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1. The document describes 4 ECG findings from patients presenting with various symptoms. The first case shows ventricular bigeminy in a patient with chest pain. The second case shows sinus tachycardia with S1Q3T3 pattern in a bedridden patient with breathlessness, indicating pulmonary embolism. The third case shows ventricular tachycardia in a patient recently diagnosed with myocardial infarction. The fourth case provides the Brugada criteria used to diagnose Brugada syndrome.
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Introduction to the presentation featuring "20 Important ECGs" by Noor Atikah Saini.
ECG findings for a 60-year-old man with crushing chest pain show an acute anterolateral myocardial infarction.
ECG findings for a 56-year-old man with chest pain indicate an acute inferior myocardial infarction.
ECG findings reveal a 78-year-old lady with acute posterior myocardial infarction associated with low BP.
Summary of ECG changes for anterolateral, inferior, and posterior myocardial infarctions.
The slide describes the progression of ischemia to injury and infarction with corresponding ECG changes.
ECG findings for a 64-year-old man show electrical alternans indicating pericardial effusion.
Physical, infectious, and metabolic causes of electrical alternans and their ECG presentation.
ECG findings for a patient with hyperkalemia list various stages and their management approaches.
Describes ECG findings and causes of hypokalemia, along with associated symptoms.
Examines the ECG changes associated with digitalis effects and toxicity, including management.
ECG characteristics for a patient with dextrocardia and differential diagnosis considerations.
ECG findings correlate with P pulmonale, including causes and association with Ebstein’s anomaly.
ECG findings associated with mitral stenosis and left atrial enlargement.
Diagnosing left ventricular hypertrophy (LVH) via various ECG criteria.
Management options for torsades de pointes, focusing on acute and long-term treatments.
WPW syndrome overview including ECG findings and potential risks.
Description of ventricular bigeminy on ECG, common causes, and compensatory pauses.
ECG findings indicative of acute pulmonary embolism, focusing on classic S1Q3T3 pattern.
Ventricular tachycardia ECG findings with definitions of fusion and capture beats.
Brugada criteria for diagnosing ventricular tachycardia and acute management strategies.
An overview of types of AV blocks including first, second, and third degree, with causes.
Diagnostic approach to identifying AV block types through analysis of ECG intervals.
ECG characteristics in elderly patients with myocardial infarction and related conditions.
Instructions on identifying atrial and ventricular pacing spikes on ECG.
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Ecg !
- 1. 20 IMPORTANT ECGs NOOR ATIKAH SAINI 080201033
- 2. Ecg 1 h/o: 60years old man with 4 hours crushing chest pain
- 3. This ECG shows: • Rate = 60/min • Rhythm = sinus rhythm • Axis = normal • P wave = normal • QRS complex = normal • T wave = normal • ST segment = elevated in the anterior leads V1-V6, I and aVL = reciprocal ST depression in the inferior leads ( leads II,III, aVF) • PR interval = normal • QT interval = normal Diagnosis = Acute Anterolateral Myocardial Infarction
- 4. Ecg 2 : H/o:A 56 years old man with chest pain and vomiting for 90 minutes
- 5. This ECG shows: • Rate = 50/min • Rhythm = sinus • Axis = normal • P wave = normal • QRS complex = normal • T wave = normal • ST segment = elevated in the inferior leads II, III, aVF. reciprocal ST depression in the anterior leads ( V1-V4). • PR interval = normal • QT interval = normal Diagnosis = Acute Inferior Myocardial Infarction
- 6. Ecg 3 : H/o:A 78 years old lady with chest pain and collapse, BP 60/40
- 7. This ECG shows: • Rate = 50/min • Rhythm = sinus • Axis = normal • P wave = normal • QRS complex = tall R wave in leads V1-V3 • T wave = tall upwright T wave in leads V1-V3 • ST segment = depression in anterior leads V1- V3 • PR interval = normal • QT interval = normal Diagnosis = Acute Posterior Myocardial Infarction
- 8. Summary : 1. Features of MI based on its site of infarction: Changes Anterolateral Inferior MI Posterior MI of ECG MI ST •ST elevetion in •ST elevation ST elevation segment leads V1-6, I in the leads in leads V1-3 and aVL II, III and aVF •With ST •With ST depression in depression in leads II,III,aVF leads V1-V4 R wave - - Tall R wave in leads V1-V3 T wave - - Tall T wave in leads V1-3
- 9. Progression of Ischaemiato Injury to Infarction ECG changes: • Ischaemia = only T wave abnormalities • Injury = T waves + ST segments abnormalities • Infarction = T waves + ST segments + QRS complexes abnormalities
- 10. Ecg 4 : H/o:A 64 years old man with breathlessness and a raised JVP
- 11. This ECG shows: •Rate = 120 beats/min • Rhythm = sinus • Axis = normal • P wave = normal • QRS complex = normal • T wave = small or inverted • ST segment = widespread • PR interval = normal • QT interval = normal Other features = alternating high and low voltages of all the ECG waveforms Diagnosis = Electrical alternans of pericardial effusion The classic example is a pericardial effusion with the heart "swinging" in it and changing its location and proximity to the chest wall (where the electrodes are) from beat to beat.
- 12. electrical alternans/low voltagealternans: =>alternate-beat variation in the direction, amplitude, and duration of any component of the ECG waveform (ie, P, PR, QRS, R-R, ST, T, U). Causes : 1. Physical : hypothermia 2. Infections : myocarditis, pericardial TB 3. Neoplasm : pericardial mesothelioma 4. Metabolic disorders : obesity, heart amyloidosis,haemochromatosis cardiomyopathy 5. Structural disorders : pericardial effusion, cardiac temponade, hydro/hemopericardium,pneumothorax 6. Poisoning : chronic alchoholism
- 13. 60 year oldmale with chronic kidney disease on mantainance hemodialysis is brought to emergency with breathlessness and volume overload
- 14. Findings: -sinus rhythm -smallor absent P wave -long PR interval -shortened ST segment -normal axis -broad QRS complexes -tall tented T waves
- 15. Hyperkalemia Definition:plasma potassiumlevel of 5.5mM Changes in hyperkalemia: 1.mild-prolongation of PR and QRS interval. 2.moderate-loss of Pwave and progressive widening of QRS complex 3.severe-sine wave sinoaventricular rhythm
- 16. Management: -IV administrationof glucose along with insulin to encourage shift of potasium from EC to IC compartment -50ml of 50% glucose plus 10 unit of soluble insulin as bolus -500ml 20% glucose plus 10 unit of soluble insulin as infusion over 6 – 12 hours
- 17. -10ml of 10%calcium gluconate IV slowly over 2- 5 min to stabilise myocardial cell -50 – 100ml of 8.4% sodium bicarbonate IV -nebulisation of beta agonist( salbutamol) -if these measure fail hemodialysis is indicated
- 19. Findings: -sinus bradycardia -longPR interval -normal axis -small T wave -Presence of U wave (repolarization of papillary muscles or purkinje fibres) -ST segment deviation -prolonged QT interval
- 20. ECG changesof hypokalemia -increased amplitude and width of Pwave -prolongation of PR interval -T wave flattening and inversion -ST depression -prominent U wave -apparent long QT interval due to fusion of T and U waves
- 21. Hypokalemia -causes: 1.Low PTHlevel:parathyroid agenesis, destruction, reduced function 2.High PTH level:vit D deficiency, drugs, PTH resistance syndrome, acute pancreatitis -features 1.Asymptomatic 2.Paresthesia of fingers ,toes,circumoral regions 3.severe:seizure, carpopedal spasm, bronchospasm, laryngospasm
- 22. Case 3 A 65year old women with congestive cardiac failure and on treatment come with the ECG.
- 23. Findings: -Abnormal rhythm -invertedT wave -downward sloping ST segment- reversed tick sign -depressed ST – J point -shortened QT interval
- 24. Digitalis effects -digitalisis a drug used in CCF and to slow the ventricular rate in atrial tachyarrhythmias -digitalis effects is due to early recovery and repolarisation of myocardial cells. 1.coved ST segment depression 2.flattened T wave 3.decreased QT interval
- 25. Digitalis toxicity -dueto excessive amount of digitalis >2ng/ml -features: 1.general symptoms-weakness, anorexia, nausea, vomitting, visual effects and mental changes. 2.arrhythmias and conduction disturbance- ventricular arrhythmia,bidirectional ventricular tachycardia,AV junctional rhythm,sinus bradycardia
- 26. -treatment: 1.prevention-baseline ECG,serum electrolyte, BUN and creatinine. 2.definitive treatment depend on arrhythmia minor-discontinuation of digitalis and careful observation serious-suppression with IV drugs lidocaine -pacemaker in patient with complete heart block -digitalis binding antibody IV (digoxin immune Fab)-lethal dose
- 27. A 40 yearold male, asymptomatic came with the ECG
- 28. Findings : -sinusrhythm -inverted P wave in lead I -increased PR interval -right axis deviation -QRS complexes get progressively smaller from V1 to V6 with small R wave
- 29. Dextrocardia It isthe condition in which the cardiac apex is in the right side of the chest D/D -accidental reversal of the left and right arm electrodes -situs inversus : congenital condition in which major visceral organs are reversed from their normal position
- 30. CASE #1 • A27 year old female, Mrs. Terry, a known case of α₁- a nt i t r y ps i n de f i c i e nc y , c o mp l a i n e d o f f e v e r , i nc r e a s e d br e a t hl e s s ne s s a nd COPD wh e e z i n g s i n c e 3 da y s .
- 32. • Rhythm : sinus rhythm • Axis : right axis deviation • P wave : P pulmonale ( >2.5mm in lead II)
- 33. D/D for Ppulmonale Valvular Pulmonary Congenital disease hypertension heart disease • Tricuspid • COPD • Ebstein’s stenosis • Pulmonary anomaly • Tricuspid embolism regurgitation • ILD • Sleep apnoea • LV systolic dysfunction
- 34. EBSTEIN’S ANOMALY -congenital condition oftenassociated with WPW syndrome ECG findings - ‘Himalayan’ P wave - prolong PR interval
- 35. ECG 2 40 ye a r o l d f e m a l e w i t h h i s t o r y o f c h r o n i c b r e a t h l e s s n e s s
- 36. • Rhythm : irregularly irregular • Axis : right axis deviation • P wave : diminished MITRAL STENOSIS
- 37.
- 38. CASE #3 • A n 83-y e a r -o l d m a n w h o i s a p p a r e n t l y a s y mp t o ma t i c c a me t o O P D .H e i s r e g u l a r l y s e e n b y y o u r c o l l e a g u e . S i n c e y o u r c o l l e a g u e i s o n l e a v e ,t h i s p a t i e n t a s k e d y o u r r e v i e w o n h i s c u r r e n t h e a r t
- 39.
- 40. • Rhythm : sinus rhythm • Axis : left axis deviation • P wave : biphasic (2nd half of wave is –ve) • QRS complex : deep S wave, tall R wave
- 41. DIAGNOSING LVH ONECG • Limb Leads (Low sensitivity, high specificity) – R wave lead I + S wave lead III > 25 mm – R wave aVL > 11mm – R wave aVF > 20mm – S wave in aVR > 14mm
- 42. ...... • Precordial Leads(High sensitivity, low specificity) – R wave V5 or V6 > 26mm – R wave V5 or V6 + S wave in V1 > 35mm – Largest R wave + largest S wave in precordial leads > 45mm
- 43. ........ • The Sokolow-Lyoncriterium R in V5 / V6 + S in V1 > 35mm • The Cornell criterium R in aVL and S in V3 >28 mm in men R in aVL and S in V3 >20 mm in women
- 44.
- 45. CASE #4 • A60-y e a r -o l d f e m a l e , k n o wn c a s e o f I HD, p r e s e n t e d wi t h pa l pi t a t i ons i n t he O P D . O n e x a mi n a t i o n , h e r me a s u r e d s y s t o l i c B P i s 80.
- 46. Tor s ade s de Poi nt e s
- 47. TORSADES DE POINTES (Polymorphic ventricular tachycardia) • Acute management • Long-term management 1)Electrolyte 1)β-blockers 2)Drugs 2)Left cardiac sympathetic 3)Heart rate denervation 4)MgSo₄ 3)Pacemaker 5)IV isoprenaline
- 48. NUR SHUHAIZA BINTISUPIAN 080201039
- 49. CASE 1 A 23years old male with h/o episodes of palpitation
- 50. ECG FINDINGS: Normalrate Sinus rhythm Normal axis Short PR interval Slurred upstroke of QRS complex, best seen in I, V4, V5 Widened QRS complex due to „delta‟ wave WPW SYNDROME
- 52. one of several disorders of the conduction system of the heart that are commonly referred to as pre-excitation syndromes. majority of individuals with WPW remain asymptomatic throughout their entire lives risk of sudden cardiac death associated with the syndrome. caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles Electrical signals travelling down this abnormal pathway (known as the bundle of Kent) may stimulate the ventricles to contract prematurely, resulting in a unique type of supraventricular tachycardia referred to as an atrio- ventricular reciprocating tachycardia.
- 53. CASE 2 A 50years old male with h/o chest pain for 24 hours
- 54. Sinus rhythm with ventricular bigeminy Normal rate and axis Bigeminy : every sinus beat is followed by a ventricular premature beat No preceding P wave The coupling interval is usually constant Usually followed by compensatory pause VENTRICULAR BIGEMINY
- 55. Compensatory pause: The R-Rinterval between the beats directly preceding and following the VPB is exactly twice that of regular R-R interval Common cause for ventricular bigeminy: May occur in normal individual Ischemic heart disease Digoxin toxicity Left ventricular dysfunction
- 56. CASE 3 A 40years old female, bedridden for 48 hours, come with c/o breathlessness
- 57. Sinus tachycardia Normal rate Normal axis Prominent S wave in Lead I Small Q wave, inverted T wave in Lead III S1 Q3 T3 PATTERN ACUTE PULMONARY EMBOLISM
- 58. CASE 4 A 60years old male, recently diagnosed with myocardial infarction
- 59. Rate increased (>100/min) Sinus rhythm Independent P wave Broad QRS complexes (>0.16s) beat to beat variability of the QRS morphology VENTRICULAR TACHYCARDIA
- 60. Fusion beat: When oneimpulse originating from ventricle and a second supraventricular impulse simultaneously activate the ventricular myocardium Capture beat: Normal conduction momentarily “captured” control of ventricular activation from VT focus
- 61. Brugada Criteria: Lackof an RS complex in the precordial leads Whether the longest interval in any precordial lead from the beginning of the R wave to the deepest part of the S wave when an RS complex is present is greater than 100 ms Whether atrioventricular dissociation is present Whether both leads V1 and V6 fulfilled classic criteria for ventricular tachycardia.
- 63. Immediate cardioversion in synchronised mode IV Amiodarone : given as bolus followed by continuous infusion IV Lidocaine
- 65. AV BLOCKS • FIRSTDEGREE- All impulses conducted, but delay present (prolonged PR interval) In coronary artery disease, drug toxicity(digoxin, CCB’s, β blockers) electrolyte disturbances(hyperkalemia) acute rheumatic carditis, congenital heart diseases(ASD, Ebstein’s anomaly)
- 66. • SECOND DEGREE- Impulse completely fails to pass through the AV node Mobitz type ll Wenkebach phenomenon/Mobitz type l Causes- o Physiological- atheletes, vagotonic individuals o Acute rheumatic carditis o MI (eg inf wall, right ventricular) o Acute diphtheric myocarditis o Drugs- digitalis o Idiopathic fibrosis of the conduction system (Lenegre’s disease)
- 69. • THIRD DEGREE- Atrial contraction is normal, but no beats are conducted to the ventricles Causes- o Drugs- o Acute MI o Acute rheumatic carditis o Congenital heart disease(ASD, VSD)
- 70. HOW TO DIAGNOSE •LOOK FOR- R-R INTERVAL P WAVES P-R INTERVAL
- 71. R-R INTERVAL REGULAR IRREGULAR P-R INTERVAL 2ND DEGREE SAME VARIABLE P-R INTERVAL 1ST DEGREE 3RD DEGREE CHANGES FIXED MOBITZ TYPE I TYPE II
- 72. CASE I • 70year old male, complains of exercise intolerance
- 74. • RATE- normal • RHYTHM- regular( dual rhythm) • AXIS- normal • P WAVE • QRS COMPLEX • T WAVE • PR INTERVAL • QRS INTERVAL
- 87. CASE II • 90year old male, presented with syncope
- 89. Rhythm : sinus rhythm Axis : normal P wave : QRS complex : wide rsR’ pattern (M shaped) in V1, V2 •T wave : inversion in V1, V2 •wide, slurred S wave in L I and V5, V6 ST segment : depression in V1, V2 PR interval : QT interval :
- 90. CAUSES • acute myocardialinfarction, • acute pulmonary embolism, • chronic cor pulmonale • Congenital heart disease(ASD, VSD, Ebstein’s anomaly) • Myocarditis • Cardiac contusion
- 91. CASE III • 90year old male presented with sudden onset of chest pain and was diagnosed to have myocardial infarction
- 93. •Rhythm : sinus rhythm •Axis : normal •P wave : •QRS complex :wide small r waves followed by deep, wide and slurred S waves in V1, V3; •broad, notched or slurred (M shaped) R wave in L I, aVL, V5, V6; absence of q waves in L I, aVL, V5, V6; •T wave : inversion •ST segment :depression in L I, aVL, V5, V6 •PR interval : •QT interval :
- 94. CAUSES • Always pathological • acute myocardial infarction, • hypertensive heart disease • dilated cardiomyopathy • Aortic valve disease • Drugs (quinidine).
- 95. CASE IV • 90year old male with a past history of MI, which was complicated by LBBB. He is currently asymptomatic
- 98. WHERE IS THEPACEMAKER ? • Atrial pacing spikes- short vertical lines preceding the P waves and best seen in lead III • Ventricular pacing spikes- precede the QRS complex and best seen in lead V2 , V3, V4 & V5