1. ECG SAMPLES AND DIAGNOSIS FOR MBBS
NABYENDU BISWAS
COMMUNITY MEMBER EXECUTIVE, ELSEVIER
drnabyendu365@gmail.com
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2. SOURCES AND PREDICTIONS
FIRST OF ALL EVERYTHING IN THIS DOCUMENT WRITTEN IN CAPITALS, SO aVF WRITTEN AS AVF IN EVERY
PORTION OF THIS DOCUMENT WHICH IS NOT COREECT.
SECONDLY IN EVERY ECG IT IS NOT POSSIBLE TO EXPLAN EACH AND EVERY FINDINGS AVAILABLE. SO, I DISCUSS
ABOUT THE MAJOR FINDINGS ONLY.
DUE TO LACK OF SPACE I AM NOT ABLE TO DISCUSS THE BASIC PHYSIOLOGY OF HEART IN THIS DOCUMENT.
THIS DOCUMENT IS ONLY FOR PRESENTATION PURPOSE SO, COPYRIGHT PROTECTION IS NOT MAINTAINED.
SOURCES-
DIAGNOSIS IN COLOUR CARDIOLOGY BY TIMMIS AND BRECKER.
DAVIDSON’S PRINCIPLES AND PRACTICE OF MEDICINE
ECG LEARNING CENTRE ecg.utah.edu
ECGpedia
NCBI
ECG COLLECTED FROM RURAL HOSPITALS, WEST BENGAL
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12. NORMAL P WAVES AND ABNORMALITIES
GENERALLY TALL P WAVES IN
LEAD II MAINLY SIGNIFIES
PULMONARY HYPERTENSION
AND HYPERTROPHY.
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13. QRS COMPLEX DETAILS
R WAVE CANNOT BE NEGATIVE
AND
Q WAVE CANNOT BE POSITIVE
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24. BUNDLE BRANCH BLOCK
LEFT BUNDLE
BRANCH BLOCK
1. M PATTERN IN LEAD I
2. W PATTERN IN V4
3. QRS COMPLEX >= 120
ms
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25. LEFT BUNDLE BRANCH BLOCK WITH MI
LEFT BUNDLE
BRANCH BLOCK
1. M PATTERN IN LEAD I
2. W PATTERN IN V1
3. QRS COMPLEX >= 120
ms
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26. LBBB is recognized by 1) QRS duration
>0.12s; 2) monophasic R waves in I and
V6; and 3) terminal QRS forces
oriented leftwards and posterior.
The ST-T waves should be oriented
opposite to the terminal QRS forces.
DIFFERENCE BETWEEN
NORMAL AND
MONOPHASIC R
WAVE
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31. RBBB is recognized by 1) rR' in V1; 2) QRS duration >0.12s. In RBBB the ST-T waves should be
oriented opposite to the terminal QRS forces. In this example there are "primary ST-T wave
abnormalities" in leads I, II, aVL, V5, V6. In these leads the ST-T orientation is in the same direction
as the terminal QRS forces.
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49. ATRIAL FIBRILLATION ECG
1. THE VENTRICULAR COMPLEXES ARE IRREGULAR
2. THERE ARE NO P WAVES AND IRREGULAR OSCILLATIONS DISTUREB THE
BASELINE.
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58. TYPES OF AV BLOCKS
1. IN 1ST DEGREE HEART
BLOCK AV CONDUCTION
IS DELAYED RESULTING IN
PROLONGED PR INTERVAL
i.e. 0.20 sec.
2. ST ELEVATION MAY BE
FOUND.
DROPPED
BEAT
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59. HEART BLOCK DISCUSSION
DOUBT
1. IN 1ST DEGREE HEART BLOCK AV
CONDUCTION IS DELAYED RESULTING
IN PROLONGED PR INTERVAL i.e. 0.20
sec.
2. IN 2ND DEGREE HEART BLOCK
(PARTIAL HEART BLOCK) SOME
IMPULSES FROM THE ATRIA FAILED TO
GET THROUGHTO THE VENTRICLES i.e.
DROPPED BEAT OCCURS.
SOMETIMES THERE IS
PROGRESSIVE LENGTHENING OF
SUCCESSIVE PR INTERVALS FOLLOWED
BY A DROPPED BEAT
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60. EXERCISE ECG CHANGES
ISCHAEMIC CHANGES ARE
VISIBLE. AFTER 3 MINUTES
PLANER ST DEPRESSION
DEVOLOPED AND AT 6
MINS IT IS MORE
PRONOUNCED.
PROBABLE DIAGNOSIS-
CORONARY ARTERY
DISEASE
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71. CLASSICAL T WAVE
INVERSION.
BUT SINCE ST ELEVATION
OR DEPRESSION NOT
PROMINENT SO DIAGNOSIS
CANNOT BE CONFIRMED.
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72. PATHOLOGICAL Q WAVES AND EVOLVING ST SEGMENT ELEVATION SIGNIFIES
STEMI, NOTE ST ELEVATION IN LEAD II, III, AVF
ST SEGMENT DEPRESSION ALSO PRESENT IN V1-3 REPRESENTS TRUE
POSTERIOR INJURY
ACUTE INFERIOR WALL MI
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73. PATHOLOGICAL Q WAVE IS MOST
SIGNIFICANT IN THIS ECG
LARGEST Q IN III, NXT IN AVF AND
SMALLEST IN II
OLD INFERIOR Q WAVE MI
DOUBT
Q. WHERE IS THE Q IN LEAD III
ANS. LOOK CAREFULLY AT LEAD III, THERE IS P WAVE
POSITIVE AND WAVE FOLLOWED BY P WAVE
SHOLULD BE POSITIVE, SINCE IT IS NEGATIVE AND
NOT FOLLOWED Y A POSITIVE WAVE SO IT ISNOT
S, IT MUT BE Q
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74. 15 LEAD ECG SHOWING ST ELEVATION IN V8-9 AND ST DEPRESSION IN V1-6
AND FINALLY SLIGHT ST ELEVATION IN I, AVL.
ST DEPRESSION IN V4R SIGNIFIES LEFT CIRCUMFLEX OCCLUSION.
ACUTE POSTERIOR MI DUE TO LEFT CIRCUMFLEX OCCLUSION ECG MADE EASY
75. TALL R WAVES IN V1-3
DEEP Q WAVE IN LEAD II, III, AVF
RESIDUAL ST-T ABNORMALITIES ALSO PRESENT
OLD INFEROPOSTERIOR MI
DOUBT
THE MAIN POINT BY WHICH WE
DIFFERENTIATE ACUTE AND OLD MI IS THAT
ACUTE MI= ST SEGMENT ELEVATION
OLD MI= ST ELEVATION + PATHOLOGICAL Q
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76. SIGNIFICANT ST ELEVATION
ACUTE INFERIOR STEMI FINDINGS IN LEAD II, III, AVF (ST ELEVATION IN II, III
AND ST DEPRESSION IN LEAD I)
AND ST ELEVATION IN V3R TO V6R ;INDICATIVE OF RIGHT VENTRICULAR
INJURY
RIGHT VENTRICULAR MI
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77. Acute anterior or anterolateral MI (note Q's V2-6 plus hyper acute ST-T changes)
ANTERIOR MI SINCE PROMINENT CHANGES FOUND IN V2, V3
Q WAVE
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78. Q-wave, slight ST elevation, and T inversion in lead AVL
LATERAL MI
TYPICAL MI FEATURES IN LEADI/ AVL
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79. The QS complexes, resolving ST
segment elevation and T wave
inversions in V1-2 are evidence for a
fully evolved anteroseptal MI. The
inverted T waves in V3-5, I, aVL are
also probably related to the MI.
ANTEROSEPTAL MI
DOUBT
Q. IS IT REALLY T INVERSION IN V2
ANS. FOR THIS JUST CHECK THERE IS A SMALL POSITIVE P WAVE, SO
AS WE KNOW AVR IS A REVERSAL OR NEGATIVE LEAD AND THERE
EACH AND EVERY WAVE FORM GIVES OPPOSITE VALUE BUT HERE P
IS IN RIGHT DIRECTION MEANS UPWARDS. SO, T SHOULD BE
UPWARDS SINCE IT IS A POSITIVE WAVE LIKE P
BUT IT IS INVERTED.
P
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80. Hyperacute T waves in inferior wall STEMI
DOUBT
WHY INFERIOR WALL STEMI
IN LEAD II MARKED ST ELEVATION FOUND
IN LEAD III ALSO MARKED ST ELEVATION
FOUND
IN AVF ALSO MARKED ST ELEVATION
FOUND
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81. The ST segments are elevated in Leads II, III,
and aVF, but the amount of elevation may
look subtle to some.
INFERIOR WALL MI
This ECG shows a common
manifestation with inferior wall
M.I., BRADYCARDIA. We see
the signs of acute inferior wall
M.I.
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83. QQQQQQQQQQQQQQQQQQQQ
ST segment depression is a nonspecific
abnormality that must be evaluated in the
clinical context in which it occurs. In a patient
with angina pectoris ST depression usually
means subendocardial ischemia.
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84. POINTS TO REMEMBER
ST ELEVATION SIGNIFIES
ACUTE MYOCARDIAL INFARCTION
CORONARY VASOSPASM (PRINTZMETAL
ANGINA)
PERICARDITIS
LEFT BUNDLE BRANCH BLOCK
LEFT VENTRICULAR HYPERTROPHY
ST DEPRESSION SIGNIFIES
MYOCARDIAL ISCHAEMIA
SUBENDOCARDIAL ISCHAEMIA
NON Q WAVE MYOCARDIAL
INFAQRCTION
ASSOCIATED WITH T WAVE CHANGES IN
UNSTABLE ANGINA
PATHOLOGICAL Q SIGNIFIES
PREVIOUS MYOCARDIAL INFARCTION
OR OLD INFARCTION
LEAD III OFTEN SHOWS Q WAVES, WHICH
ARE NOT PATHOLOGICAL AS LONG AS Q
WAVES ARE ABSENT IN LEAD II AND AVF
T WAVE MORPHOLOGY
UPRIGHT IN ALL LEADS EXCEPT AVR, V1
AMPLITUDE < 5MM IN LIMB LEADS, < 15MM IN PRECORDIAL
LEADS
PEAK T WAVES FOUND IN HYPERKALEMIA
BROAD, ASYMMETRICALLY PEAKED OR HYPERACUTE T WAVES
ARE SEEN IN THE EARLY STAGE OF ST ELEVATION MI( STEMI)
T WAVE INVERSION PRESENT IN MYOCARDIAL ISCHAEMIA,
BUNDLE BRANCH BLOCK MAINLY AND IT IS A NORMAL FINDING
IN CHILREN.
IN MI INFERIOR- II,III,AVF
LATERAL- I, AVL, V5-6
ANTERIOR- V2-6
P WAVE SIGNIFIES
IT REPRESENTS ATRIAL DEPOLARISATION
MONOPHSIC IN LEAD II
BIPHASIC IN V1
IN RIGHT ATRIAL ENLARGEMENT LEAD II GIVES TALL
P WAVE ALTHOUGH THE WIDTH REMAINS
UNCHANGED
IN LEFT ATRIUM ENLARGEMENT THE WIDTH
INCREASES BUT THE HEIGHT OF P WAVE REMAINS
CONSTANT.
IN PULMONARY HYPERTENSION AND HYPERTROPHY
GENERALLY TALL P WAVE FOUND.
RT ATRIUM
LT ATRIUM
NORMAL P WAVE TALL P WAVE
RT ATRIUM ENLARGEMENT
WIDE P WAVE
LT ATRIUM ENLARGEMENT
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86. P-R SEGMENT- 2-3 SMALL SQUARES
P-R INTERVAL – 4-5 SMALL SQUARES
QRS COMPLEX SHOULD BE < 3 SMALL SQUARES
UPRIGHT IN LEAD I, II
QRS AND T WAVES HAVE THE SAME CONFIGURATION IN LIMB LEADS(I, II, III,
AVL, AVR, AVF)
ALL WAVES ARE NEGATIVE IN AVR
IN V LEADS R WAVE SHOLUD GROW FROM V1-V2Q AND REACHES
MAXIMUM IN V3
IN S WAVE- IT WILL ALSO GROW FROM V1-V3 BUT IN V5-V6 IT WILL BE
ABSENT
ST SEGMENT SHOULD BE ISOELECTRIC EXCEPT V1, V2
P WAVE SHOULD BE UPRIGHT IN I, II, AVF, V2- V6
T WAVE SHOULD BE UPRIGHT IN I, II, AVF, V2 TO V6
Q WAVE MAY BE ABSENT IN II, III, V2-V6 LESS THAN 0.04 SECOND
AXIS DETERMINATION
NORMAL
LEFT AXIS
DEVIATION
RIGHT AXIS
DEVIATION
INDETERMINATE
THUMB RULE
LEFT THUMB- LEAD I
RIGHT THUMB- AVF
LEAD I AVF
+ - + -
INTERPRETATION
2 THUMBS UP- BOTH +
LEAD I UP 0+, AVF DOWN - LEFT AXIS DEVIATION
LEAD I DOWN -, AVF UP + RIGHT AXIS DEVIATION
RULES
FOR
EASY
DIAGNOSIS
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87. XRAY DIAGNOSIS MADE EASY CT SCAN DIAGNOSIS MADE EASY
COMING SOON
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