This is the lecture notes that I have been giving to the medical students (2nd, 3rd, final year) for the last two years (updated 2008).

1. Tutorial in ECG Dr. Chew Keng Sheng Emergency Medicine Universiti Sains Malaysia http://emergencymedic.blogspot.com

3. Vertical and horizontal perspective of the ECG Leads Leads Anatomical II, III, aVF Inferior surface of heart V1 to V4 Anterior surface of heart I, aVL, V5, and V6 Lateral surface of heart V1 and aVR Right atrium

4. Location of MI and Affected Coronary Arteries Location of MI Affected Artery Lateral Left circumflex Anterior LAD Septum LAD Inferior RCA Posterior RCA Right Ventricle RCA

5. Right Sided & Posterior Chest Leads

7. Normal Sinus Rhythm

8. Instant Recognition of Axis Deviation

9. Cardiac Axis Normal Axis Right Axis deviation Left Axis Deviation Lead I Positive  Negative  Positive  Lead II Positive  Positive  Negative  Lead III Positive Positive Negative

10. Calculating Cardiac Axis

15. P Pulmonale and P Mitrale

17. RAH and LAH Right Atrial Hypertrophy Left Atrial Hypertrophy

20. QRS In Hypertrophy

22. Conditions with Tall R in V1

23. Right Atrial and Ventricular Hypertrophy

24. COPD

27. Hypertrophy Strain Pattern vs ACS

29. Variable Shapes Of ST Segment Elevations in AMI Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified Approach. 7th ed: Mosby Elsevier; 2006.

33. QT Interval

34. Long QT Syndrome

38. Calculation of Heart Rate

41. Rhythm Disturbances

43. Note that by this time, if 3 rd shock is required, it is the DRUG ->SHOCK-> CPR sequence. It is the same sequence thereafter The drugs to be given at this stage are vasopressors Cardiac Arrest

44. After the 3 rd sequence and giving adrenaline/vasopressin, consider giving antiarrhythmics like amiodarone for VF or magnesium for torsades de pointes. The sequence is still the same DRUG->SHOCK-> CPR. At any time, if rhythm becomes non-shockable, follow the non-shockable algorithm Cardiac Arrest

45. For cardiac arrest, the first thing to know is whether the rhythm is shockable or not shockable. In periarrest rhythms (bradyarrhythmias and tachyarrhythmias, the first thing to know is whether it STABLE or NOT STABLE

47. Atropine 0.5 mg each bolus up to 3 mg. Atropine as temporizing measure only. Needs transcutaneous/transvenous pacing

50. * For polymorphic VT – if patients become unstable, perform defibrillation rather than cardioversion. If ever in doubt whether to perform cardioversion or defibrillation, then perform DEFIBRILLATION Rule of thumb – if your eye cannot synchronize to each QRS complex, neither can the machine!

53. Narrow complexes and regular – attempt vagal maneuver and adenosine; Narrow complexes but not regular- likely AF. Don’t give adenosine. May attempt rate control using beta blocker or diltiazem

54. Amiodarone can be given for both regular and irregular broad complexes

56. Thank You Contact me: Dr. K.S. Chew [email_address] http://emergencymedic.blogspot.com