REQUIREMENTS
Atrial Arrhythmias
Atrial Fibrillation ECG Evaluation
Atrial Flutter ECG Review
Atrioventricular Crucial Reentrant Tachycardia (AVNRT) ECG Evaluation
Atrioventricular Reentrant Tachycardia (AVRT) ECG Evaluation
Ectopic Atrial Rhythms ECG Review
Multifocal Atrial Tachycardia (MAT) ECG Review
Premature Atrial Contractions (PACs) ECG Review
Sinoatrial (SA) Exit Block ECG Review
Sinus Arrhythmia ECG Evaluation
Nose Bradycardia ECG Evaluation
Sinus Tachycardia ECG Review
Wandering Atrial Pacemaker (WAP) ECG Review
CHAMBER ENLARGEMENTS
Left Atrial Enhancement (LAE) ECG Evaluation
Left Axis Change (LAD) ECG Evaluation
Left Ventricular Hypertrophy (LVH) ECG Evaluation
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Poor R Influx Progression ECG Evaluation
Right Atrial Enhancement (RAE) ECG Evaluation
Right Axis Change (RAD) ECG Evaluation
Right Ventricular Hypertrophy (RVH) ECG Evaluation
CONDUCTION MALOCCLUSIONS
Atrioventricular (AV) Block ECG Evaluation
Bifascicular Block ECG Review
First-Degree Atrioventricular (AV) Block ECG Review
Left Informer Fascicular Block (LAFB) ECG Evaluation
Remaining Bundle Branch Prevent (LBBB) ECG Evaluation
Left Posterior Fascicular Block (LPFB) ECG Review
Right Package Branch Block (RBBB) ECG Evaluation
Second-Degree Atrioventricular (AV) Prevent Type I (Wenkebach) ECG
Evaluation
Second-Degree Atrioventricular (AV) Prevent Type II ECG Review
Third-Degree Atrioventricular (AV) Block ECG Review
Trifascicular Prevent ECG Evaluation
ISCHEMIC HEART DISEASE
Informe Wall ST Section Elevation Myocardial Infarction (MI) ECG
Evaluation
Inferior Wall SAINT Segment Elevation Myocardial Infarction (MI) ECG
Review
Posterior Walls Myocardial Infarction (MI) ECG Review
MISCELLANEOUS
Arrhythmogenic Right Ventricular Dysplasia (ARVD) ECG Review
Atrial Septal Defect (ASD) ECG Review
Brugada Symptoms ECG Review
Dextrocardia ECG Review
Digoxin Effect ECG Evaluation
Early Repolarization ECG Review
Hypercalcemia ECG Review
Hyperkalemia ECG Review
Hypertrophic Obstructive Cardiomyopathy (HOCM) ECG Review
Hypocalcemia ECG Review
Hypokalemia ECG Review
Hypothermia ECG Review
Limb Guide Reversal ECG Evaluation
Low Voltage ECG Review
Lown-Ganong-Levine Symptoms ECG Review
Remaining Ventricular (LV) Aneurysm ECG Review
Neurologic Insult ECG Evaluation
Pericarditis ECG Evaluation
Prolonged QT Period ECG Review
Pulmonary Embolism ECG Evaluation
Takotsubo Cardiomyopathy ECG Review
Wellens’ Symptoms ECG Review
Wolff-Parkinson-White (WPW) ECG Evaluation
VENTRICULAR ARRHYTHMIAS
Asystole ECG Review
Idioventricular Rhythms ECG Evaluation
Junctional Rhythms ECG Review
Premature Ventricular Contractions (PVCs) ECG Review
Ventricular Fibrillation ECG Review
VENTRICULAR TACHYCARDIA (VT) ECG REVIEW
Atrial Fibrillation ECG Review
Atrial fibrillation happens when action possibilities fire very quickly within
the pulmonary veins or innenhof inside a chaotic way. In this way a really fast
atrial price — about four hundred to 600 is better than per minute. Since the
atrial rate is really fast, and the particular action potentials created are of this
kind of low amplitude, G waves will not really be seen around the ECG in
individuals with atrial fibrillation.
At times, the particular P wave exercise might be observed because “coarse
fibrillatory dunes,” and the particular term “coarse atrial fibrillation” is
utilized, although there is simply no clinical significance in order to this
finding.
The particular atrial action possibilities all try to carry out through the
atrioventricular node; however, the particular AV node gets intermittently
refractory and can only allow a specific number of atrial action potentials in
order to reach the ventricles. This is the particular reason the ventricular rate
is just not furthermore 400 to six hundred bpm, but instead close to 100 to two
hundred bpm. The amount in order to which action possibilities can cross the
particular AV node towards the ventricles is adjustable and reduced simply by
AV blocking medicines.
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Because the AUDIO-VIDEO node is periodically (not regularly) refractory,
the QRS things that are made when a good atrial action possible does reach
the particular ventricles will happen in an “irregularly irregular” manner,
because there is simply no pattern for their rate of recurrence. This is
generally described as different RR intervals.
The particular only two some other rhythms which are irregularly irregular
are atrial flutter with adjustable conduction and multifocal atrial tachycardia,
or even MAT. Atrial flutter has the common “sawtooth pattern” whereas
multifocal atrial tachycardia requires 3 distinct P influx morphologies in 1 12-
lead ECG doing a trace for. Remember that there are usually pretty several
arrhythmias that are frequently irregular, such because second-degree AV
prevent type I (Wenkebach).
This implies an ECG displaying atrial fibrillation may have no obvious G

waves and a good irregularly irregular QRS complex. The ventricular rate is
regularly fast, unless the particular patient is upon AV nodal obstructing drugs
like beta-blockers or non-dihydropyridine calcium mineral channel blockers.
Fibrillatory waves may or even may well not be recognized.
ECG Examples:
Atrial Fibrillation with Bradycardia ECG (Example 1)
Atrial Fibrillation along with Bradycardia ECG (Example 2)
Atrial Fibrillation with Bradycardia ECG (Example 3)
Atrial Fibrillation with Regular Ventricular Rate ECG (Example 1)
Atrial Fibrillation with Quick Ventricular Rate ECG (Example 1)
Left Atrial Enlargement (LAE) ECG Review
Anytime left atrial improvement occurs, it needs longer for coronary heart
action potentials within order to journey with the atrial myocardium; thus, the
particular P influx furthermore lengthens. Consequently, the particular needs
for figuring away LAE on the 12-lead ECG will be as follows:
The size of the P influx in lead 2 is greater compared to 120 milliseconds
OR
The downward deviation from the P influx in lead V1 is greater compared to
40 milliseconds within length, with more than 1 millimeter unfavorable
deflection ( < -1 millimeter in amplitude).
P-mitrale occurs when the particular depolarization from the correct atrium
and remaining atrium are noticeable in the G wave. This will be seen as a
notch within the P influx and takes place when the remaining atrium is
substantially enlarged, like within mitral valve stenosis.
Note that remaining atrial enlargement struggles to be diagnosed within the
existence of atrial fibrillation because this particular rhythm is described by
erratic atrial activity and simply no noticeable P influx on the ECG. Also,
LAE is really a considerable risk element for developing atrial fibrillation.
ECG Good examples:

Left Atrial Enhancement (LAE) ECG (Example 1)
Left Atrial Enlargement (LAE) ECG (Example 2)
Remaining Atrial Enlargement (LAE) with P-Mitrale ECG
RIGHT Atrial Enlargement (RAE) ECG Review
Any time right atrial augmentation occurs, it really does not much more
regarding cardiac action possibilities to travel from the atrial myocardium
(similar to left atrial enlargement). However, typically the amplitude of
typically the P wave is usually exaggerated due to be able to the close
distance of the hypertrophied right atrial myocardium for the SA client. This
is certainly referred to be able to as p-pulmonale considering that lung
disease could cause extreme right center strain and proper atrial enlargement.
Hence, the P trend height becomes greater. The ECG conditions for
diagnosing proper atrial enlargement (RAE) are as employs:
The P trend amplitude in business lead II > 2.not 5 logistik, or perhaps
The up deflection of typically the P wave inside lead V1 > 1) a few mm in
exuberance.
ECG Examples:
Proper Atrial Enlargement (ECG Example 1)
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POOR R Wave Development (PRWP) ECG Evaluation
Poor R influx progression refers in order to the lack of the particular normal
increase within scale the L wave in the particular precordial leads whenever
advancing from guide V1 to V6.
In lead V1, the R wave should be small. The R wave becomes larger
throughout the precordial leads, to the point where the R wave is larger than
the S wave in lead V4. The S wave then becomes quite small in lead V6.
Note that an old anterior myocardial infarction can cause poor R wave
progression. In this setting, there is no R wave in the anterior precordial leads
and instead Q waves are present; see Anterior Myocardial Infarction Topic
Review.
The causes of PRWP are as follows:
1. Old anterior myocardial infarction
2. Lead misplacement (frequently in obese women)
3. Left bundle branch block or left anterior fascicular block
4. Left ventricular hypertrophy
5. Wolff-Parkinson-White syndrome
6. Dextrocardia
7. Tension pneumothorax with mediastinal shift
8. Congenital heart disease
RIGHT Ventricular Hypertrophy (RVH) ECG Review
Right ventricular hypertrophy takes place when the right ventricular wall
structure thickens due to be able to chronic pressure excess, just like that
regarding left ventricular hypertrophy.
RVH is clinically diagnosed on ECG inside the occurrence of any R/S ratio of
more than 1 in business lead V1 in typically a shortage of other will cause, or
if typically, the R wave inside lead V1 is usually greater than several
millimeters tall. The load pattern occurs any time the right ventricular wall is
pretty thicker, and the strain is high, at the same time. Strain causes STREET
segment depression in addition to asymmetric T trend inversions in qualified
prospects V1 to V3.
Other causes associated with an R/S percentage of greater than 1 within lead
V1:
Trasero wall myocardial infarction (also causes SAINT segment depression
within V1-V3, but to waves are symmetrically inverted, and the particular
patient will be showing with chest pains)
Right bundle department block
Wolff-Parkinson-White Kind A
Lead misplacement (if V1 will be positioned too high)
Isolated posterior walls hypertrophy (occurs within Duchenne’s muscular
dystrophy)
ECG Examples:
Correct Ventricular Hypertrophy (RVH) ECG
Right Ventricular Hypertrophy (RVH) along with Strain Pattern ECG
LEFT VENTRICULAR HYPERTROPHY (LVH) ECG REVIEW
Still left ventricular hypertrophy may be diagnosed on ECG with good
specificity. When the myocardium is hypertrophied, right now there is a
greater mass of myocardium for electrical service to pass via; thus the
extravagance of the QRS complex, representing ventricular depolarization, is
improved.
Likewise, when the particular myocardium is unusually thickened, and
electric activity takes lengthier to traverse all through the whole coronary
heart, the duration of the particular QRS complex might be widened. This
really is referred to because “LVH with QRS widening” Furthermore,
repolarization might be influenced via similar systems that can lead to
abnormal ST sections or T dunes. This is known to as “LVH with strain” or
even “LVH with repolarization abnormality.”
Sometimes, these repolarization abnormalities can mimic ischemic ST
changes, plus distinguishing them through those during the myocardial
infarction will be important, though frequently difficult. The normal design
with LVH consists of deviation from the SAINT segment within the reverse
direction from the QRS complex (discordance), plus a typical to wave
inversion design is present, because observed in the picture here:
LEFT Ventricular Hypertrophy ECG Criteria

Through numerous studies, multiple requirements have been created to
diagnose LVH with an ECG; these people are the following.
Cornell criteria: Add the particular R wave within aVL as well as the H wave
in V3. If the amount is greater compared to 28 millimeters within males or
higher than 20 millimeters in females, LVH is present.
Altered Cornell Criteria: Analyze the R influx in aVL. When the R wave will
be greater than twelve mm in extravagance, LVH is existing.
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Sokolow-Lyon Criteria: Include the S influx in V1 in addition the R influx in
V5 or even V6. If the particular sum is higher than 35 millimeters, LVH is
present.
Romhilt-Estes LVH Point Rating System: When the rating equals 4, LVH is
present along with 30% to 54% sensitivity. If the particular score is greater
compared to 5, LVH will be present with 83% to 97% specificity.
Amplitude of major R or T in limb qualified prospects ≥ 20 logistik = 3
details
Amplitude of T in V1 or perhaps V2 ≥ 35 mm = three or more points
Amplitude regarding R in V5 or V6 ≥ 30 mm sama dengan 3 points
STREET and T trend changes opposite QRS without digoxin sama dengan 3
points
STREET and T trend changes opposite QRS with digoxin sama dengan 1
point
Still left Atrial Enlargement sama dengan 3 points
Still left Axis Deviation sama dengan 2 points
QRS duration ≥ ninety days ms = just one point
Intrinsicoid deviation in V5 or perhaps V6 > 50 ms sama dengan 1 point
ECG Examples:
Left Ventricular Hypertrophy (LVH) ECG (Example 1)
Still left Ventricular Hypertrophy (LVH) ECG (Example 2)
Still left Ventricular Hypertrophy (LVH) with Strain Routine ECG (Example
1)
Left Ventricular Hypertrophy (LVH) with Tension Pattern ECG (Example 2)
RIGHT AXIS DEVIATION OVERVIEW
Right axis change occurs when typically, the QRS axis is usually shifted
between ninety days and 180 certifications. A number regarding things can
cause right axis change such as lung condition, right sided center strain, right
pack branch block, in addition to right ventricular hypertrophy.
TRIFASCICULAR BLOCK ECG EVALUATION
A trifascicular prevent is the blend of the right package branch block,
remaining anterior or trasero fascicular block plus a first-degree AUDIO-
VIDEO block (prolonged PAGE RANK interval). The word “trifascicular
block” is really a misnomer, since the AUDIO-VIDEO node itself is just not a
fascicle. The trifascicular block is really a precursor to total heart block.
Whilst a trifascicular prevent itself does not really require any treatment, high
doses of AV blocking agents likely should be avoided. Some series report a
50% lifetime need for a permanent pacemaker in the setting of a trifascicular
block.
ECG Examples:
Trifascicular Block (ECG Example 1)
SECOND-DEGREE ATRIOVENTRICULAR (AV) OBSTRUCT TYPE I
(WENKEBACH) ECG REVIEW
Inside second-degree atrioventricular critique block — also referred to as
Wenckebach block or perhaps Mobitz Type I actually AV block — varying
failure regarding conduction through typically the AV node takes place, so that
some L waves might not exactly end up being then a QRS complex. Unlike
close AV nodal obstruct, the 1: 1 P-wave-to-QRS-complex ratio is not
necessarily maintained. Second-degree sort I AV obstruct is especially
characterised by an improving delay of AV nodal conduction until a P wave
fails to conduct through the AV node. This is seen as progressive PR interval
prolongation with each beat until a P wave is not conducted. There is an
irregular R-R interval. Sometimes when the block is consistent, the QRS
complexes are said to demonstrate "group beating. "
A second-degree type I AV block occurs when conduction within the AV node

itself is delayed in this progressive manner. It does not necessarily indicate
intrinsic conduction disease, and rarely requires a pacemaker to be implanted.
A second-degree type I AV block can be caused by AV blocking medications
or increased vagal tone. AV nodal ischemia during an inferior MI can cause
AV nodal blocks, as well.
Note that if every second P wave is not conducted, there will not be enough
time to see PR prolongation. This is called 2: 1 AV block, as depicted below:
When 2: 1 AV block is present, the rhythm may be second-degree type I or

second-degree type 2 AV block. Working out the individual will boost AV
nodal bail and help differentiate these two. In case second-degree type We AV
block will be present, then your coronary heart rate will boost as well as the
progressive extension of PR time periods just before a non-conducted P wave
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will certainly be apparent. In case second-degree type 2 AV block will be
present, there might be no modify with exercise.
ECG Examples:
Second Level AV Block Kind I - Wenkebach (Example 1)
2nd Degree AV Prevent Type I -- Wenkebach (Example 2)
THIRD-DEGREE ATRIOVENTRICULAR (AV) BLOCK ECG REVIEW
Third-degree atrioventricular nodal block, also known as third-degree heart
block or complete heart block, occurs when no action potentials conduct
through the AV node. This results in the P waves (atrial depolarizations) being
completely unrelated to the QRS complexes (ventricular depolarizations) ―
meaning the P waves occur at one rate and the QRS complexes at another.
This is termed “AV dissociation”
In this situation, the ventricles never see action potentials originating from the
atria and compensate by making action potentials of their own. However, the
ventricles are unable to create action potentials at a fast rate. This means the
ventricular rate (QRS complexes) is slow (around 30 to 40 bpm), and the
atrial level (P waves) is usually faster than typically the ventricular rate
(around 60 to a hundred bpm).
“High level AV nodal obstruct” a form of 3rd degree heart obstruct, occurs if
you have UTAV dissociation just like full heart block, nevertheless occasional
P surf do conduct by means of the AV client to produce a new QRS complex.
Full heart block is often symptomatic through the slower ventricular rates.
These kinds of symptoms include tiredness, dyspnea, dizziness in addition to
syncope. Because innate conduction disease in the His-Purkinje system is
usually the main cause of 3rd diploma AV block (ofcourse not autonomic tone
or perhaps AV blocking medications), the rhythm is often irreversible and a
new everlasting pacemaker is usually indicated.
ECG ILLUSTRATIONS:
Third-Degree Atrioventricular (AV) Block ECG (Example 1)
Third-Degree Atrioventricular (AV) Obstruct ECG (Example 3)
Third-Degree Atrioventricular (AV) Obstruct with Ventricular Pacing ECG
ATRIOVENTRICULAR (AV) BLOCK ECG OVERVIEW
Atrioventricular block is a new sort of second-degree UTAV nodal block in
addition to occurs when every single other P trend is not performed through
the UTAV node to acquire to the ventricles, and so every additional P wave is
usually not then a new QRS complex.
AV obstruct can possibly end up being from either second-degree AV nodal

obstruct type I (Wenkebach) or second-degree UTAV nodal block sort II. This
differentiation is crucial, since the former is often benign, whereas typically
the later requires société of an everlasting pacemaker.
A basic rule to bear in mind is that in the event the PR interval in the
conducted beat is usually prolonged and typically the QRS complex is usually
narrow, then that is most most likely second-degree AV critique block type I
actually (Wenkebach). Alternatively, when the PR interval is normal and the
QRS duration is prolonged, then it is most likely second-degree AV nodal
block type II, and a pacemaker is probably warranted.
Recall that second-degree AV nodal block type I (Wenkebach) is an issue in
the AV node itself, which is subject to sympathetic and parasympathetic tone,
whereas second-degree AV nodal block type II is an “infranodal” conduction
disease of the His-Purkinje system, meaning that altering AV nodal conduction
would have no effect.
Various maneuvers can be employed to distinguish between the two potential
rhythms when an ECG reveals 2: 1 AV nodal block:
Carotid sinus massage or adenosine: This slows the sinus rate, allowing the
AV node more time to recover, thus reducing the block from 2: 1 to 3: 2 and
unmasking any progressing prolonged PR intervals that would indicate
second-degree AV nodal block type I (Wenkebach).
Atropine administration: This enhances AV nodal conduction and could get rid
of second-degree AV nodal block type I (Wenkebach), as it is due to slowed
AV nodal conduction.
Exercise ECG testing: This enhances AV nodal conduction and could also get
rid of second-degree AV nodal block type I (Wenkebach), as it is due to
slowed AV nodal conduction.
ECG Examples:
2: 1 Atrioventricular (AV) Block ECG (Example 1)
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SECOND-DEGREE ATRIOVENTRICULAR (AV) BLOCK TYPE II ECG
REVIEW
In second-degree type II AUDIO-VIDEO nodal block (a. k. a. Mobitz Type II
AUDIO-VIDEO block), the AUDIO-VIDEO node becomes totally refractory
to bail on spotty basis. For instance, three consecutive G waves might be
adopted by a QRS complex, giving the particular ECG a regular appearance,
then the particular fourth P influx may suddenly not really be followed simply
by a QRS complicated because it does not really conduct with the AUDIO-
VIDEO node towards the ventricles.
The PR interval might be regular or prolonged, nevertheless it is regular in

length in contrast to second-degree AV prevent Mobitz Type We
(Wenckebach) in which usually the PR period progressively lengthens till a P
influx is not carried out. A second-degree kind II AV prevent indicates
significant bail disease in this particular His-Purkinje system plus is
irreversible (not subject to autonomic tone or AV blocking medications). This
is a very important distinguishing factor compared to second-degree type I AV
block. Because of this, a permament pacemaker is indicated in every patient
with second-degree type II AV block.
ECG Examples:
Second-Degree AV Block Type II (Example 1)
FIRST-DEGREE ATRIOVENTRICULAR (AV) PREVENT ECG REVIEW
The first-degree atrioventricular node block occurs any time conduction
through typically the AV node is usually slowed, thereby slowing down
enough time it will take for the activity potential to traveling through the
sinoatrial client from the AV client, and the ventricles.
A first-degree, or perhaps 1st degree, UTAV block is suggested within the
ECG by simply a prolonged PUBLIC RELATIONS interval, as noticed below.
1st_Degree_AV_Block
Recollect that the L wave indicates atrial depolarization, initiated by simply
firing of typically the SA node. Typically, the atrial depolarization at some
point spreads to typically the AV node, wherever there is a new slight delay
just before the electrical instinct is conducted for the ventricles. If typically,
the AV nodal louage (dromotropy) is lowered, it should take longer regarding
the impulse to be able to reach the ventricles, meaning there may be for more
distance in between the P trend and the QRS complex. Remember typically
the QRS complex signifies ventricular depolarization; hence the PR time
period will probably be prolonged.
Typically, the PR interval is usually normally between zero. 12 and zero. 20
seconds. A new PR interval constantly longer than zero. 20 seconds, or
perhaps greater than several small boxes, signifies a first diploma AV block.
Right now there is a 1/1 ratio between L waves and QRS complexes in close
AV block, as opposed to second-degree, or subsequent degree, and third-
degree, or 3rd diploma, AV nodal obstructs.
In general, a new first-degree AV obstruct is actually a benign getting that
would not demand any treatment. On the other hand, it can be a sign of higher-
degree UTAV block in the foreseeable future in addition to, according to the
PAGE RANK interval, AV obstructing medications might be prevented.
Note: A first-degree AV block will be also part associated with a trifascicular
prevent, since the AV node is oftentimes considered the particular third
fascicle.
ECG Examples:
First-Degree Atrioventricular (AV) Block ECG (Example 1)
First-Degree Atrioventricular (AV) Prevent ECG (Example 2)
First-Degree Atrioventricular (AV) Prevent ECG (Example 5)
Trifascicular Block ECG (Example 1)
Trifascicular Prevent ECG (Example 3)
BIFASCICULAR BLOCK ECG OVERVIEW
A bifascicular obstruct on ECG is usually defined by typically the combo of a
new right bundle part block and both a left preliminar fascicular block or
perhaps left posterior fascicular block. When these kinds of occur in blend,
significant conduction condition is often present, in addition to there is a new
risk for larger examples of atrioventricular obstruct in the foreseeable future
triggering systematic bradycardia and demanding pacemaker implantation.
Note: A bifascicular block is connected to a trifascicular block, which also

contains a first-degree UTAV block. Even even though technically incorrect,
typically the AV node inside this situation is usually considered the 3rd
fascicle.
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A bifascicular block can take place as a portion of the ischemic heart disease
or as a part of the normal degeneration of the conduction system (Lev's
disease). Although the 2009 American College of Cardiology/American Heart
Association scientific statement on ECG interpretation does not recommend
the utilization of the terms “bifascicular” or “trifascicular,” they are quite
commonly used.
ECG Examples:
Bifascicular Block - RBBB + LAFB (ECG Example 1)
Bifascicular Block - RBBB + LPFB
LEFT POSTERIOR FASCICULAR BLOCK (LPFB) ECG REVIEW
A left posterior fascicular block ― also known as a left posterior hemiblock,
LPHB ― occurs on the ECG when the posterior fascicle of the left bundle
branch is no longer able to conduct action potentials. This is much less
common than a left anterior fascicular block, or LAFB, as the posterior
fascicle is much more sparsely distributed; thus, a large amount of myocardial
tissue must be damaged to block the posterior fascicle.
The criteria to diagnose a LPFB on a 12-lead ECG include the following:
Right axis deviation of 90-180 degrees
Presence of a qR complex in lead III and a rS complex in lead I
Absence of right atrial enlargement, or RAE, and/or right ventricular
hypertrophy, and RVH
LPFB-criteria-small
Note: The above pattern can appear similar to the S1Q3T3 pattern sometimes
present in patients with a pulmonary embolus.
A LPFB can occur in the setting of a bifascicular block as well.
ECG Examples:
Left Posterior Fascicular Block (LPFB) ECG
Bifascicular Block - RBBB + LPFB ECG
LEFT ANTERIOR FASCICULAR PREVENT (LAFB) ECG EVALUATION
A left informed fascicular block, also called left anterior hemi block, occurs
when the anterior fascicle of the left package branch has ceased to be able to
conduct action potentials.
The problems to diagnose the LAFB, or LAHB, on ECG are usually the
following:
Remaining axis deviation associated with at least -45 levels
The presence of the qR complex in guide I along with a rS complicated in
guide 3
Usually the rS complex within guide II plus 3 (sometimes aVF as well)
An extremely fast way to identify a remaining informed fascicular prevent

upon ECG is in order to first identify the particular left axis change; see image
beneath. If the QRS complex is upward in guide We and down within lead
aVF whilst also down within lead 2, and then left axis change exists. After of
which look at guideline III. If right now there is an rS complex, then you
certainly have got a LAFB about ECG. This certain technique is going to be
able to take just a number of seconds.
Take note: An old second-rate wall myocardial infarction struggles to be

clinically diagnosed inside the setting regarding a left preliminar fascicular
block as a result of the substandard Queen waves present coming from the
LAFB.
A new left informe fascicular block can likewise derive from the establishing
in the bifascicular or perhaps trifascicular prevent. Under is actually a
bifascicular obstruct using a LAFB about ECG. Note right now there is also a
new right bundle section block.
ECG Examples:
Bifascicular Stop - RBBB & LAFB ECG (Example 1)
Bifascicular Prevent - RBBB & LAFB ECG (Example 2)
Left Informe Fascicular Block (LAFB) ECG (Example 1)
Left Anterior Fascicular Block (LAFB) ECG (Example 2)
Remaining Anterior Fascicular Prevent (LAFB) ECG (Example 3)
Trifascicular Prevent ECG (Example 1)
RIGHT BUNDLE BRANCH OBSTRUCT (RBBB) ECG OVERVIEW
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The ECG standards for a proper bundle branch obstruct range from the
following:
QRS duration greater as compared to 120 ms
rsR’ “bunny ear” routine in the preliminar precordial leads (leads V1-V3)
Slurred T waves in leads I, aVL and frequently V5 and V6
Remember that T wave inversions and ST segment depression are normal in

leads V1 to V3 in the existence of a right bundle branch block; thus,
myocardial ischemia technically cannot be easily determined in these leads.
However, unlike in the existence of a left bundle branch block, myocardial
ischemia and infarction can simply be detected on ECG when a RBBB is
present.
Below is an ECG displaying a right bundle branch block with an anterior ST
segment elevation MI, followed by some other examples.
Anterior Wall ST Segment Elevation Myocardial Infarction (MI) with RBBB

ECG (Example 1)
Anterior Wall ST Segment Elevation Myocardial Infarction (MI) with RBBB
ECG (Example 2)
Inferior Wall Myocardial Infarction (MI) with RBBB ECG (Example 1)
Some variations of right bundle branch blocks can occur. There are times
when a QRS complex may appear in a RBBB pattern intermittently. This is the
case in premature ventricular contractions that arise from the left ventricle,
which take time to travel to the right ventricle, thereby resulting in a RBBB
QRS morphology. This may also occur in the setting of an Ashman beat, a
premature atrial contraction or supraventricular beat that occurrs when the
right bundle is refractory, leading to the beat to conduct with a RBBB pattern.
Here is an example:
A typical “bunny ear” pattern is not always present in a RBBB, as the R or the
R’ may be very small; therefore, do not depend on identifying “bunny ears” to
diagnose a RBBB. Here is an example of a QRS complex with a RBBB
pattern, but without the typical rsR’ pattern:
A “rate-dependent” right bundle part block can likewise occur during periods
of fast heartrate. When the center rate slows, typically the narrow QRS
intricate returns. A rate-dependent RBBB can, from times, be incorrect for
ventricular tachycardia. The Brugada Conditions can be beneficial in
distinguishing these kinds of two entities.
Last but not least, VT itself will often have a RBBB pattern if that arises from
typically the left ventricle. When tachycardia is current — that is usually,
heart rate higher than 100 beats each minute — in a new RBBB pattern, VT
should be thought about.
The QRS morphology standards to be able to diagnose VT together with a
RBBB contain the following:
A new monophasic R or perhaps biphasic qR intricate in V1
A great RSR’ or “bunny ear” pattern found in V1 or A HUGE SELECTION
OF, with the Ur peak higher inside amplitude than typically the R’ peak (see
image below)
A new rS complex inside lead V6 (favors VT)
ECG Examples:
Incomplete Proper Bundle Branch Obstruct (RBBB) ECG (Example 1)
Incomplete Proper Bundle Branch Obstruct (RBBB) ECG (Example 2)
Monomorphic Suffered Ventricular Tachycardia ECG (Example 3)
Rate-Dependent Right Bundle Part (RBBB) Block ECG
Right Bundle Part Block (RBBB) ECG (Example 1)
Proper Bundle Branch Obstruct (RBBB) ECG (Example 2)
Right Pack Branch Block (RBBB) ECG (Example 3)
Proper Bundle Branch Obstruct (RBBB) ECG (Example 5)
Right Pack Branch Block (RBBB) ECG (Example 6)
LEFT BUNDLE BRANCH BLOCK (LBBB) ECG EVALUATION
The ECG conditions for a left bundle branch block include:
QRS duration greater than 120 milliseconds
Absence of Q wave in leads I, V5 and V6
Monomorphic R wave in I, V5 and V6
STREET and T trend displacement opposite to be able to the major deviation
of the QRS complex
A basic way to detect a left pack branch in a ECG with an increased QRS
complex (> 120 ms) would be to be able to look at business lead V1. If
typically, the QRS complex is usually widened and downwardly deflected in
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business lead V1, a still left bundle branch obstruct exists. If typically, the
QRS complex is usually widened and upwardly deflected in business lead
V1, an appropriate pack branch block is usually present. The graphic below
shows typically the typical findings regarding a left pack branch block inside
the precordial ECG leads.
Note: In the event the QRS duration is usually 100 to 119 ms with conditions
2, 3 in addition to 4 of typically the above, an unfinished LBBB is current.
A rate-dependent LBBB can occur occasionally of fast center rates. This may
possibly be due to myocardial ischemia or refractoriness of the still left
bundle at more quickly heart rates. Any time occurring at center rates greater
as compared to 100 beats each minute, a rate-dependent LBBB can
occasionally be difficult to be able to distinguish from ventricular tachycardia
because the two create a wide intricate QRS complex. Typically, the Brugada
Criteria regarding diagnosing ventricular tachycardia is useful to help to make
this distinction.
Typically, the ECG strip under shows normal sinusitis rhythm, then atrial
fibrillation using a fast ventricular reply builds up. With the more quickly
heart rate, typically the QRS complex morphology becomes that regarding a
LBBB. Since sinus rhythm restored, and the ventricular rate slows, typically
the QRS morphology results to normal.
Sgarbossa Criteria
Typically, the Sgarbossa conditions can be used inside the diagnosis
regarding an acute myocardial infarction every time a LBBB is present.
Usually, it has recently been taught that UNA is not in a position to be
clinically diagnosed via ECG inside the occurrence of any LBBB. However,
Sgarbossa et al referred to in 1996 some ECG changes seen in patients with
LBBB and concomitant MIs and devised a point scoring system. This is called
the Sgarbossa criteria, and they are listed below.
ST segment elevation > 1 mm and in the same direction (concordant) with the
QRS complex = 5 points
ST segment depression > 1 mm in leads V1, V2 or V3 = 3 points
ST segment elevation > 5 mm and in the opposite direction (discordant) with
the QRS = 2 points
A score of 3 points is required to diagnose an acute MI. Criteria #3 is under
debate as to its usefulness; therefore, either criteria 1 or criteria 2 are
essentially required. This patient just made 1 mm ST segment elevation in
lead V5 and about 0. 5 mm ST elevation in V6 — an ECG indeed from a
patient with an acute left anterior descending thrombosis.
Note: Cabrera’s sign and Chapman’s sign have also been used to diagnose
acute MI in the setting of a LBBB. Examining the T wave in leads V5 to V6
can be helpful, as well. In the Sgarbossa study, there was a 26% sensitivity to
detect acute MI when the T wave was upright rather than inverted.
ECG Examples:
Incomplete Left Bundle Branch Block ECG
Left Bundle Branch Block - Cabrera’s Sign ECG
Left Bundle Branch Block - Chapman’s Sign ECG
Left Bundle Branch Block ECG (Example 1)
Rate-Dependent Left Bundle Branch Block ECG
Trasero Wall Myocardial Infarction (MI) ECG Evaluation
The ECG results of a trasero wall myocardial infarction are very different
than the typical ST segment elevation seen in other myocardial infarctions. A
posterior wall MI occurs when posterior myocardial tissue (now termed
inferobasilar), usually supplied by the posterior descending artery — a
branch of the right coronary artery in 80% of individuals — acutely loses
blood supply due to intracoronary thrombosis in that vessel. This frequently
coincides with an inferior wall MI due to the shared blood supply.
The ECG findings of an acute posterior wall MI include the following:
ST segment depression (not elevation) in the septal and anterior precordial
leads (V1-V4). This occurs because these ECG leads will see the MI
backwards; the leads are placed anteriorly, but the myocardial injury is
posterior.
A R/S wave ratio greater than 1 in leads V1 or V2.
ST elevation in the posterior leads of a posterior ECG (leads V7-V9).
Suspicion for a posterior MI must remain high, especially if inferior ST
segment elevation is also present.
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ST segment elevation in the inferior leads (II, III and aVF) if an inferior MI is
also present.
ECG Examples:
Inferior-Posterior Wall Myocardial Infarction (MI) ECG (Example 1)
Inferior-Posterior Wall Myocardial Infarction (MI) - Right-Sided ECG
Posterior Wall Myocardial Infarction (MI) - Standard ECG
Posterior Wall Myocardial Infarction (MI) - Posterior ECG
Substandard Wall ST Section Elevation Myocardial Infarction (MI) ECG
Evaluation
An inferior walls myocardial infarction — also called IWMI, or even inferior
MI, or even inferior ST section elevation MI, or even inferior STEMI —
occurs when substandard myocardial tissue provided by the best heart artery,
or RCA, is injured because of thrombosis of that will vessel. When an
inferior MI extends to posterior regions as well, an associated posterior wall
MI may occur.
The ECG findings of an acute inferior myocardial infarction include the
following:
ST segment elevation in the inferior leads (II, III and aVF)
Reciprocal ST segment depression in the lateral and/or high lateral leads (I,
aVL, V5 and V6)
Note: If the reciprocal ST segment depressions are not present, consider

alternative causes of ST segment elevation, such as pericarditis.
An inferior MI can have multiple potential complications and can be fatal.
See the STEMI Topic Review for more detail on these complications and a
detailed discussion on treatment.
ECG Examples:
Inferior Wall Myocardial Infarction (MI) ECG (Example 1)
Normal Inferior Q waves - not Old Inferior Wall Myocardial Infarction (MI)
ECG
Old Inferior Wall Myocardial Infarction (MI) ECG (Example 1)
Old Inferior Wall Myocardial Infarction (MI) ECG (Example 2)
ANTERIOR WALL ST SEGMENT ELEVATION MI ECG REVIEW
An anterior wall myocardial infarction — also known as anterior wall MI, or
AWMI, or anterior ST segment elevation MI, or anterior STEMI — occurs
when anterior myocardial tissue usually supplied by the left anterior
descending coronary artery suffers injury due to lack of blood supply. When
an AWMI extends to the septal and lateral regions as well, the culprit lesion is
generally more proximal in the LAD or even in the left main coronary artery.
This large anterior myocardial infarction is termed a considerable anterior.
The ECG findings of an acute anterior myocardial infarction wall include:
ST segment elevation in the anterior leads (V3 and V4) at the J point and
sometimes in the septal or lateral leads, depending on the extent of the MI.
This ST segment elevation is concave downward and frequently overwhelms
the T wave. This is called “tombstoning” for apparent reasons; the shape is
similar to that of a tombstone.
Reciprocal ST segment depression in the inferior leads (II, III and aVF).
According to the American College of Cardiology/American Heart

Association guidelines for STEMI, there must be “new ST segment elevation
at the J point in at least two contiguous leads of ≥ 2 mm (0. 2 mV) in men or 1.
5 mm (0. 15 mV) in women in leads V2-V3 and/or of ≥ 1 mm (0. 1 mV)
consist of contiguous chest qualified prospects or the arm or leg leads. ” This
specific means 1 millimeter in any two contiguous leads, except leads V2 or
V3, where the elevation must be 2 mm in men or 1. 5 mm in women.
See the full 12-lead ECG example below and a few more at the bottom.
The ECG findings of an old anterior wall MI include the loss of anterior
forces, leaving Q waves in leads V1 and V2. This is a cause of poor R wave
progression, or PRWP.
Here is an example of an old anterior wall MI:
Note: To distinctly say that an old anterior wall MI is present on the ECG,
there must be no identifiable R wave in lead V1 — and usually V2, as well. If
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there is an R wave in V1 or V2, the term poor R wave progression, but not
old anterior wall MI, can be used.
On rare occasions, persistent ST segment elevation may be seen in V1 and/or
V2, indicating a ventricular aneurysm — a known complication of a
myocardial infarction. Visit Left Ventricular Aneurysm ECG Review or Left
Ventricular Aneurysm Topic Overview. An example regarding a vintage
anterior myocardial infarction with a new left ventricular aneurysm is below.
ECG Examples:
Preliminar Wall ST Portion Elevation Myocardial Infarction (MI) ECG
(Example 1)
Anterior Wall structure ST Segment Level Myocardial Infarction (MI) ECG
(Example 2)
Anterior Wall STREET Segment Elevation Myocardial Infarction (MI) ECG
(Example 3)
Preliminar Wall ST Portion Elevation Myocardial Infarction (MI) ECG
(Example 4)
Anterior Wall structure ST Segment Level Myocardial Infarction (MI) ECG
(Example 5)
Anterior Wall STREET Segment Elevation Myocardial Infarction (MI) ECG
(Example 6)
Preliminar Wall ST Portion Elevation Myocardial Infarction (MI) with RBBB
ECG (Example 1)
Anterior Wall STREET Segment Elevation Myocardial Infarction (MI)
together with RBBB ECG (Example 2)
Old Preliminar Wall Myocardial Infarction (MI) ECG
EKG/ECG CASE QUESTIONS AND ANSWERS
1. Just what would be typically the treatment indicated inside this case?
Answer: Standard acute heart syndrome (ACS) remedy for your ST level MI
and zero treatment for your louage abnormality.
Therapy regarding any ST level myocardial infarction contains aspirin, beta-
blockers, nitrates or morphine regarding chest pain, air, anticoagulation with
heparin, statins, and at some point ACE-inhibitors. For volatile angina, these
may possibly suffice, but also for NSTEMI, coronary angiography need to be
performed by using an urgent basis (within 24-48 hours). As opposed, for an
STREET elevation MI (STEMI) for example case #1, emergent
revascularization together with coronary angiography in addition to stent
placement or perhaps thrombolytic remedy need to be performed within just
90 minutes regarding the patient delivering to the unexpected emergency
room.
The next diploma type II UTAV block would not demand any remedy
considering that it is a new benign rhythm in addition to rarely causes
systematic bradycardia. Once typically the AV nodal ischemia is treated by
simply revascularization, the UTAV block will handle.
2. What explains this specific patient's nausea, nausea and a suffocating
feeling? Just what explains the actual physical test findings regarding a low-
grade temp, bibasilar rales in addition to an S4 coronary heart sound?
Answer/Explanation:
During myocardial ischemia, both the particular sympathetic (SNS) plus
parasypathetic nervous program (PNS) are overactive, leading to several
symptoms.
Sympathetic nervous system over-stimulation contributes to chilly sweats
(diaphoresis), heart palpitations (from tachycardia plus increased inotropy),
chilly and clammy pores and skin (from vasoconstriction) along with a feeling
of impending doom.
Parasympathetic anxious system over-stimulation contributes to nausea,
vomiting (via vagal stimulation) plus generalized weakness.
The particular physical examination results that can become noted during
energetic myocardial ischemia consist of:
1. Low-grade heat because of inflammation (remember atherosclerosis is a
good inflammatory process).
2. Tachycardia and hypertonus from SNS over-stimulation.
3. An S4 heart sound. Keep in mind the S4 coronary heart sound ("atrial
gallop") occurs when bloodstream ejected from your remaining atrium during
atrial contraction (late remaining ventricular diastolic filling) strikes a non-
compliant left ventricle. Throughout active myocardial ischemia, the left
ventricle cannot relax (relaxation is an energetic process requiring ATP) and
becomes non-compliant, resulting in a good S4 heart audio.
4. A murmuration, murmuring, mussitation, mutter, muttering of mitral
regurgitation (due to papillary muscle dysfunction).
Question 3
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A 62-year-old woman having a history associated with hypertension, diabetes
plus end-stage renal illness requiring hemodialysis provides to the crisis
department with growing shortness of breathing and dizziness. The girl
actually passed away twice in the last one hour. She skipped her last 2
dialysis sessions. Beneath is her ECG tracing.
. Question 4: What are the ECG findings?
ANSWER:
The ECG conclusions include:
1. Typical sinus rhythm using a 1st degree UTAV block (PR time period is
prolonged).
2. A non-specific intraventricular conduction delay (IVCD) is present. This
specific occur in the occurrence of any widened QRS complex (> 120 MS) of
which does not satisfy right or still left bundle branch obstruct criteria.
3. Peaked T waves.
4. Low amplitude G waves.
5. SAINT depression in V4-V6, I, II, plus aVL.
These conclusions are regular together with hyperkalemia (elevated
potassium levels).
QUESTION 4.
What are the modern ECG changes since hyperkalemia gets more serious?
ANSWER:
Potassium levels > 5.5 mEq/L: Peaked Capital t waves best noticed in the
precordial leads, shortened QT interval and often STREET segment
depression.
Potassium levels > 6. 5 mEq/L: Widening in the QRS complex occurs
(usually requires a potassium level of 6th. 5 or greater). This frequently
shows up as a possible "interventricular louage delay" or IVCD, which can be
characterized by simply a widened QRS complex of > 120 microsoft that
does not necessarily fulfill the standards regarding a left or perhaps right
bundle part block. Frequently, a great IVCD may be like a new left bundle
part block in business lead V1 by having an rS complex or monomorphic S
wave, in addition to it appears without any consideration bundle branch
obstruct in leads I actually and V6 using a broad, slurred T wave.
Potassium ranges > several. 0 mEq/L: Lowered amplitude of typically the P
waves, a great increase in typically the PR interval in addition to bradycardia
in typically the sort of atrioventricular obstructs occur as typically the
potassium level is greater than 7. 0.
Potassium levels > 8. 5 mEq/L: Absence of typically the P waves and in the
end a "sine wave" pattern (see below), which is often a fatal beat.
Question 4
What medical remedy will resverse typically the ECG changes regarding
hyperkalemia almost quickly without changing using the potassium level?
Question 5
What medical remedy will reverse typically the ECG changes regarding
hyperkalemia almost quickly without changing using the potassium level?
4 calcium administration. Appearance at the under two ECGs (note time
stamp inside lower right). The foremost is the original ECG tracing, the next
is an ECG from the similar patient just a couple of minutes after calcium
supplement has intravenously.
Question 6
The reason why physiologically does intravenous calcium reverse the
particular ECG changes associated with hyperkalemia?
ANSWER
• Why, physiologically, will IV calcium invert the ECG modifications of
hyperkalemia?
• Explanation: An arrhythmia regularly occurs when electric potentials across
myocardial cell membranes turn out to be altered. Hyperkalemia increases the
resting membrane potential (RMP), getting it closer in order to the threshold
possible. When the RMP reaches threshold, an action potential is produced.
So since hyperkalemia brings the RMP closer to threshold, it really is much
simpler to generate an actions potential (only minimum stimulus will boost the
RMP sufficiently in order to reach threshold). The particular administration of
calcium mineral raises the threshold potential, which makes it more
challenging for the RMP to achieve threshold and therefore more challenging
to open fire an action possible.
• CLINICAL PEARL: In case a patient has hyperkalemia resulting from
digoxin toxicity, giving IV calcium can trigger life threatening arrhythmias and
should in no way be provided. Thus, in case you suspect digoxin toxicity,
USUALLY DO NOT provide calcium whether or not hyperkalemia is present.
Question 7
What are effects of heart failure pacing in a new person with hyperkalemia?
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Answer:
What are typically the associated with cardiac pacing within a person together
with hyperkalemia?
Cardiac pacing will not be successful in treating bradycardia associated with
hyperkalemia. When potassium ranges are elevated to be able to the degree to
be able to which bradycardia or even a sine wave takes place, the ventricles
are unable to depolarize at just about all as a result of interruption regarding
cardiac action possibilities. Thus even rousing the ventricle by simply
artificial pacing would certainly not work. Typically, the hyperkalemia must
have dealt with to resolve typically the bradycardia.
Question 8
Why the actual P waves dissappear as hyperkalemia becomes worse?
Answer:
Why the actual P waves go away as hyperkalemia becomes worse?
The atrial myocardial cells are definitely more sensitive to potassium level
changes compared to the ventricular myocardial tissue. Thus, as potassium
levels increase, typically the atrial myocardial tissue is not capable to
depolarize (which normally makes the particular P wave upon the ECG). In
spite of the absence associated with P waves, electric activity is nevertheless
occurring inside the bail system and regular sinus rhythm might still be
existing.
Question 9
• A 23-year-old female and first-year medical student provides to the crisis
room with modified mental status. The girl friends say the girl has been
consuming hard liquor non-stop for 1 7 days after her last exams and offers
not been consuming well for months. The girl was recently beginning on
erythromycin with regard to an upper respiratory tract infection.
• Her heat is 37. 0, blood pressure will be 90/50 mm Hg, heart rate is seventy
beats per moment and respiratory price is 10 for each minute. She seems thin
and cachectic. She is arousable but unable in order to answer questions or
even follow commands. The girl heart and lung examination are regular.
• Her laboratory research reveals a potassium level of two. 1 mmol/L
(normal: 3. 5 mmol/L to 5. 0 mmol/L), a magnesium degree of 0. nine mEq/L
(normal: one. 8 mEq/L in order to 3. 0 mEq/L), and a calcium mineral degree
of 5. 0 mg/dL (normal: nine. 0 mg/dL in order to 10. 5 mg/dL). Her ECG will
be below.
10. What are usually the ECG findings?

Answer:
• The ECG findings include:
• 1. Normal sinus tempo
• 2. Prolonged QT interval
Question 11
The tempo suddenly changes to the particular below rhythm observed on the
ECG strip and the girl passes out. Exactly what is the tempo present at this
particular time?
Polymorphic ventricular tachycardia (Torsades sobre Pointes)

Questions 12
A thirty-five-year-old person presents with tremors. He's been ingesting
heavily with close friends this past weekend. This is usually his ECG. Current
your findings in addition to give a medical diagnosis.
ANSWER:
Rate 100 – one hundred fifty
Rhythm Irregularly irregular
Axis Normal
PR/P-wave No p-wave noticed. Fibrillating base range
QRS Narrow
ST/T-wave Normal
QTc/other Normal
Diagnosis:
This ECG shows atrial fibrillation (AF) with a new fast ventricular reply.
With this historical past the underlying medical diagnosis would fit together
with a ‘holiday heart’ syndrome.
Question 13:
A 45 yr old business man offers with an experience that his center is racing.
He or she has some lack of breath. This is certainly his ECG. Current your
findings and offer a diagnosis.
ECG - Question 2 (atrial flutter)
ANSWER:
Rate 150
Rhythm Regular
Axis Normal
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PR/P-wave No p-waves. Seesaw baseline
QRS Narrow
QTc/other Normal
Diagnosis:
This is atrial flutter. Typically, the atria contract at 300 beats each minute
causing a ‘seesaw’ baseline. Beats are transmitted with a 2: 1, 3: 1 or 4: 1
block, leading to ventricular rates of 150, 100 and 75 BPM respectively.
Question 14:
A 75-year-old man with a history of COPD presents with fever and increased
sputum production. An ECG is taken in the emergency department. What does
it show?
ECG - Question 3 (atrial tachy)
ANSWER:
Demonstration:
Rate 100 – a hundred and fifty
Rhythm Irregularly irregular
Axis Normal
PR/P wave Polymorphic p-waves (see arrows)
QRS Narrow
ST/T wave Normal
QTc/other Normal
Diagnosis:
This will be polymorphic atrial tachycardia. It occurs within respiratory
disease plus reflects an inepte foci of atrial excitation. The morphology of the
p-waves is therefore adjustable but all p-waves are transmitted with the
bundle of Their and therefore the particular QRS complexes are usually all
the exact same.
Question 15
The 65 year aged man is located unconcerned. He has simply no key pulse and
it is making no respiratory system effort. Surprisingly somebody has done a
good ECG. What might you do?
ECG - Question 4 (PEA)
ANSWER:
We will not go through the particular ECG as the most crucial information is
in the medical history.
This really is pulseless electrical activity (PEA). It is the particular most
extreme instance of why you need to appear at the individual in conjunction
with the ECG! Presently there are no particular ECG changes in PEA – the
most crucial point is to identify this patient will be in cardiac arrest and also
to start chest compressions and Advanced Existence Support (ALS) instantly.
However, the ECG may help a person ascertain the fundamental pathology. In
this particular case there are usually low voltage QRS complexes which might
simply due to large body habitus or could indicate pathology ‘interrupting’ the
signal between the heart and the electrode. This can include pericardial fluid
or pneumothorax. This is worth thinking about as tamponade and tension
pneumothorax are both reversible causes of PEA.
Question 16
A fit and well 31-year-old man presents for a routine insurance medical. This
is his ECG. Present your findings and give the diagnosis.
ECG - Question 5 (normal)
ANSWER:
Rate 85
Rhythm Regular
Axis Normal
PR/P-wave Normal
QRS Narrow
ST/T-wave Normal
QTc/other Normal
Diagnosis:
This is a normal ECG. There are many variants of normal and it is worth
looking at as many ECGs as possible to get exposed to the common variants.
It is crucial to remember that a very sick patient can have a normal ECG so
always use all the information available to you and don’t rely on the ECG
alone.
Question 17
A 65-year-old man with a history of ischemic heart disease is found
unresponsive. He has no central pulse and is making no respiratory effort.
This is his ECG. What is the diagnosis and what will you do?
ECG - Question 6 (VT)
ANSWER:
Rate 150
Rhythm Regular
Axis Left axis deviation
PR/P wave Not visible
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QRS Wide
ST/T wave Unable to assess
QTc/other Unable to assess
Diagnosis:
This is ventricular tachycardia (VT) and in this case the patient is in cardiac
arrest as they have no main pulse. He should be treated as per ALS guidelines
with chest compressions beginning immediately. This is a shockable rhythm
and should be treated using the ALS algorithm with DC cardioversion and
adrenaline.
If typically, the patient was aware the ALS protocol will not be essential and
management is determined by symptoms. If severely symptomatic urgent
POWER cardioversion is suggested. When there were zero regarding
decompensation (e. g. shortness regarding breath, chest soreness, shock,
confusion, syncope) maybe he is managed pharmaceutically in the beginning.
Question 18
A 72-year-old lady presents with collapse. This is her ECG. Present your
findings. How would you proceed?
ANSWER:
Rate 50 bpm
Rhythm Regular
Axis Normal
PR/P wave Normal
QRS Narrow
ST/T wave Normal
QTc/other Normal
QUESTION 19
A 62-year-old person presents with restricted core chest soreness radiating to
his / her left shoulder. This specific is his first ECG. Present your current
findings and offer an analysis.
ECG - Question 10 (STEMI)
ANSWER:
Rate 90
Rhythm Regular
Axis Normal
PR/P wave Normal
QRS Narrow
ST/T wave Grossly elevated inside V2, V3, V4, V5 and V-6. Reciprocal
depression inside II, III in addition to aVF.
QTc/other Normal
Medical diagnosis:
This patient provides ST elevation inside the anterior in addition to lateral
leads. This specific is therefore a great anterolateral ST level MI (STEMI).
This specific dramatic ST level is also referenced to as ‘tombstone’ ST
elevation, for both its resemblance into a tombstone and since a mirrored
image on typically the poor prognosis without rapid intervention.
This patient should be assessed and treated urgently for a STEMI, ideally
with primary angioplasty (primary coronary intervention: PCI). Immediate
management also includes aspirin, clopidogrel, heparin, nitrites, morphine
and managed oxygen.
Question 20
A 55-year-old renal dialysis patient presents to the emergency department
having missed his last session of dialysis due to feeling dizzy and unwell.
This is his ECG. Present your findings and give a diagnosis.
ANSWER:
Rate 100 – 150
Rhythm Irregular
Axis Unable to establish
PR/P wave Not visible
QRS Widened
ST/T wave Merged with QRS
QTc/other Unable to assess
Diagnosis:
This is the classic sine wave ECG pattern of severe hyperkalaemia. It can
quickly deteriorate into ventricular fibrillation (VF). There are three main
ECG changes in hyperkalaemia:
1. In the early stages of you may only see tenting or peaking of the t-waves.
2. Later changes involve a decrease in height of the p-wave and increase in
length of the PR interval as conduction is slowed through the atrial
myocardium.
3. This is later accompanied by widening of the QRS and merging of the QRS
complex and the t-wave. This pattern eventually deteriorates to the sine wave
pattern seen above.
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This is a medical emergency. Treatment is with 10ml 10% calcium gluconate
for cardioprotection, followed by 10 units of fast acting insulin (with 50ml
50% dextrose) to drive potassium into the intracellular space. Inhaled
salbutamol has a similar effect if there is no IV access. Bicarbonate 50ml IV
can also be given. Ultimately total body potassium needs to be decreased – in
this case urgent dialysis or haemofiltration is indicated.
Question 21
A 65-year-old woman presents with chest pain radiating to her jaw and down
her left arm. It feels like her ‘normal’ angina nevertheless at this juncture it
provides not eased together with GTN spray. This specific is her ECG.
Present your conclusions and give typically the diagnosis.
ANSWER:
Rate 60
Rhythm Normal
Axis Normal
PR/P wave Normal
QRS Normal
ST/T wave T trend inverted in 2 III and aVF, V4 – V5. ST elevation inside
aVR> 1mm
QTc/other Normal
Diagnosis:
On first inspection this seems such as an inferolateral NSTEMI. There exists
(we believe new) t-wave cambio in consecutive qualified prospects which fit
together with an anatomical area (inferolateral) and a lot important there is
continuous ischaemic sounding heart problems not eased by simply GTN.
However, take note the ST level in aVR. As a result, this is even more
suggestive of essential left main come occlusion. This ECG should therefore
end up being discussed with cardiology expecting to to important PCI.
Question 22
A 25 year old man offers with a failure which occurred when he was playing
within a football match. He's suffered episodes regarding fainting in typically
the past. This is certainly his / her ECG. Is usually medical diagnosis?
ANSWER:
Rate 60
Rhythm Regular
Axis Normal
PR/P wave Shortened PR interval
QRS ‘Slurred’ upstroke on QRS
ST/T wave Normal
QTc/other Normal
Diagnosis:
This picture of shortened PR interval and slurred QRS upstroke – also known
as a ‘delta wave’ – are typical of Wolff-Parkinson White (WPW) syndrome.
These changes represent transmission through an accessory pathway. The
history of collapse in this case is concerning as these episodes could be due
to re-entrant tachycardias which can be fatal. Other features not seen here
which may be present in WPW include a dominant R wave in V1 and T wave
inversion in the anterior chest leads.
A further example to illustrate the delta wave is shown below:
QUESTION 23
A 20-year-old person subscribes to become a member of the army. He or she
is fit in addition to well. This is usually his ECG obtained at his health care
examination. Is that normal?
ANSWER:
Rate 60
Rhythm Regular
Axis Normal
PR/P wave Prolonged PR time period
QRS Wide inside the second-rate lateral qualified prospects
ST/T wave Abnormal in V1, V2 and V3 with unusually-shaped ‘coved’ ST
level
QTc/other Normal
Diagnosis:
No that is certainly not necessarily normal. This ECG is characteristic
regarding Brugada Syndrome (Type 1). In qualified prospects V1 – V3 there
exists > 2mm ST elevation, typically the T waves usually are inverted and
typically the ST segment provides a characteristic ‘coved’ shape. This
problem contains a high chance of sudden loss of life from ventricular
fibrillation (VF). Aligners are together with an implantable cardioverter-
defibillator (ICD).
Question 24
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A 58 years old smoker presents together with tight epigastric soreness. He
looks wet and unwell. One of many nurses shows a person his routine ECG.
Very best diagnosis?
ANSWER:
Rate 45
Rhythm Regular
Axis Normal
QRS Narrow
ST/T wave Dramatic ST depression in V1 – V3
Diagnosis:
This is acute posterior MI. What we see in the anterior leads is the equivalent
of ‘upside down’ ST elevation. Imagine flipping the ECG paper over and
looking at it from behind or looking at the ECG in a mirror held along the
inferior border. You would see ST elevation (the deep ST depression
reversed), t-wave inversion (upright t-waves seen upside down) and this
represents what is going on in the posterior region of the heart. Another clue
is the bradycardia seen in this case: the vessels supplying the posterior of the
heart also supply the ‘pacemaker’ region of the SA node.
Question 25
A 29-year-old presents with central chest pain. She has a history of recent flu-
like illness but no significant past medical history. This is her ECG. What is
the diagnosis?
ANSWER:
Rate 60
Rhythm Regular
Axis Normal
PR/P wave PR segment depression
QRS Narrow
ST/T wave Widespread ST elevation (saddle shaped)
QTc/other Normal
Diagnosis:
The diagnosis is pericarditis. Pericarditis often presents in young people after
a history of viral illness. He you can see the characteristic widespread
saddle-shaped ST elevation and PR depression.
Question 26
A 70-year-old woman presents with sudden onset of chest pain. The pain is
crushing in nature and radiates up to her jaw. This is her ECG. Present your
findings and give the diagnosis.
ECG - Question 17 (STEMI)
ANSWER:
Rate 100
Rhythm Regular
Axis Normal
PR/P wave Every p-wave followed by a QRS
QRS Narrow
ST/T wave ST elevation in II III and aVF
QTc/other Normal
Diagnosis:
This ECG shows ST elevation in the inferior region of the heart. This patient
should be assessed and treated urgently for a STEMI, ideally with primary
angioplasty. Immediate management also includes aspirin, clopidogrel,
heparin, nitrites, morphine and controlled oxygen.
Question 27
A 45 woman has just stepped off a flight from Japan when she develops
severe pleuritic chest pain and shortness of breath. On examination her chest
is clear. Present your findings. What is the most likely diagnosis?
ANSWER:
Rate 100
Rhythm Regular
Axis Right axis deviation
PR/P wave Normal
QRS Wide – right bundle branch block (RBBB)
ST/T wave T wave inversion in lead III
QTc/other Normal
Diagnosis:
Given the history, examination and ECG findings, pulmonary embolism (PE)
is the most likely diagnosis. In PE the constellation of ECG findings of
‘S1Q3T3’ is classically described. It refers to a deep S wave in lead I,
pathological Q wave in lead III and inverted T in V3 (and other anterior
leads). However, though it may be classical it is extremely rare in clinical
practice! The most commonly observed ECG abnormality in PE is a sinus
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tachycardia. There may also be RBBB or a RV strain pattern with T wave
inversion in V1 to V4.
Question 27
It is early January and a middle-aged man is found lying in a park. He is
surrounded by bottles of Buckfast and has a GCS of 9. An ECG is performed
in the ambulance. What is going on?
ANSWER:
Rate 50
Rhythm Regular
Axis Normal
PR/P wave Normal
QRS Narrow
ST/T wave Normal
QTc/other J influx noticeable after the QRS
This particular patient is hypothermic. Good deflection after the QRS but
before the t-wave is an Osbourne J-wave; these can be observed in
subarachnoid haemorrhage (SAH) and hypercalcaemia. Classically a
hypothermic patient is bradycardic and the ECG will show J-waves. Therapy
in this situation would be with gentle rewarming provided there was no
immediate risk to our lives from an arrhythmia.

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1. Phase O Rapid Depolarization also called "upstroke", "overshoot", or

This is certainly concerning +20 mV

10. prevent prayers are required

Rate: Generally, 60-100 beats/min yet may be possibly faster or reduced.

Rate: Usually 60-100 beats/min but may be either faster or sluggish.

Rate: Usually normal, but depends upon underlying rhythm

Early Ventricular Complexes (PVCs)

Type II (Mobitz II)

Mobitz II 2nd level AV block is normally a sign associated with bilateral

1. 1st degree AV block

1. 1st degree AV block

1. 1st degree AV block

27. The indications for a Pacemaker are the following:

All of the Above

30. The three problems a pacemaker could have are:

2. Price your achievement associated with this objective: Determine and

5. Rate your accomplishment of this goal: Understand the various guide

6. Rate your accomplishment of this goal: Utilize an organized process when

7. Rate your own achievement of this particular objective: Recognize nose,

1. Examining the pace

This implies an ECG displaying atrial fibrillation may have no obvious G

ECG Good examples:

LEFT Ventricular Hypertrophy ECG Criteria

A second-degree type I AV block occurs when conduction within the AV node

When 2: 1 AV block is present, the rhythm may be second-degree type I or

AV obstruct can possibly end up being from either second-degree AV nodal

The PR interval might be regular or prolonged, nevertheless it is regular in

Note: A bifascicular block is connected to a trifascicular block, which also

An extremely fast way to identify a remaining informed fascicular prevent

Take note: An old second-rate wall myocardial infarction struggles to be

Remember that T wave inversions and ST segment depression are normal in

Anterior Wall ST Segment Elevation Myocardial Infarction (MI) with RBBB

Note: If the reciprocal ST segment depressions are not present, consider

According to the American College of Cardiology/American Heart

10. What are usually the ECG findings?

Polymorphic ventricular tachycardia (Torsades sobre Pointes)

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