Understanding the Electrocardiogram
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About this ebook
Master the skill of efficient ECG Interpretation with this book.
Dazzle your colleagues with your ECG interpretation skills in the Emergency Room.
Are you looking for a simple but comprehensive pocket book that you can carry while taking rounds in the wards and the Intensive Care Unit? A must-have book for those managing Intensive Care Units.
What this book will help you with :
Interpret 12 lead ECGs with ease.
Analyze Arrhythmias methodically and arrive at a diagnosis.
Recognize arrhythmias in the ECG – the tracings have been augmented with pointer arrows to simplify explanations.
Solve clinical problems based on ECG interpretations.
Know the Basics of Cardiac Electrophysiology.
Understand the Conduction System of the Heart.
Acquaint himself with the ECG paper, ECG waves and intervals.
Recognize Atrial enlargement and Ventricular hypertrophy.
Diagnose Myocardial Infarction and its various types.
Recognize Miscellaneous abnormalities of ECG in Electrolyte disturbances, Hypothermia, Pre excitation, Brugada's Syndrome, Wellens' Syndrome and many more.
Commit to memory Takeaway Points given throughout the book.
Get an excellent Correlation between Clinical Findings and the ECG of the patient.
A book valuable to the Anesthesiologist who is baffled by arrhythmias in the Operating Room.
Then here is the book for you. Get this book today and reap immense benefits. A book for Nurses, Nurse Practitioners, Emergency Medical Technicians, Paramedics, General Practitioners, Junior doctors and Medical Students.
Dazzle your colleagues with your ECG Diagnostic Skills.
With this book, your ECG Diagnostic Skills improves and examinations will be a cakewalk. Get through the Nursing and Medical examinations with the aid of this book.
A must-have book by all Interns, Residents, Emergency Medical Physicians, Nurses, Junior doctors, Medical Students and Paramedics / EMTs.
This book is a companion book to the three courses on Udemy platform namely, 'Learn the Basics of 12 lead ECG interpretation, Cardiac Arrhythmias Part 1 and Cardiac Arrhythmias Part 2.'
This book is for doctors of all levels of expertise. Numerous ECG strips and ample diagrams drawn personally by the author are available to supplement the interpretations. More than 150 illustrations are given.
The explanations are easy in simple, easy-to-understand English to benefit medical students and nurses from all countries.
The processes for interpreting the Arrhythmias have been simplified. Wherever needed, differential diagnosis is emphasized.
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Understanding the Electrocardiogram - Sahasranam Kalpathy
TABLE OF CONTENTS.
PREFACE
UDEMY COURSES IN ECG
THE 12 LEAD ELECTROCARDIOGRAM
Basics & Interpretation.
1. HISTORY OF ELECTROCARDIOGRAPHY
2. CONDUCTION SYSTEM-ECG PAPER- ECG LEADS
THE CARDIAC CONDUCTION SYSTEM
P-QRS-T WAVES.
THE ECG PAPER
ECG RATE CALCULATION
ECG LEADS
HOW TO AVOID ARTEFACTS WHILE RECORDING THE ECG.
3. BASIC CARDIAC ELECTROPHYSIOLOGY. THE ACTION POTENTIAL
THE AP OF THE NORMAL MYOCARDIAL CELL.
AP OF THE PACEMAKER CELL.
4. THE NORMAL ECG
THE P-QRS-T WAVES
THE INTERVALS & SEGMENTS.
5. ATRIAL ENLARGEMENT & VENTRICULAR HYPERTROPHY
ATRIAL ENLARGEMENT
VENTRICULAR HYPERTROPHY
6. ELECTRICAL AXIS OF THE HEART -THE QRS AXIS
7. ISCHEMIC HEART DISEASE
PATHOPHYSIOLOGY.
LOCATION OF THE INFARCT AREA.
POSTERIOR WALL MYOCARDIAL INFARCTION. (PWMI).
PROGRESSIVE CHANGES OF Acute MI
RIGHT VENTRICULAR MYOCARDIAL INFARCTION. (RVMI)
NON-ST ELEVATION MYOCARDIAL INFARCTION.
8. MISCELLANEOUS CONDITIONS
ACUTE PULMONARY EMBOLISM
DIGOXIN EFFECT & TOXICITY.
HYPERKALEMIA
HYPOKALEMIA
PERICARDITIS
EARLY REPOLARIZATION SYNDROME
HYPERCALCEMIA
HYPOCALCEMIA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
PRE-EXCITATION SYNDROMES
LOWN GANONG LEVINE SYNDROME
HYPOTHERMIA
DEXTROCARDIA
BRUGADA SIGN / BRUGADA SYNDROME
WELLENS’ SYNDROME
CARDIAC ARRHYTHMIAS
PART 1.
Disorders of Impulse Formation.
9. INTRODUCTION TO ARRHYTHMIAS
10.ABNORMALITIES OF SINUS RHYTHM
SINUS ARRHYTHMIA.
SINUS BRADYCARDIA.
SINUS TACHYCARDIA.
11. ATRIAL ARRHYTHMIAS
ATRIAL PREMATURE BEATS.
SUPRAVENTRICULAR TACHYCARDIA
ATRIOVENTRICULAR NODAL RE-ENTRY TACHYCARDIA
ATRIOVENTRICULAR RE-ENTRANT TACHYCARDIA
ATRIAL TACHYCARDIA (ECTOPIC ATRIAL TACHYCARDIA)
MULTIFOCAL ATRIAL TACHYCARDIA
12. ATRIAL FLUTTER – ATRIAL FIBRILLATION.
ATRIAL FLUTTER
ATRIAL FIBRILLATION
13. VENTRICULAR ARRHYTHMIAS
VENTRICULAR PREMATURE COMPLEXES
VENTRICULAR TACHYCARDIA
VENTRICULAR FLUTTER
VENTRICULAR FIBRILLATION
POLYMORPHIC VENTRICULAR TACHYCARDIA
TORSADES DE POINTES
14. ESCAPE BEATS, ESCAPE RHYTHMS
JUNCTIONAL ESCAPE BEAT
VENTRICULAR ESCAPE BEAT
JUNCTIONAL RHYTHM – (Idiojunctional Rhythm)
ACCELERATED JUNCTIONAL RHYTHM
VENTRICULAR RHYTHM (Idioventricular Rhythm)
ACCELERATED VENTRICULAR RHYTHM
CARDIAC ARRHYTHMIAS
PART 2.
Disorders of Impulse Conduction.
15. BUNDLE BRANCH BLOCK
THE CONDUCTION SYSTEM
RIGHT BUNDLE BRANCH BLOCK (RBBB).
LEFT BUNDLE BRANCH BLOCK (LBBB).
BUNDLE BRANCH BLOCK WITH AMI.
16. FASCICULAR BLOCKS
LEFT ANTERIOR FASCICULAR ....................................BLOCK
LEFT POSTERIOR FASCICULAR ...................................BLOCK
BIFASCICULAR BLOCK
MASQUERADING BUNDLE BRANCH BLOCK.
TRI FASCICULAR BLOCK
17. ATRIOVENTRICULAR BLOCKS
FIRST DEGREE ATRIOVENTRICULAR BLOCK
SECOND DEGREE ATRIOVENTRICULAR BLOCK
THIRD DEGREE AV BLOCK - COMPLETE HEART BLOCK
18. MISCELLANEOUS ARRHYTHMIAS
SINOATRIAL BLOCK
INTRAVENTRICULAR CONDUCTION DEFECT
ECHO BEAT (Reciprocal Beat)
PARASYSTOLE
19. CLINICAL – ECG CORRELATIONS
12 LEAD ECG – Clinical Correlation.
ARRHYTHMIAS – Clinical Correlation.
BIBLIOGRAPHY
About the Author
Books by the Author
Acknowledgements
PREFACE
This is a pocket book for students of Electrocardiography. It was written as a chapter for a book planned to be published by the Indian Medical Association in Calicut. But due to some technical difficulties, the book never saw the light of day and I was left with the article which I had named ‘Understanding the ECG’.
A year later, on the request of a few friends and students of mine, I decided to print this as a small booklet of 44 pages for private circulation among my interns, residents, and nurses in the Cardiology ICU in my institution. In the year 2012, the Calicut Forum of Internal Medicine (CALFIM) offered to get the booklet printed for distribution to their members, other physicians in the profession, interns, residents and post graduate students in Medicine. Thus, the first edition was born and distributed free for private circulation only.
My interest in teaching ECG had been inculcated by my mentor Prof. K. Sugathan who was my teacher and later senior colleague in the department of Cardiology in the Medical college, Calicut, Kerala. He had been trained in Cardiology under Padmabhushan Prof. Sujoy B Roy from the prestigious All India Institute of Medical Sciences in New Delhi and was awarded the DM degree in 1971. I was posted in the department of Cardiology as an intern, fresh with an undergraduate degree in Medicine and bubbling with enthusiasm and the eagerness to learn. Prof. Sugathan was instrumental in indoctrinating me into this passion of interpreting the ECG. This was in the year 1973 when ECGs and Chest X rays were almost the only diagnostic procedures available in Cardiology. Cardiac catheterization had not yet reached our institution.
Another of my mentors during that period in the department of General Medicine was Prof. P.C. Easaw who was instrumental in guiding me in this endeavor during my internship days. Between them, they taught me all that I know and ushered me into the intricate and fascinating world of ECGs.
This passion of mine stimulated my mentor, Prof. Sugathan to teach me all the complexities of interpreting the ECG and this forged in me a lifelong interest in learning and teaching ECG interpretation. He taught me the tips and tricks in ECG interpretation and some ‘rule of thumb’ shortcuts. Even after becoming a member of the teaching faculty in the Calicut Medical College, I continued to learn and teach ECG to my interns and residents and was sought after in medical circles for my ECG classes.
This book is a humble attempt on my part to share this knowledge with my students and the medical fraternity. After retiring from my profession, I decided to continue my ‘ECG teaching Odyssey’ and prepared three video courses on ECG interpretation for the platform the Udemy learning platform for the benefit of students and doctors world over.
‘What the mind does not know, the eyes do not see’ is a dictum which is true in the interpretation of ECG.
Subsequently, I decided to leave a legacy of my work to the initiates in this skill of interpreting ECGs by updating my previous booklet. This book is the result of that attempt.
Having time on my side, I decided to update my original booklet ‘Understanding the ECG’ with more ECG tracings, diagrams, and content in line with my ECG courses on Udemy. Thus, was born this book which is a companion to the three courses on Udemy namely, Learn the Basics of ECG Interpretation, Cardiac Arrhythmias -Part 1 and Cardiac Arrhythmias – Part 2.
This book is not intended as a complete text book of Electrocardiographic interpretation. Intricate arrhythmias and complicated annotations have been avoided. This books aims to be a handy guide for learning the basics of ECG interpretation only. It is a pocket book for the zealous clinicians and nurses in the ICU. It aims to provide a quick bedside reference for the diagnosis of ECG abnormalities for students, interns, and nurses in the intensive care units. For more detailed information, the student is referred to the Bibliography given at the end of the book.
Throughout the book, "Takeaway Points" have been included which emphasize certain important essentials to be committed to memory. A special chapter at the end of the book is included under ‘Clinical-ECG Correlations’.
I have included the ECG tracings which I had collected from my internship days in 1973 till my retirement over a span of 45 years and some of them are rare specimens. Some ECGs were sent to me by my protégés and colleagues. To substantiate my explanations, I have included some simple hand-drawn diagrams in the book.
I have to pay my respects to my teachers Late Prof. K.N. Ravindran, Prof. Ashokan Nambiar and Dr. Kunhali in addition to the numerous colleagues who have been a source of encouragement, help and inspiration to me in all my ventures.
The management of Baby Memorial Hospital where I had been working for over 24 years prior to my retirement as a Senior Consultant Cardiologist and lately as the Chief of Medical Services always gave me its unstinted support and help in my professional and teaching career. They had my original book reprinted for private circulation in 2018.
With these few words, I humbly submit this book to my students.
Dr. K. V. Sahasranam. MD, DM (Cardiology)
UDEMY COURSES IN ECG
The Udemy Courses are available with Video content, Power point presentations and Resources in their platform. The courses extend to over 8 hours totally with detailed explanations being provided in each module. Plenty of diagrams and ECG tracings have been included in these modules for the benefit of the student.
The courses are as under:
LEARN THE BASICS OF 12-LEAD ECG INTERPRETATION
CARDIAC ARRHYTHMIAS PART -1
CARDIAC ARRHYTHMIAS PART -2
THE 12 LEAD ELECTROCARDIOGRAM
Basics & Interpretation.
1.
HISTORY OF ELECTROCARDIOGRAPHY
The Electrocardiogram (ECG) revolutionized the diagnosis of heart diseases in the early twentieth century. It was Augustus Waller who in 1887 first recorded and demonstrated the ECG of the human heart. He was a British physiologist in London. But at that time, he did not recognize the importance of this discovery. Willem Einthoven, who was a witness to this demonstration by Waller was inspired by this and took up the challenge to develop this further.
Thus, it was Willem Einthoven (1860-1927), a Dutch physiologist, who took this idea forward and recorded the ECG using a string galvanometer. It was he who named it the ‘Electrocardiogram’. He designated the deflections ‘P-QRS-T’ and published his findings in 1902. His ECG tracing was of fairly good quality. In 1905 he presented cases of atrial and ventricular hypertrophy, ventricular bigeminy, ventricular premature beats and identified the ‘U’ wave in the ECG. The same year, he transmitted the ECG via telephone and recorded it 1500 meters away.
Willem Einthoven (1860-1927)
Einthoven’s electrocardiograph which recorded the first ECG weighed 600 lbs.
In 1924, Einthoven was awarded the Nobel prize in Physiology and Medicine "for the discovery of the mechanism of the electrocardiogram". His recording had only three leads – the Triaxial Bipolar Limb Leads. Einthoven conceived the famous Einthoven’s Equilateral Triangle with leads I, II and III as its sides. This facilitates electrical axis calculation.
In 1934, Dr Frank N Wilson of the University of Michigan developed the concept of the ‘central terminal’ and the Unipolar chest leads and named them V1-V6. (V stood for Vector) In 1938 he