The. ECG. Made Easy. EIGHTH EDITION. John R. Hampton. DM MA DPhil FRCP FFPM FESC. Emeritus Professor of Cardiology. University of Nottingham, UK. John R. Hampton-The ECG Made Easy-Churchill Livingstone ().pdf. Ashraf Alqudwa. Figure The structure of [M(N2S2)]. The ECG Made Easy For. ECG Made Easy - John R Hampton - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. ECG Made Easy.
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𝗣𝗗𝗙 | A true medical classic should be novel, stimulate thought and discussion, transcend both specialty and The ECG Made Easy . John R Hampton. The ECG Made Easy John R. Hampton. years The ECG Made Easy has been regarded as one of best introductory guides to the ECG. صيغة الكتاب: pdf. The ECG Made Easy. 8th Edition. Authors: John Hampton. eBook ISBN: eBook ISBN: Paperback ISBN.
Tlrcrc is a delay while thc clJpolarization;lireacls througlr anotheisp". Thereafter; the electricat discharge tiavels very rapiclly,Eiln specializecl conduction tissug: Fi-e leftr bundle branch itielf divicleffn-b two. Within tir,ffiof ventricular muscle, concluction spreaclffiewhat n'lore slowly, through specialized tissue called 'Purkinje iibres'. The rhythm of. The different parts of the QRS conrplex are labelled as shown in Figure Times ond speeds ECC.
All ECC machines. Table 1. JtrsI as tlrc lcrrgtlr of l 'lpcr be twccn R wavcq gives the lrearl, ratc the distancc bctweerr thc cliffcrcsni'parts of the P-QRS-T conlplcx shows the Linrc taken for conduction of.
Iowf the burrclle of His arncl intt vgltricular nruscE. Tlre normal PR interval is 0. Most ol'[re time is taken trp by clelay irr the AV noclc lrig. S; tlrt, I,R irrterval is veryshort, t'i[lrer the atria have [r. Tht, QRS duration is nornrally 0.
Ttre wrtrcl 'lcacl' srlnretirncs cAusos c nfrrsirlrr. Sonrctinrcs it is used to nrean the pieces t'lf wire that connect tlre patient to the ECC recorclegr? It nray be neccssary to shave the chest. The six 'statrclat'd' leads, rvhich are recorclccl from the electrodes attrtchetl to tlrc linrbs, carr bc tlrouglrt of as lookirrg at thc hcarrt iu a verlical pl. The six nnmbere'd V lcacls look at thc'hcart in a horizontal pla.
Thus, lcads V1 and V, lt-lok: CC prattern ltig. In each lead the pattern is characteristic, bcinl; sirnilar irr different individttals who htrve nornral lreirrts. Note that the 2nd, 3rd, and 4th rib sl aces are numbered.
QIIS cornplexes ancl T waves, pr. A stanc-lard sigrral of 'l rnillivolt nrV shotrld nlovc the sjylus. F x Moking o recording Y.
Conuect up the limb electrodes,, making certain that they are applied to the correct linrb 3. Calibrate the record with Lhe L mV signal 4. Record tlre six standard lcads - three or four complexes 1. Wc trorv treetl to consiclcr why the ECC has a characterisl. Depolarization moving a towards the lead, b away from the lead and c at right angles to the lead.
I tflttre QRS conrplex is predornirrantly rrpwarcl, or positive i. S wave , thc' dqolarization is moving towards tlrat leacl f,ig. Ifl Pt".
Q waves have a special significArlce, which lve shall discuss Iater. Leads VR and II look at the heart fronr opposite c-lircctions. The average directiorr of sprcarJ of the depolarization wave l.
A rrornral 11 o'ik: CBtlrc riglrt verrtriclc beiomc's lryl'rertrophied, tl're axis will svllg towards the right: It is, of course, likcly tlrat the axis will rrot be precisgly at right arnglcs to any of the lt'ads, but will be somewhere Lrctwct'rr Iwo of thcr-rr. Leads VL arrd VR. For cxa: Tlrercforc tlre trr"re axis is at"- this is thc linrit of nortnality towarcls what is called the 'left'. This is tlrc linrit of nornrality towards thc'ri. Why worry obout the cordioc oxis?
V o In tlic normal lriart lltt'rc is rnt r' , r'r'rusctt: In a right ventricular leacl the'cleflection is first sl wi1'rls R wave as tlre septtrm is tlt,pota riz,,tl Fig. Irr l lc[t vcntrictrlirr lcltl tlrere is an trpwarcl cleflection l wavt as the vcrttricular nrusclc is clc;: Vhy worry obout the tronsition point? Ytru now know cnough about the ICG to understand the lrasis of a rcport. Tl'ris slrotrld take the form of a description, ' "' followcd by orr inte rprctation.
The interpretation indicates whethcr the record is normal the underlying pathology needs or to be id. Examples of lcacl llCCs are showtr itr Figures 1,23 and "1. Qln,;t-hylhm, q1 olr-ift 3 Xr' J. Sinus rfrylhm, rala 75lmln. PR interval ms. ORg eornploxoo. Unfortunately, there are a lot of minor variallons in ECGs which ars consistont with perfectty normal hearts.
Recofrizlng the limits of normality is one of the main dilflcultles of ECG intorpretation. Atrial activation causcs tlrc P wave. Any'upward deflection is an I wave. A downward deflection after an.
Wlren the depolarization wave sprcads towards alead, the deflection is predominantly upward. When the wave sprcads away from a lead, tlre dcflection is prcdt-rnr i rra rr tly downwa rd. Lead V, is'positioned vcr thc right venl,riclc, and lead V,, over the left vt. We can ttiir',t of conduction problems in tlre orcler in whiclr the, depolariz. I enrernbcr in all tlrat follows that we are assuming clcpxrlarizatiotr bcgilrs in l,hc ntlrnral way in the SA node, The rhythm of the heart is best interpreted from whichever ECG lead shows the P wave most clearly.
This is usually, but not always, lead II or lead Vr. You can ilrinurnr. TIre tin're taketr for the spreacl of depolariz. Q4d is not rrormally Sfeater than 0,2s one large squarclEcG events are usually timed in irrilliscctln. Interference with the conduction Process '", causcs tlrc ECC phcrr.
AV node or ttrc bundle of I'lls. Wlrcn tlrisl. There may be progressive lengthening of thc, Pli irrtc'rvnl and thcn fallu rc of concluctlon of arr atrial Lreat,. Tlris is called '2: F'ff Qt ll. Wlren this occtrrs the 33 i. Abnorrnally-slraporJ QRS comploiog bocauso ol abnorm al apread ol dopolarlzation from a vontricutar focus. Broad ORS complexes ms Blght bundlo hranch block pallorn Ths cause ol the block could not tlo determlned, though ln most pationts it rcsulla lrom llbrosls of lhe bundlo ol Hls.
If llrc dcpolariz. Thc extra time taken for depolarization of the whole of the ' vcrrtricular rrrusclc causes widcning of tlre QRS complcx, lrr tl're rrorrrral heart, tlre tirrre taken for the depolarizr,tion. Illock of both bundle branchcs has the same effect as block of the His bundle, and causes complete third degree ': Remembep see Ch. The eeptum ie nornrally clepolirriz. Excitation spreading towards a leacl caLlses an uprward.
Excitation tlren spreacls to tlre left ventricle, causinll arl in lead V1 and an R wave in tcacl V6, Fig. It takes longer than in a nornral Ircart for excitation to reaclr tlre righ"t ventricte bccausc of tlrc faiturc oI ltrc normal conducting pathway.
The right ventriclc, thert,forc' ctepolarir,esafter ttrc lcft. Tlris causr,lr il! It is seldom of significance, ancl can be congidered to be a normal variant. S wave. Tlre right ventrlcle is clepolar. Subrequent depolarization of llrc tcft vcrltrictc causes nn lead V1 and another R wave irr leacl V6, trig. The cardi. Upr,vards Fig.
Always remelnber that it is the patient who should be treatt: I elief of symptoms always comes first. I lowcvcr; sotllc gcrrcral ptlintr can bc made about the action that rnight bc takur if tlrc liCC shows conduclion arbnornra litics.
First degree block. Often sccn in nornral pcople, Think about acute myocardial infarction. No specific action needed. Third degree block Atwnyn inclicntcn conductirrg timue diseasc - lrlor often fibrosiE tlrarr isclracnric.
Consider a temporary or Pcrmanent pacemaker. Risht buncllebronch block t? B t3E. Think about an atrial septal defcct. No spccific treatnrent. P0irr, I-ll lil i may indicate. Left oxis d"r,iotion olia ,rnt',t bundle bronch btock o lndlcafclr severe conductllrg tisstrc cliscttsc. No specific treatment needed. Pacemaker rgquired if the paticnt ltas synrptoms suggcstive of intermittent complctc heart block. A conduction abnormality citn dcvclop at arty of tltesc.
Conduction problems. IJlock of the anterior division or fascicle of the left bundle. Depolarization can, lrowever, bcgirr in otlter pllccs. Abnormalltlcs of carcliac rtrythnl ilrc casy: The two things to look at are the P waves and tl're widtl-r of tlre QRS conrplexes.
Atrial contractiorr is associated wil. Tl'rerefrlre the rate of t rrrrlr',rt'liorr of llrrt vt,rrtrir: Conslant PR interval. Progresslve beal-lo-beat change in R-R interval. Supraventricular rhythms. Ventricular rhythms have wide QRS complexes. Abnormal;ftythms arising in the atrial nrttscle', thc iuncfionrdl resion or the ventricular rDrtscle can t're slt-lw arrd 'sustgy'ne.
Whclr activation of the atria or ventriclcs is Iotrrlly tlisor'1ialr. Tl'ris is erchit: If the SA node fails to depolarize, control will bc i. These slow and protective rhythrns are called escape rhyl. Escape rhythms are trot primary disordcrs, but are the rcsporlsc to problcrlts Irighcr in thc'conducting pathway.
A ,atriol escope t-- tf the rate of depolarization of the SA node slows down and a focus in the atrium takes over control of tlre hear't, tlte rhyl. Atrial t'scaire beats can occrrr singly. After one sinus beat,the SA node fails to depolarize. After a delay, an". Thd remaining beats show a return to sinus. U ';'. Ventricular escape rhythms can occur withotrt conlpletc heart block.
Ventricrrlar e'scapc beats carr be single i. The rlrl,tlinr is called'accelerated idioventricular rhyth rn' Fig. Althougl'r the appearance of the ECC is sinrilar to ttrat of ventricular tachycardia descriLred la ter , accelcra [c.
Vc'ntricular tachycarclia shoulcl not trc-rliagnosecl rrnlcss tlrc heart rate exceeds lnrin' e. L-vL'r'rtric,rar nrtrsctC, iS trrc sa,lle as rtrat. I Ir t QIis c rrpl" rrig. I atri;rr arrtr jtlrrctiort.
Supraventricular beats look thc sanre, velrtricular beats look different. Is tlrc T wave the sanre way up as in the normal beat? In sa' l. Docs thc rrcxt P wave aftcr thc cxtrasystole appear at an cxpcctcrl tirnc? SA noclc clischarge and P wrrve collles late. QRS complex and an abnormal T wave: A ventricular extrasystolc, orr the othe. Three sinus beats are followed by a junctlonal extrasystole. Three sinus beats are followed by a ventricular extrasystole.
No P wave is seen after this beat, but the next P wave arrives on time. Jr Foci in the atria, the junctional AV nodal region, and ventricler.
The criteria already descritrt'd carr ['re trsctl to decicle the origin of the arrhythrnia, ancl trs before tht nrost important thing is to try to identify a P wave. P waves can be seen superimposed on the T waves of the prececling beats. The QRS complexes have the same shape as those of the sinus. However, you must think ECG reporting is that there is quite a lot of about all the findings every time you interpret variation in the normal ECG.
Figures 1. If the first deflection is downward, plane. Lead V1 is positioned over the right it is a Q wave. Any upward deflection is an ventricle, and lead V6 over the left ventricle.
R wave. When the wave spreads away from a lead, the deflection is predominantly ECG downward. The conduction of this wave front His bundle 37 can be delayed or blocked at any point. However, conduction problems are simple to Conduction problems in the right and left analyse, provided you keep the wiring diagram bundle branches — bundle branch block 43 of the heart constantly in mind Fig.
Conduction problems in the distal parts We can think of conduction problems in the of the left bundle branch 49 order in which the depolarization wave normally spreads: Remember in all that follows that we are assuming depolarization begins in the normal way in the SA node.
We have already seen that electrical The rhythm of the heart is best interpreted depolarization normally begins in the sinoatrial from whichever ECG lead shows the P wave SA node, and that a wave of depolarization most clearly.
This is usually, but not always, lead spreads outwards through the atrial muscle to II or lead V1. This is called through the AV node or the bundle of His. There are three and nonconducted atrial beats or one variations of this: There may be progressive lengthening of the or three or four times as many P waves PR interval and then failure of conduction as QRS complexes.
This is the Fig. It is important to remember that, as with any 2. Most beats are conducted with a constant other rhythm, a P wave may only show itself as PR interval, but occasionally there is atrial a distortion of a T wave Fig.
You have to look at the PR interval in to occur when atrial contraction is normal but no all the leads to see that there is no consistency. It may also be caused by the obvious in a lead ECG, where there may be block of both bundle branches.
Block of both bundle branches has the same If the depolarization wave reaches the effect as block of the His bundle, and causes interventricular septum normally, the interval complete third degree heart block. However, if there is abnormal but RBBB patterns with a QRS complex of normal conduction through either the right or left duration are quite common in healthy people. The extra time taken for ventricle.
If the first principles. Remember see Ch. However, remember an upward deflection within the ECG.
In RBBB, no conduction occurs down the right The right ventricle therefore depolarizes after bundle branch but the septum is depolarized the left.
This causes a second R wave R1 in from the left side as usual, causing an R wave in lead V1, and a wide and deep S wave, and a right ventricular lead V1 and a small Q wave consequently a wide QRS complex, in lead V6 in a left ventricular lead V6 Fig. It is It takes longer than in a normal heart for seldom of significance, and can be considered excitation to reach the right ventricle because to be a normal variant. Conduction in right bundle branch block: Remember that any upward deflection, however Fig.
Conduction in left bundle branch block: At this point it is worth considering in a little If the anterior fascicle of the left bundle more detail the anatomy of the branches of the branch fails to conduct, the left ventricle has to His bundle. The right bundle branch has no be depolarized through the posterior fascicle, and main divisions, but the left bundle branch has so the cardiac axis rotates upwards Fig.
Relief of symptoms always comes first. However, some general points Left bundle branch block can be made about the action that might be taken if the ECG shows conduction abnormalities. AV node, the His bundle, the right and left IP — the septum is depolarized first from left branches of the His bundle, and the anterior For more on to right and posterior fascicles of the left bundle conduction — lead V1 looks at the right ventricle and problems, see branch. When attempting to analyse a cardiac rhythm Extrasystoles 63 remember: The keys to rhythm abnormalities are: Look for depolarization that follows the normal activation the lead in which they are most obvious.
Depolarization can, however, begin P wave per QRS complex. The SA node normally has the be ms or less. The rate be seen most easily, full lead ECGs are of discharge of the SA node is influenced by the better than rhythm strips.
Although rhythms Fig. In the supraventricular Fig. The QRS In ventricular rhythms, on the other hand, complex is therefore normal, and is the same the depolarization wave spreads through the whether depolarization was initiated by ventricles by an abnormal and slower pathway, via the Purkinje fibres Fig.
The QRS complex is therefore wide and is abnormally shaped. Repolarization is also abnormal, so the T wave is also of abnormal shape. Abnormal rhythms arising in the atrial muscle, the junctional region or the ventricular muscle can be categorized as: Atrial inactive if competition between normal and escape beats can occur singly.
If the region around the AV node takes over as The heart is controlled by whichever site is the focus of depolarization, the rhythm is spontaneously depolarizing most frequently: If block Fig. This rhythm is more active SA node.
Escape rhythms are not primary disorders, 3. Although the appearance conducting pathway. They are commonly seen of the ECG is similar to that of ventricular in the acute phase of a heart attack, when they tachycardia described later , accelerated may be associated with sinus bradycardia. It is idioventricular rhythm is benign and should important not to try to suppress an escape not be treated.
Ventricular tachycardia should rhythm, because without it the heart might not be diagnosed unless the heart rate exceeds 60 stop altogether. The bradycardias — the slow rhythms 3 Fig. In a junctional extrasystole there is Fig.
However, when they QRS complex Fig. The QRS complexes occur early in the T wave of a preceding beat of atrial and junctional extrasystoles are, of they can induce ventricular fibrillation see p.
Ventricular extrasystoles, however, have It may, however, not be as easy as this, abnormal QRS complexes, which are typically particularly if a beat of supraventricular origin wide and can be of almost any shape Fig. QRS complex and an abnormal T wave: It is advisable 4. Is the T wave the same way up as in the to get into the habit of asking five questions normal beat? In supraventricular beats, it every time an ECG is being analysed: Does an early QRS complex follow an early 5.
Does the next P wave after the extrasystole P wave? If so, it must be an atrial extrasystole. In both 2. Can a P wave be seen anywhere? P wave cycle Fig. If the causing a sustained tachycardia. The difference between this important thing is to try to identify a P wave. In first, second or 3. In the record in Figure 3. The QRS complex is of normal seen in any lead. Note Sinus rhythm: It is the latter which is important in the and is always worth trying because it may make diagnosis and treatment of arrhythmias.
Carotid the nature of the arrhythmia more obvious sinus pressure completely abolishes some Fig. Carotid sinus pressure activates a supraventricular arrhythmias, and slows the reflex that leads to vagal stimulation of the SA ventricular rate in others, but it has no effect and AV nodes.
This causes a reduction in the on ventricular arrhythmias. Excitation has to spread by an abnormal path through the ventricular muscle, and the QRS complex is therefore wide and abnormal.
Finding P waves and seeing how they relate help to differentiate between the two possible to the QRS complexes is always the key causes of a tachycardia with broad QRS to identifying arrhythmias. Always look complexes. If a patient with an acute myocardial carefully at a full lead ECG. If possible, compare the QRS complex will almost always be ventricular tachycardia. Fibrillation can occur in have the same shape as during normal the atrial or ventricular muscle. When the atrial muscle fibres contract 4.
Left axis deviation during the tachycardia independently there are no P waves on the usually indicates a ventricular origin, as ECG, only an irregular line Fig. At times does any change of axis compared with a there may be flutter-like waves for 2—3 s. The record taken during sinus rhythm.
AV node is continuously bombarded with 5. If during the tachycardia the QRS complex depolarization waves of varying strength, and is very irregular, the rhythm is probably depolarization spreads at irregular intervals atrial fibrillation with bundle branch block down the His bundle. The AV node conducts see below. Because conduction into and All the arrhythmias discussed so far have through the ventricles is by the normal route, involved the synchronous contraction of all the each QRS complex is of normal shape.
When individual often be seen much better in some leads than in muscle fibres contract independently, they are others Fig. Lead V1: The accessory identified, and the ECG is totally disorganized bundles form a direct connection between the Fig. The PR interval is short, due to a loose connection, the diagnosis is easy.
Some more detail in Chapter 7. Depolarization can certainly accounts for some tachycardias, others IP spread down the His bundle and back up the are due to re-entry circuits within the heart For more accessory pathway, and so reactivate the atrium. Although this — Sinus tachycardia: For fast or slow sinus rhythm, treat the the arrhythmia or may have no effect.
Extrasystoles rarely need treatment. In patients with acute heart failure or low in block e. Patients with any bradycardia that is has no effect. IP affecting the circulation can be treated 6. Narrow complex tachycardias should For more on with atropine, but if this is ineffective they be treated initially with adenosine. Wide complex tachycardias should pp. WPW syndrome. Is the abnormality occasional or sustained? Are there any P waves? Are there as many QRS complexes as P waves?
Are the ventricles contracting regularly extent like recognizing an elephant — once seen, IP or irregularly? However, in cases of difficulty 5. Is the QRS complex of normal shape? For more on it is helpful to ask the following questions, tachycardias, 6.
What is the ventricular rate? Is the QRS complex of normal duration? Is the ST segment raised or depressed? Abnormalities of the T wave 98 6. Is the T wave normal? Other abnormalities of the ST segment Remember: The P wave can only be normal, unusually tall or unusually broad.
Then ask the following questions — always too tall, and it may contain an abnormal in the same sequence: Q wave. Are there any abnormalities of the P wave? The ST segment can only be normal, 2.
What is the direction of the cardiac axis? Apart from alterations of the shape of the P wave 2. Left atrial hypertrophy usually due to mitral associated with rhythm changes, there are only stenosis causes a broad and bifid P wave two important abnormalities: Anything that causes the right atrium to become hypertrophied such as tricuspid Fig.
Since characteristics: Its duration is no greater than ms three in lead V1 becomes upright i. In a right ventricular lead V1 , the S wave this is nearly always abnormal Fig. There is greater than the R wave. In a left ventricular lead V5 or V6 , the height of the R wave is less than 25 mm. Left ventricular leads may show Q waves due to septal depolarization, but these are less than 1 mm across and less than 2 mm deep.
In each case, the increased width S indicates that depolarization has spread V6 through the ventricles by an abnormal and therefore slow pathway. Peaked P waves.
Right axis deviation S waves in lead I. In pulmonary embolism the ECG may show 3. Tall R waves in lead V1. Right bundle branch block. Inverted T waves in lead V1 normal , abnormal other than sinus tachycardia. When a spreading across to lead V2 or V3.
A shift of transition point to the left, of the following: If in doubt, V4 clockwise rotation. A deep S wave will treat the patient with an anticoagulant. Left ventricular hypertrophy causes a tall R However, do not hesitate to treat the patient if wave greater than 25 mm in lead V5 or V6 the clinical picture suggests pulmonary embolism and a deep S wave in lead V1 or V2 Fig. It is difficult to diagnose minor degrees of left ventricular hypertrophy from the ECG.
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Home Contact us Help Free delivery worldwide. Free delivery worldwide. Bestselling Series. Harry Potter. Popular Features. New in Medical Diagnosis Cardiovascular Medicine. Description This highly respected book is a simple, readable guide to the accurate identification and interpretation of normal and abnormal electrocardiogram ECG patterns for medical students, nurses and junior doctors.
The emphasis throughout is on the straightforward practical application of the ECG. It will prove useful to all medical and health care staff who require clear, basic knowledge about the ECG. Product details Format Paperback pages Dimensions x x 12mm Other books in this series.