1. ECG PRACTICAL APPROACH Dr. Hossam Hassan Consultant Emergency Medicine

2. Objectives To emphasize simplicities Practical approach Interpretation & clinical scenario are inseparable Systematic approach

3. Conduction System

4. Nomenclature

5. Magic numbers of Dr. Hossam

6. Systematic approach Rate Rhythm axis P-wave PR interval QRS complex ST segment T-wave

7. Rate The interval between 2 successive R-wave How many big squares? Divide 300 / # big squares Normal 60 – 100/min

8. Rhythm Sinus Rhythm Every P=wave is followed by QRS complex P-wave is upright in lead II

9. NSR

10. Types of Sinus Rhythm NSR Sinus Tachycardia Sinus Bradycardia Sinus arrhythmia

11. Sinus tachycardia

12. Axis Normal axis Right axis deviation Left axis deviation

13. RAD

14. LAD

15. P-wave Atrial depolarization Atrial contraction is a result Normally a dome-like structure

16. Abnormalities of P-wave Peaked p-pulmonle –Pulmonary HTN –PE –Pulmonary valve stenosis M-shaped M-mitrale –Mitral valve stenosis –Left atrial hypertrophy Inverted 2 nd atrial / junctional ectopy

17. P-pulmonale

18. PR interval Definition From the start of P to beginning of QRS Represent the delay in transmission in AV node Normally 0.12 – 0.20 msec

19. Abnormalities of PR interval Prolonged > 1 st degree HB Short < Pre-excitation syndromes –WPW Syndrome –LGL Syndrome Junctional rhythm

21. QRS Complex Amplitute Duration Shape Q-wave R-wave

22. QRS AMPLITUTE LVH By voltage criteria –S-wave in V 1 or V 2 + R-wave in V5 or V6

23. LVH & STRAIN PATTERN

24. Causes of LVH HTN Aortic stenosis HOCM Aortic regurgitation Mitral regurgitation

25. QRS DURATION Ventricular depolarization Ventricular contraction is a result Normally < 0.12 msec < small squares

26. Causes of wide QRS Ventricular tachycardia BBB –Left BBB –Right BBB

27. L BBB

28. R BBB

29. Shape Upstroke & downstroke of R-wave Delta wave

30. Q-wave 1 st negative deflection after the P-wave Normally 1mm wide & 2 mm deep Lead III, V5 & V6 Pathological Q-wave Wider & deeper >1/4 of the ensuing R-wave Old MI

31. +ve R-wave in V1

32. Causes +ve R-wave in V I RVH R BBB Posterior MI Type A WPW

33. ST-Segment From the end of S-wave to the beginning of T-wave Normally iso-electric Abnormalities –Elevated –depressed

34. Elevated ST segment Acute MI Pericarditis Early repolarization pattern in the young

35. Infarct localization Inferior –Lead II, III, aVF Septal –V I, V II Anterior –V3, V4

36. Lateral –Lead I, AVL,V5, V6 Posterior MI - Prominent R wave in V1,V2 with depressed ST segment

37. Acute inf MI

38. Anteroseptal MI

39. Anterior MI

40. Lateral MI

41. Depressed ST Segment Unstable angina Left ventricular strain pattern

42. LVH & strain pattern

43. T-wave Ventricular repolarization Dome like structure Abnormalities –Peaked / tented t-wave Hyperkalaemia Subendocadial ischemia –Inverted LV Strain pattern Dynamic t-wave changes of ischemia

44. DYNAMIC T-WAVE CHANGES

45. Hay….. wake up we are done