1. ECG

2. Electrocardiography
It is a voltage difference, record the electrical activity of the heart as well as valuable information about the heart function and structure.
Willem Einthoven 1924

3. Leads (lead x electrode)
LIMB LEADS I II
III
AVF
AVL
AVR
CHEST LEADS V1 V2 V3 V4 V5 V6
bipolar
unipolar

4. Limb leads

5. Limb leads

6. Both limb leads

7. Chest leads

8. What chest lead represent ?

9. ECG Leads - Views of the Heart

10. einthoven's triangle :

13. ECG Paper
ECG Speed 25mm/sec

14. See video

16. ECG Cardiac Cycle

18. What is the isoelectric line؟

19. P wave
Represent the electrical activity of both atria ( atrial depolarization)
The depolarization slow within the AV node, there is a brief delay or PAUSE before the depolarization conducted to the ventricles

20. Normal duration <0.12 sec Absent P wave: Atrial fibrillation SA Block AV Rhythm Peak P wave: Atrial hypertrophy

21. PR interval Normally :0.12-0.2sec Prolonged in : heart block.
Short in : W-P-W syndrome.

22. QRS Complex Represent the electrical activity of both ventricles.
Ventricular depolarization( initiation of the ventricular contraction

23. QRS Complex Q wave R wave: S wave :
: Normal QRS duration < 0.12 sec

24. QRS Complex Q wave first downward deflection . septal depolarization.
0.04sec.

25. R wave: first upward deflection.
height: 5-8 mm.
early ventricular depolarization

27. S wave : late ventricular depolarization,

28. Large QRS indicate Ventricular hypertrophy.

29. ST - Segment
ST segment: the plateau phase of ventricular repolarization.
Isoelectric or> or<1mm.
If the ST segment elevated or depressed beyond the normal baseline this usually sign of serious pathology. (MI)

30. T- Wave T-wave :represent rapid phase of ventricular repolarization.
peaked T wave:
early MI
hyperkalemia
Black races
Inverted :
MI .
Ventricular hypertrophy.
Hypokalemia
Digoxin

31. Q-T interval 0.4 sec in HR 70 Prolonged in : Hypocalcemia
hypomagnesemia

32. U wave repolarization of the interventricular septum. low amplitude
Prominent: suspect hypokalemia, hypercalcemia or hyperthyroidism

33. J wave
represents the approximate end of depolarization and the beginning of repolarization
camel-hump sign .
Hypothermia
hypocalcemia.

34. Low voltage ECG
Obesity
Emphysema
COPD
Severe hypothyroidism

35. Rate Normal heart rate 60-100/ min < 60 called bradycardia
>100 called tachycardia

36. How To Calculate Heart Rate ?

38. 300
No. of Large box btw R-R
HR=
1500
No. of Small box btw R-R
HR=

40. RHYTHM Look For The Distance between Identical waves.
Most commonly used R-R

43. AXIS
At any point during depolarization and repolarization electrical potential are being propagated in different directions. Most of these cancel each other out and only the net force is recorded. This net is called AXIS or cardiac VECTOR

45. How To Check Axis in ECG

49. Principles of ECG recording
Explain the indication and the procedure for the patient. (assurance )
Ask the patient to take off any metals he/she wears.
Expose the wanted sites.
Cleaning of skin and shaving if necessary.
Place the electrodes in the correct positions .
Instruct the patient to remain still (should not talk during the test ) and relax their shoulders and legs while the recording takes place (1 min)

50. See video

51. How to comment on ECG Name.Age ,Date and time.
Calibration and Speed of paper
RAWIHI :

52. RAWIHI R: rate, regularity,rhythm(sinus or asinus), A: axis. W:waves.
I :intervals.
H: hypertrophy.
I: ischemia

53. Normal Sinus Rhythm Rate = 60-100 beat / minute. The rhythm is regular
All intervals are within normal limits
There is a P for every QRS and a QRS for every P.
P : QRS ratio = 1 : 1.
The P waves all look the same
Presence of P, QRS, T in each cycle.
Normal shape, time of waves, segments and intervals

54. Interfering factors Inaccurate placement of the electrodes
Electrolyte imbalances
Poor contact between the skin and the electrodes
Movement or muscle twitching during the test
Drugs that can affect results include digitalis, quinidine, and barbiturates

55. MI Ischemia ( subendocardial or transmural) Injury
When myocardial blood supply is abruptly reduced to
a region of the heart, a sequence of injurious events
occur :
Ischemia ( subendocardial or transmural)
Injury
Necrosis, and eventual fibrosis (scarring) if the blood supply isn't restored in an appropriate period of time

57. Hyperacute T wave is the earliest sign of acute myocardial infarction

58. Precordial Septal Leads
V1 – V2
– Look at the Septum of the heart
– The septal branch of the LAD

59. Precordial Anterior Leads
V3 – V4
–anterior wall of the left ventricle
–The LAD diagonal branch)

60. Anterior-Septal Terminology

61. Lateral Precordial Leads
I,AVL,V5 – V6
lateral of the left ventricle
The left circumflex

62. Inferior border leads II, III and aVF the Inferior wall of the RV
Posterior Descending Branch of the RCA.

63. Posterior MI No leads look at the posterior wall.
usually associated with inferior and/or lateral wall MI.
The changes of posterior myocardial infarction are seen indirectly in the anterior precordial leads. Leads V1 to V3 face the endocardial surface of the posterior wall of the left ventricle. As these leads record from the opposite side of the heart instead of directly over the infarct, the changes of posterior infarction are reversed in these leads. The R waves increase in size, becoming broader and dominant, and are associated with ST depression and upright T waves. This contrasts with the Q waves, ST segment elevation, and T wave inversion seen in acute anterior myocardial infarction.
ST depression is considered reciprocal ECG changes in what should be ST elevation for acute posterior wall injury.

64. ECG Leads - Views of the Heart
Arterial supply
border
lead
RCA
anterior Right Ventricle
V3 & V4
LAD
Septum
V1 & V2
LCX
Lateral Left Ventricle
a VL,V5 & V6
inferior borderof right ventricle
II+III+AVF

65. THANKS