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The ECG in Practice John R. Hampton. The ECG in Practice is a clinically- orientated book, showing how the electrocardiogram can help صيغة الكتاب: pdf. The ECG In Practice. 6th Edition. Authors: John Hampton. Paperback ISBN: Paperback ISBN: eBook ISBN: ECG. PROBLEMS. John R. Hampton. Emeritus Professor of Cardiology. University of Made Easy or The ECG in Practice is fine so far as it goes, but it.

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ECG. Made Easy. EIGHTH EDITION. John R. Hampton. DM MA DPhil FRCP . cross-references to useful information in the book The ECG in Practice, 6th edn. Ebook The Ecg In Practice pdf by David Adlam, Jo Hampton, John R. Hampton Ebook The Ecg In Practice djvu by David Adlam, Jo Hampton. John R. Hampton-The ECG Made Easy-Churchill Livingstone ().pdf . The ECG in Practice deals with the Foundation Professor of Medicine at the.

Conduction and its problems 36 3. The rhythm of the heart 56 4. Making the most of the ECG 5. The ECG in healthy subjects 6. The ECG in patients with chest pain or breathlessness 7. The ECG in patients with palpitations or syncope 8.

Part I of this book explains why the speed of electrical conduction through different electrical activity of the heart can be recorded parts of the heart, and to determine the rhythm as an ECG, and describes the significance of of the heart. The ECG can provide evidence to support a diagnosis, and in some cases it is The shape of the QRS complex 11 crucial for patient management.

It is, however, Making a recording — practical points 19 important to see the ECG as a tool, and not as an end in itself.

In some countries, the upon it. This chapter is about these rules and facts. Since all muscular contraction will be detected, the electrical changes associated with contraction Sinoatrial node of the heart muscle will only be clear if the patient is fully relaxed and no skeletal muscles are contracting.

There is a delay while to the part of the heart which is controlling the depolarization spreads through another special activation sequence. The left The muscle mass of the atria is small compared bundle branch itself divides into two. Within with that of the ventricles, and so the electrical the mass of ventricular muscle, conduction change accompanying the contraction of the atria spreads somewhat more slowly, through is small.

P U Its origin is uncertain, though it may represent repolarization of the papillary muscles. If a U Q wave follows a normally shaped T wave, it can S be assumed to be normal. If it follows a flattened T wave, it may be pathological see Ch. The different parts of the QRS complex are labelled as shown in Figure 1.

If the first deflection is downward, it is called a Q wave ventricular mass is large, and so there is a large Fig. An upward deflection is called an R deflection of the ECG when the ventricles are wave, regardless of whether it is preceded by a depolarized: Q wave or not Figs 1. ECG machines run at a standard rate of of the heart. Each large square 5 mm represents beginning of the P wave to the beginning of the 0.

QRS complex, and it is the time taken for 1. Therefore, there are five large squares per excitation to spread from the SA node, through second, and per minute. The normal PR interval is — ms, Just as the length of paper between R waves represented by 3—5 small squares. Most of this gives the heart rate, so the distance between the time is taken up by delay in the AV node Fig.

The QRS complex duration is conduction from the atria to the ventricles. The QT interval varies with the heart rate. It 1 cm is prolonged in patients with some electrolyte abnormalities, and more importantly it is prolonged by some drugs. A prolonged QT interval greater than ms may lead to ventricular tachycardia. A standard signal of 1 millivolt mV A limited amount of information is given by should move the stylus vertically 1 cm two the height of the P waves, QRS complexes and large squares Fig.

For example, heart. Each lead electrodes, which are joined to the ECG gives a different view of the electrical activity of the heart, and so a different ECG pattern. Strictly, each ECG pattern should be called Table 1. Thus, leads V1 and V2 look at the surface of the heart, leads III and VF at the right ventricle, V3 and V4 look at the septum inferior surface, and lead VR looks at the right between the ventricles and the anterior wall of atrium.

In each lead the pattern is characteristic, being We now need to consider why the ECG has a similar in individuals who have normal hearts. The cardiac rhythm is identified from whichever lead shows the P wave most clearly — usually lead II.

If predominantly downward, many directions at once, but the shape of the or negative the S wave is greater than the R QRS complex shows the average direction in wave , the depolarization is moving away from which the wave of depolarization is spreading that lead Fig.

When the depolarization through the ventricles Fig. Q or positive i. Hence, the axis may wave — the axis — will swing towards the right. It is associated mainly with pulmonary fact this axis change is usually due to a conditions that put a strain on the right side of conduction defect rather than to increased bulk the heart, and with congenital heart disorders. Lead I is taken as looking at deviation is present. Right and left axis deviation in themselves are Fig. The shape of the QRS complex 1 Leads V1 and V2 look at the right ventricle; In a left ventricular lead there is an upward leads V3 and V4 look at the septum; and leads deflection R wave as the ventricular muscle is V5 and V6 at the left ventricle Fig.

In a right ventricular lead the deflection is first When the whole of the myocardium is upwards R wave as the septum is depolarized. If the more of the precordium than is normal, the limb electrodes are wrongly attached, the transition point will move from its normal lead ECG will look very odd Fig.

Seen from below, the to repeat the recording. ECG is characteristic of chronic lung disease. POINTS Identify the second rib interspace by feeling for the sternal angle — this is the point where the Now that you know what an ECG should look manubrium and the body of the sternum meet, like, and why it looks the way it does, we need and there is usually a palpable ridge where the to think about the practical side of making a body of the sternum begins, angling downwards recording.

Some, but not all, ECG recorders in comparison to the manubrium. This is particularly the second rib space is just below this. Having useful when the rhythm is not normal. The effects the imaginary vertical line starting from the on the ECG of poor skin contact are shown in midpoint of the clavicle ; V5 in the anterior Figure 1. The skin must be clean and dry — axillary line the line starting from the fold of in any patient using creams or moisturizers skin that marks the front of the armpit ; and V6 such as patients with skin disorders it should in the midaxillary line.

Hair is a poor conductor of patients all that is needed is a rub with a paper the electrical signal and prevents the electrodes towel. In exercise testing, when the patient is from sticking to the skin. Shaving may be likely to become sweaty, abrasive pads may be preferable, but patients may not like this — if used — for these tests it is worth spending time the hair can be parted and firm contact made to ensure good contact, because in many cases with the electrodes, this is acceptable.

After Fig. It can be that 1 mV of signal causes a deflection of 1 cm Fig. If the calibration setting pericardial effusion reducing the electrical is wrong, the ECG complexes will look too signal from the heart. So, check the calibration. The faster activity, which in extreme cases can mask the speed is used regularly in some European ECG Figs 1. So, the ECG recorder will do most of the In theory this can make the P wave easier to see, work for you — but remember to: It is therefore essential that a patient is Then just press the button, and the recorder relaxed, warm and lying comfortably — if they will automatically provide a beautiful lead are moving or shivering, or have involuntary ECG.

This should Many ECG recorders automatically provide a take the form of a description followed by an report, and in these reports the heart rate and interpretation. However, the description of the rhythm and of the QRS and T patterns should 1. Rhythm be regarded with suspicion. Recorders tend to 2. Cardiac axis none exist: A description of the QRS complexes 32 your own reporting. A description of the ST segments and T waves. How to report an ECG 1 Fig. One of the main problems of frequently not done.

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.

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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.

The ECG in Practice

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.

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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. However, Q waves greater than one small square in width representing 40 ms and greater than 2 mm in depth have a quite different significance.

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Enlarge cover. Error rating book. Refresh and try again. Open Preview See a Problem? Details if other: Thanks for telling us about the problem. Return to Book Page. Hampton ,. David Adlam. This clinically-orientated book shows how the electrocardiogram is used to aid the diagnosis of patients with cardiovascular disease. Each chapter begins with a brief consideration of the history and examination of the patient to assist the doctor plan how to use the ECG in the most intelligent and profitable way.

The text explains the variations in the patterns of ECGs wh This clinically-orientated book shows how the electrocardiogram is used to aid the diagnosis of patients with cardiovascular disease. The text explains the variations in the patterns of ECGs which are seen in both healthy people as well as those with cardiac problems, and illustrates the abnormalities with a comprehensive range of examples.

A new page size and text design gives a much clearer presentation of the ECGs, allowing full traces to be presented on one page A new chapter on electrophysiology and electrical devices responds to the increasing occurrence of pacemakers and implanted defibrillators in patients The "What to do" sections at the end of chapters have been fully updated Get A Copy.

Kindle Edition , pages.

The ECG In Practice

Published June 11th by Churchill Livingstone first published January 1st More Details Other Editions Friend Reviews. To see what your friends thought of this book, please sign up. Lists with This Book. This book is not yet featured on Listopia. Community Reviews. Showing Rating details. Sort order. Aug 06, vinay rated it really liked it. Ajay Nenwani rated it it was amazing Aug 10, Awfa Zain rated it really liked it Mar 31, Middlethought rated it it was amazing Aug 05, With pacemakers and implanted defibrillators now common among patients on general medical take, this material guides the reader in recognising their purpose and making a preliminary analysis of any malfunction.

Books by John R. Details if other: Right and left axis deviation in themselves are Fig. A few seconds before the cardiac arrest, he A QTc interval longer than ms is likely developed a transient broad complex tachycardia to be abnormal. The unique page size allows presentation of all lead ECGs across a single page for clarity.

Kindle Edition , pages. If VF or pulseless VT persists, give amiodarone mg i.