ECG

Normal ECG

cont
PR Interval: 0.12 - 0.20 sec
QRS Duration: 0.06 - 0.10 sec
QT Interval (QTc<0.40 sec)

sec

Tachy arrythmia

Atrial Flutter

Atrial Fibrillation

AF

Heart rate Irregular & > 350 b/ m

P absent (fibrillary p wave)
Narrow QRS complex <.12
Irregular R-R interval

 S/S :Palpitation,

Chest pain , SOB, Chest

tightness, Syncope,
Pounding heart and fatigue .

Management:
If Pt is unstable - Electrical cardio version
If pt is stable- blocker , diltiazem , verapemil,
Digoxin
Anticoagulent

SVT

HR > 200 b/m

P wave - absent
R-R interval regular
QRS - narrow

 S/S :Palpitation, SOB, dizziness, fainting

episode associated
with exercise, activity, angina, CHF, caffeine.
Management:
If pt is unstable - synchronised cardioversion
If pt is stable Vegal maneuver, carotid massage
I/V Adenosine
blocker , verapemil

Ventricular Tachycardia
P absent
QRS wide and bizarre
shaped but regular

Ventricular Fibrillation

 Management:
If pt is unstable Synchronized electrical cardio
version
If pt is stable Amioderon , procainamide,
Quinidine

Torsades de Pointes

It is a variant of Vent Tachycardia

QRS is twisted at its base

 Management :
I/V Mg ,
Temporary pacing
Lidocane

WPW Syndrome

Short P-R interval(< 3 small sq),

No iso- electric line bet P and R wave, R wave starts just
after P wave
QRS complex is wide > .12 sec
Delta wave - after P wave there is a slurred upstroke in R
wave in lead L1, V4,V5 and V6

 Management :
If pt is unstable Synchronized electrical cardio
version
If pt is stable I/V Procainamide, amioderon
Radio frequency ablation of bypass tract

Brady arrythmia
(Heart block)
1st degree H.B :

Heart rate and rhythm is normal

P-R interval is> .2 sec (> 5 small box)
QRS is normal

2nd degree H.B

Mobiz type

Gradual prolongation of P-R interval with one drop, P wave with

no QRS complex after it

Cont.
Mobiz type

P-R interval is fixed or constant

2:1 or 3:1 block , every 2 or 3 QRS complex , P
wave fails to conduct

3rd Degree H.B

H.R < 40 b/m

P wave normal but not related with QRS complex
No relation bet P and R
P-P distance is constant and R-R is distance is
constant

Cont.
Management:
1st degree H.B and Mobiz type , need no
treatment.
Mobiz type and 3rd degree H.B need treatment.
Permanent Pacemaker.
Drug Atropin , Dopamin , epinephrin

Bundle Branch Block

RBBB :

Wide QRS
rSR

pattern in V1 and V2
Broad
S in V5 and V6
Rt axis
deviation

LBBB
Wide QRS
complex
RR pattern in V5
and V6
Broad S wave in
V1 and V2
Lt axis deviation

Myocardial Infarction

Anterior wall- V2, V3 and V4

Septal wall V1 and V2
Lateral wall- V5 , V6 and L , aVL
Inferior wall- L ,L , aVF

CONT.
STMI

Deep

Q wave >.04sec
ST
elevation>2mm in
chest lead,>1mm inLL
T
inversion

Deep Q wave

CONT

Antero Septal. MI

Anterior. MI

Inferior. MI

Lateral MI

Question 1
A 25 year old male presents to the ER complaining of palpitations of 1 hour duration.
He denies any major medical illness. He does not smoke but admits that he drinks
caffeine excessively.
His vitals are within normal limits except for a pulse rate of 160/min. The EKG showed
a SVT which has been controlled by carotid massage. A second EKG tracing is done
and showed the following:

Which of the following is the most likely diagnosis of this patient?

a) Brugada syndrome
b) James preexcitation syndrome
c) Mahaim Preexcitation syndrome
d) Right bundle branch block
e) Wolff Parkinson White syndrome

 Ans is E
WPW is a congenital heart abnormality in which an accessory pathway
connects the atria to the ventricle leading to a preexcitation syndrome. It
is present in around 0.2-0.3% of the population. It is characterized by its
special EKG showing: the Delta wave (slow depolarization of the QRS
Complex), a wide QRS complex and a short PR interval.
Brugada syndrome is presented on the EKG by ST elevation with at least
2 mm J-point elevation a gradually descending ST segment and a
negative T-wave.
James and Mahaim syndromes are preexcitation syndromes without a
Delta wave.
RBBB is characterized by a wide QRS complex and an M shape of the
QRS complex in V1 and V2; moreover, it has no delta wave.

Question 2
A 30 year old male patient presents to the ER complaining of palpitations that
started about an hour ago.
The patient is concerned because nothing like this has ever happened to him
before. He denies any past medical problems. He admits that, due to stress at
work, he smoked too much and drank five cups of coffee a few hours ago.
His vital signs are: BP is 125/80, temp is 37C, pulse is 160/min and respiratory
rate is 22/min. a STAT EKG shows the tracing below (Lead II):

You start carotid massage immediately; however the heart tracing is still the
same. What would you do next?
a) Adenosine
b) Asynchronous cardioversion
c) Magnesium sulfate
d) Propranolol
e) Synchronized cardioversion

Ans Is A
Explanation:
The patient is having supraventricular tachycardia this
EKG shows: narrow and regular QRS plexes with absent P
wave. The patient is clinically stable; thus, the goal is to
convert him back to sinus rhythm through a brief
episode of AV block. Adenosine is the drug of choice for
short-term termination of SVT.
Synchronized cardioversion would be appropriate if the
patient was unstable.
Asynchronous cardioversion is the treatment of choice
for ventricular fibrillation.
Although propranolol is effective, it is slow in action and
much less effective than adenosine in the treatment of
SVT.

Question 3
A 35 year old man presents to the ER complaining of
retrosternal chest pain that began 2 days ago.
The pain is sharp and pleuritic in nature and increases when
the patient lies down. He recalls flu like illness one week ago.
The EKG shows the following tracing below:

What is the most appropriate next step of management of this

patient?
a) Azithromycin
b) Heparin
c) Ibuprofen
d) Prednisone
e) Streptokinase

 Correct Answer:C
Acute pericarditis is usually viral in etiology and
presents by a sharp, pleuritic chest pain that is
decreased when leaning forward. The patients EKG is
characteristic for acute pericarditis: diffuse ST-segment
elevation in all leads with PR-segment depression.
This is not MI! Dont be fouled!
Acute pericarditis is best treated with NSAIDS.

 Ans is C

Question 6

Thank You