ecg diagnosis. aims 10 ecg rules ecg signs of m.i. evolution of changes in m.i. classical...
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![Page 1: ECG diagnosis. Aims 10 ECG rules ECG signs of M.I. Evolution of changes in M.I. Classical Appearences](https://reader036.vdocument.in/reader036/viewer/2022082217/56649d255503460f949fc723/html5/thumbnails/1.jpg)
ECG diagnosis
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Aims
• 10 ECG rules
• ECG signs of M.I.
• Evolution of changes in M.I.
• Classical Appearences
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QRS waveform nomenclature
R r qR qRs Qrs QS
Qr Rs rS qs rSr’ rSR’
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The 10 rules for a normal ECG
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
.2
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Rule 1
PRinterval
Mil
liv
olt
s
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
P
R
T
Q
S
PR interval should be 120 to 200 milliseconds or 3 to 5 little squares
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Rule 2
Mil
liv
olt
s
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
QRS
P
R
T
Q
S
The width of the QRS complex should not exceed 110 ms, less than 3 little squares
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Rule 3
I II III aVR aVL aVF
The QRS complex should be dominantly upright in leads I and II
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Rule 4
I II III aVR aVL aVF
QRS and T waves tend to have the same general direction in the limb leads
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Rule 5
P
Q
T
S
All waves are negative in lead aVR
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Rule 6
V1
V2
V3
V4
V5
V6
The R wave in the precordial leads must grow from V1 to at least V4
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I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Rule 7
The ST segment should start isoelectric except in V1 and V2 where it may be elevated
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Rule 8
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The P waves should be upright in I, II, and V2 to V6
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Rule 9
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
There should be no Q wave or only a small q less than 0.04 seconds in width in I, II, V2 to V6
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Rule 10
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The T wave must be upright in I, II, V2 to V6
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Characteristic changes in AMI
• ST segment elevation over area of damage• ST depression in leads opposite infarction• Pathological Q waves• Reduced R waves• Inverted T waves
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ST elevation
R
P
Q
ST
• Occurs in the early stages
• Occurs in the leads facing the infarction
• Slight ST elevation may be normal in V1 or V2
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Deep Q wave
R
P
Q
T
ST
• Only diagnostic change of myocardial infarction
• At least 0.04 seconds in duration
• Depth of more than 25% of ensuing R wave
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T wave changes
R
P
Q
T
ST
• Late change
• Occurs as ST elevation is returning to normal
• Apparent in many leads
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Bundle branch block
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Anterior wall MI Left bundle branch block
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Sequence of changes in evolving AMI
1 minute after onset 1 hour or so after onset A few hours after onset
A day or so after onset Later changes A few months after AMI
Q
R
P
QT
STR
P
Q
ST
P
Q
T
ST
R
P
S
T
P
QT
ST
R
P
Q
T
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Anterior infarction
Anterior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left coronary artery
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Inferior infarction
Inferior infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Right coronary artery
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Lateral infarction
Lateral infarction
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Left circumflexcoronary artery
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Location of infarct combinations
aVR V1 V4I
II
III
LATERAL
INFERIOR
ANTPOST ANT
SEPTAL
ANT
LAT
aVL
aVF
V2
V3
V5
V6
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Diagnostic criteria for AMI
• Q wave duration of more than 0.04 seconds
• Q wave depth of more than 25% of ensuing r wave
• ST elevation in leads facing infarct (or depression in opposite leads)
• Deep T wave inversion overlying and adjacent to infarct
• Cardiac arrhythmias