||

Dr. Shaf3y

ECG

:




: : :
:
ECG

,, ,,
,,
,,
4
12 2013
,,
ECG

,, ECG
exam oriented ,,
,, )
,, (


,, ,,
mentality
,,
Anyway

,, ECG

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Dr. Shaf3y

ECG

) Limb leads electrodes limbs

(
Limbs
leads 6
lead 1 ,, lead 2 ,, Lead 3 ,, AVR ,, AVL ,, AVF
chest leads
V1, V2, V3, V4, V5 and V6

AVR ,, ,,
,,
ECG

,, ) (
,,
) ( second >> 0.04
,,
) P wave ( 0.04
second 0.08

) X 2 ( =

,,

) 0.1 (
,,


,,
ECG
,,

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Dr. Shaf3y

ECG

ECG ,,

lead ,, lead ,, lead

,, aVR ,, aVL aVF

V1 ,, V2 ,, V3
V4 ,, V5 ,, V6

,,
lead ,, P QRS T wave ,, P QRS R
wave

lead P QRS T wave ,, P QRS T wave ,,

lead ,, ,,

Lead
,,
Long strip
Long strip

lead ,, lead
aVF




,,

ECG ,,

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Dr. Shaf3y

ECG

rhythm
rhythm
Long strip

,,
rhythm
Long strip
rhythm << regular irregular
Rs

Regular

) RRR ( Rs
Irregular

ECG long strip

Lead 3
lead 3
rhythm
Long strip
,,
Long strip ,,
lead 3
rhythm << regular irregular
,,
3
regular irregular
rhythm
3

rhythm
,, rhythm
rate
rate
,,
rhythm regular

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Dr. Shaf3y

ECG

rate 300

,, ,,

QRS ,, QRS
rate
150 = 2 / 300
,, 3

100 = 3 / 300

,,
,,

,,
rate 1500

,, ,, >> ,, >>
,,
13
rate
1500 13 115.38
115



,,
,, heart rate rhythm regular
,,
rhythm ,, regular
rhythm << irregular
rhythm << irregular heart rate
30 ,,

30

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Dr. Shaf3y

ECG

,, ,,
,, 5
heart rate
X 10 = 50 5
,,
30
,,
15 ,, ,, 30
15 ,,
30
30 ,, 30

,,



!!
P:
,, ,,
,,
heart rate rhythm
Axis
Axis
,, ,,

) English school << vector ( P:



,,
vector

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Dr. Shaf3y

ECG

,,
,, SA node
SA node
SA node
,,
AV node ventricles
both ventricles

,,
Axis

SA node ,,
Axis ,,


Axis
Axis

,,

lead ,, lead aVF
,,
,, aVF


QRS

QRS
QRS
Lead ,, QRS << Positive

) (
Positive

lead ,,

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Dr. Shaf3y

ECG

QRS positive
normal

lead
QRS << positive
lead aVF
QRS << Positive
Axis is normal
Axis is normal

,,
,,

>> heart left ventricle

,,

axis left
Left
right ventricle ,,

axis ,, right axis deviation

Left ventricle
left axis deviation

,,
Left right axis deviation

Lead ,,
) QRS << negative (

lead aVF
QRS << positive
,,

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Dr. Shaf3y

ECG

QRS

QRS ,,
,,
,,


,, right
axis deviation

QRS
lead positive
lead negative

,,

,, left axis
deviation

right axis deviation
Right ventricular enlargement
Right bundle branch block

Left axis deviation

Left ventricular enlargement
Left bundle branch block
axis

,,
rhythm
Long strip
long strip

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Dr. Shaf3y

ECG

lead 3
rate
,, regular
300
1500
Irregular

30 ,,
rhythm
axis
lead lead ) ( aVF
,, Positive Normal
Lead positive lead ) Negative ( aVF
,, left axis deviation
Lead ,, negative lead ) positive ( aVF
,, right axis deviation

,,
rhythm rate axis
lead :
lead :
,, P PR
lead
Lead


,, P PR

,, P wave
P wave
X 2.5 2.5

2.5

10

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Dr. Shaf3y

ECG

2.5
lead
Lead
X 2.5 2.5

P wave
,,
P wave ,, 2.5 ,, 3

P mitral
Left atrial enlargement

P mitral
P wave ,, 2.5
P pulmonale

Right atrial enlargement

,,
,, ,,
,, ,,
: ,,
: ,,
,,
,, ,, Normal Mitral
,,
!!!
V1
P pulmonale P mitral Normal

V1

,, V1
P wave biphasic
V1
P wave biphasic

11

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Dr. Shaf3y

ECG

right atrium
left atrium

,,
SA node activate
right atrium
activate Left ventricle
SA node right
wave
right atrium
wave
Left atrium
,,

positive Negative

,,
wave ,, ,, right atrial enlargement

P wave
,, biphasic ) ,, Positive ( negative
Positive ,, right atrial enlargement
negative ,, left atrial enlargement
Lead

,,

P wave << absent

P wave << is absent

AF

rhythm << irregular

12

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Dr. Shaf3y

ECG

AF

,,
rhythm << regular

rhythm << regular
P wave
QRS

QRS

QRS << wide
wide
QRS 3
) 3 (
3
Wide QRS :
Ventricular tachycardia

Ventricular fibrillation

,,
QRS << narrow
:
supra ventricular tachycardia

Nodal rhythm

rate
>> supra ventricular tachycardia
,,
Nodal rhythm

Sawtooth appearance ,,
atrial flutter

,,

Lead

13

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Dr. Shaf3y

ECG

P PR
P wave
X 2.5 2.5
P

) P mitral ( left atrial enlargement

) P pulmonale ( right atrial enlargement

P wave V1

>> P wave << Sawtooth Atrial flutter

P wave >>
>> rhythm << irregular AF
rhythm << regular
QRS
: Wide
Ventricular fibrillation
ventricular tachycardia
: Narrow
supra ventricular tachycardia
Nodal rhythm

supra ventricular tachycardia
Nodal rhythm ) nodal rhythm (


,,
P wave

PR interval
,, PR
Lead

14

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Dr. Shaf3y

ECG

,, PR
P QRS
>> Normally 3 5

0.1 second >> 0.2

0.4

X 0.04 = 0.12 3

X 0.04 = 0.20 5

PR
PR normal l

,,
PR << prolonged
5
1st degree heart block

First degree heart block

,,
PR 3
) WPW ( Wolff-Parkinson-White

PR << variable
variable

PR variable
Lead
:
,, P QRS ,, P QRS P QRS

15

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Dr. Shaf3y

ECG

PR << variable

ECG

Variable QRS

QRS
>> QRS << wide
complete heart block
Complete heart block
QRS << wide
complete heart block

wide QRS
>> QRS 3
complete heart block
>> QRS << narrow
second degree heart block
,, Mobitz one Mobitz two
,, Wenckebach!!!
PR !!!

wide QRS
Complete heart block

,,
Narrow QRS
second degree heart block
PR
QRS

16

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Dr. Shaf3y

ECG

,, QRS
,,

rhythm

long strip
,,
,, regular irregular
long strip
lead
rate
rhythm << regular

300
1500
rhythm << Irregular
30 ,, 10


,,
Axis
axis lead
Lead Lead ) ( aVF
Lead Positive lead ) positive << Normal ( aVF

axis deviation
lead positive lead ) >> negative ( aVF
left axis deviation
lead negative lead ) >> positive ( aVF
right axis deviation

,, Lead
:
P wave
PR interval
P wave << Normally

17

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Dr. Shaf3y

ECG

X 2.5 2.5
>> P mitral
left atrial enlargement
>> P pulmonale
right atrial enlargement

Lead
P wave V1
>> P wave << biphasic ) positive
( Negative
right atrium
left atrium
right atrial enlargement
left atrial enlargement

,,
Sawtooth
atrial flutter
P wave << absent
Regular
irregular

: rhythm

irregular
AF
regular
QRS
Wide QRS
Ventricular tachycardia
ventricular fibrillation
QRS << Narrow
supra ventricular tachycardia

Nodal rhythm

rate
>> supra ventricular tachycardia

18

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Dr. Shaf3y

ECG

,,
Nodal rhythm

PR
lead
Lead

PR << Normally
3 5
5
first degree heart block

3
) WPW ( Wolff-Parkinson-White
variable PR interval
: QRS
>> wide QRS complete heart block
narrow QRS << Second degree heart block

) WPW ( Wolff-Parkinson-White ) ( Preexcitation syndrome

Nodal

QRS
,,
QRS

comment QRS
V1

V1

19

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Dr. Shaf3y

ECG

>> V1
RSR
right bundle branch block

RSR
V1 right bundle branch block
,,
V6
,,,
V
V1

V6
V6
left bundle branch block

RSR V1
right bundle branch block

,,
V6
,, left bundle branch block
,,
V1

V1

V1 << normally

P wave biphasic
RS
Normal

20

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Dr. Shaf3y

ECG

,,
ECG ,, QRS

ECG heart
,,
,,
electrodes ,, heart
Heart
,,



ECG QRS


Q wave ,, negative wave P wave
,, R wave Positive P wave
,, P wave
>> Q wave
>> R wave
S wave
negative R wave

,,,
S wave

,,
V1 normally << RS

,, ,, ,,
ECG
>> electrode positive
electrode
Positive
electrode

21

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Dr. Shaf3y

ECG

Negative

,,
electrode ) (
Positive
,, negative
,,


,, heart
Inter ventricular septum
,, AV node bundle
of His
,, right bundle left
bundle

V1 V2 V3 V4
V5 V6
chest leads

,,
AV node bundle of His

septum
activate septum
left bundle branch
from left to right
Left activation

,,
V1
Positive

right ventricle
At the same time

left ventricle

V1

22

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Dr. Shaf3y

ECG

right

right

right ,, Positive
,, left left ,,
Negative

Negative Positive
Left ventricle
r S ,,
V1 << r
r septum right ventricle
S
Left ventricle

,,
right ventricle septum
r
left ventricle
S
,, V6

bundle of His
septum
,, negative
>> Q
,, ventricle

left ventricle

Positive

right

Negative
s wave

23

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Dr. Shaf3y

ECG

V6 QRS

Q
septum
R
Left ventricle
s
right ventricle
,, right ventricular enlargement
V1
r
R
left ventricular enlargement

S
,, V6
Q septum
R left ventricle
S right ventricle
right ventricular enlargement
V6 S
left ventricular enlargement
V6 R

,,
,,
septal hypertrophy
V1
R
V6
Q

24

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Dr. Shaf3y

ECG

,,
V

V1
,, V1
>> right bundle branch block

,,

V6
>> left bundle branch block

,,

right bundle branch block

right

,, right bundle

V1
septum
activation septum
Left
r
Left ventricle

,, wall activation right

ventricle

R

right bundle branch
septum ,,
,,
activation
From left to right
Positive ) r (

25

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Dr. Shaf3y

ECG

V1

) left ventricle ( left bundle branch
V1
) S ( negative
,,
right ventricle
wall
,,
right ventricle activated
,, activated
) ( V1
V1
R
R
,,
left bundle branch block
,, V6


left bundle branch
Left bundle branch
right bundle branch
,, ,,
septum
left bundle
activation septum
right bundle branch
right left

,,
activation septum
Positive

right ventricle

negative

26

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Dr. Shaf3y

ECG

wall activation left ventricle

positive
RSR

,,

RS R
,,
V1
,, right bundle branch block

,,
V6
,, left bundle branch block

V1

V1

V1
,, V1 R S
right ventricular enlargement
r
septum right ventricle
,, R s
) V1 r ,, S

,, S V1
V6
R wave V1
V6

,, ECG
r ,, small letter R << capital letter
R ,, capital
,,
r ,, Small

27

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Dr. Shaf3y

ECG

S wave ) S ( capital ) s ( small

,,
,,
,,
(
r
septum right ventricle
,, R s
r ,,
R >> S right ventricular enlargement

V6
) V1 ( V6
,,
V6
ECG P QRS T ,,
Q septum
R left ventricle
S right ventricle

R 5 ,,
left ventricular enlargement
R Left ventricle
Q septum
S right ventricle

,, ,,
V1
Right bundle branch block

,,

V6

Left bundle branch block

28

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Dr. Shaf3y

ECG

V1
R ,, S right ventricular enlargement
) septal hypertrophy septal hypertrophy (

,,
V6
R 5
left ventricular enlargement
,,
,, V1 ,,
V1 V2
V5 V6

,, ,,
,,
V1 ,,
V6 ,,
V1 R S
V6 R 5
QRS leads
QRS leads

QRS Leads
,,
Pathological Q

Pathological Q

Pathological Q
Pathological Q
:
,, Q
,, P Q T complex Q
Q 1/3 R
Q R pathological Q

29

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Dr. Shaf3y

ECG

Pathological Q

,, pathological Q
Old myocardial infarction
,,
Old
: pathological Q
,, aVF Old inferior MI

: Pathological Q
V1 V2 V3 V4
old anterior MI
: pathological Q
V5 V6
old lateral MI
High lateral
Low lateral
antero-septal extensive anterior
,, left anterior hemiblock left posterior hemiblock
block right bundle

left anterior hemi-

,,
,, ,,


Spot diagnosis

,, ECG
left anterior hemi-block : left ventricular enlargement
: !! !!! left
anterior !!!!
Spot diagnosis

,,
,, ,,
,,

30

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Dr. Shaf3y

ECG

,, ECG

,,
,, ,,

,,
,,

: ,, ,, ,,
,, Over
,,
,, ,,
:

,, ,,
,, ,,
,,

,,
,,
,, ,, ,,

: ,, ECG 12

ECG
,, ECG
ECG << 12 : !!!
,,
,,
: ,, ECG ,,

,,

31

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Dr. Shaf3y

ECG

,,
pathological Q
pathological Q
leads
aVF
old inferior MI
V1 V2 V3 V4
old anterior MI
V5 V6
old lateral MI
aVL
High lateral

topographism ,,
,,

Wall of the heart leads of ECG
topographism

topographism
topographism
Leads artery wall

anterior Inferior Lateral
Wall

Leads

Inferior

II - III - aVF

High lateral wall

I - aVL

)Septal ( antro-septal

V1 - V2

Strict anterior

V3 - V4

Low lateral

V5 - V6

32

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Dr. Shaf3y

RV free wall

V1 - V3R V6R

Atrial Activity

Louis Leads

ECG

N.B. posterior wall potentials are recorded in the anterior

leads as a mirror image for waves provided to be drawn in
the posterior leads because posterior leads are
technically difficult to be made.

pathological Q
(
) width of the QRS

3
wide QRS
already ,,
P
: wide QRS
Ventricular tachycardia

Ventricular fibrillation

QRS
,, wide QRS P wave

,, QRS
ST segment leads

ST segment leads

,, ST segment
PR
,,

,,
ST segement ,,
ST segment << elevation
ST segment elevation PR

33

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Dr. Shaf3y

ECG

Pericarditis
Myocardial infarction
Prinzmetals angina

,, Pericarditis
ST segement elevation Leads
Angina Myocardial infarction
some leads

,,
angina myocardial infarction
Cardiac enzymes

infarction

,, timing
ECG ,, ECG elevated
myocardial infarction
angina ,,
,,

ST segment depression

,,
,,
ST segment depression

ST segment depression
Digitalis
Hypokalemia
angina
Myocardial infarction
Pericarditis
cardiac hypertrophy
bundle branch block
,,

34

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Dr. Shaf3y

||

digitalis ,, pericarditis ,, hypokalemia ,, ST segement depression

angina ,, myocardial infarction
Hypertrophy ,, bundle branch block

,,

Digitalis

hypokalemia

pericarditis

diffuse ST segment depression

Leads
Leads ST segment depression

,, digitalis
sagging ,, ST segment depression

pericarditis Hypokalemia
hypokalemia
serum potassium
Pericarditis
pain << stitchy ,, clinically

Leads ST segment depression
digitalis

,,
some leads
angina
myocardial infarction
hypertrophy
bundle branch block
,,
,,
ST segment depression

Page |

35

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"

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Dr. Shaf3y

ECG

V1 V2 V3
Leads right ventricle

,,
right ventricle ,,
V1 V2 V3
ST segment depression
V1 V2 V3
right ventricular hypertrophy
strain pattern
right ventricular hypertrophy :
With strain pattern
secondary changes

left ventricular enlargement
ST segment depression

V4 V5 V6

,,
right bundle branch block
ST segment depression V1 V2 V3
left bundle branch block ST segment depression V4 V5
V6

,,
,, V1

Right bundle branch block

ST segment
depressed
right bundle

,,
right bundle branch block ,,
ST segment depression ,, angina
anterior wall

36

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Dr. Shaf3y

ECG

ischemia anterior wall

ST segment depression ,,
,, right bundle branch block right ventricular hypertrophy

left ventricular enlargement
V6 ,, left ventricular
enlargement
V4 V5 V6
ST segment depression
secondary left ventricular hypertrophy

ventricular hypertrophy
bundle branch block
angina

ST segment depression
angina
,, leads hypertrophy
) ,, angina
angina bundle branch block
,, Hypertrophy already ,, ST segment depression
exercise ECHO
,, Exercise ECG already ST segment
( depression

T wave
,,
,, ST segment elevation
Hyper acute T
ST segment depression ,,
T wave ineversion

,, ECG ECG

37

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Dr. Shaf3y

ECG

Exam oriented
,,
ECG ,,


rhythm
,, rhythm strip
rhyhm
Regular irregular
long strip
,, lead 3
,,
rate
rhythm regular
300
1500
rhythm irregular
30 ,,

Axis
lead lead ) ( aVF
Lead Positive lead ) positive << Normal ( aVF

axis deviation
lead positive lead ) >> negative ( aVF
left axis deviation
lead negative lead ) >> positive ( aVF
right axis deviation

lead

:
P wave
PR interval

38

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Dr. Shaf3y

ECG

P wave << Normally

X 2.5 2.5
P wave

) P pulmonale ( right atrial enlargement

P wave
) P mitral ( left atrial enlargement

P wave
V1

P wave << sawtooth
atrial flutter
absent P wave
rhythm << regular irregular
rhythm << irregular << AF
>> rhythm << regular
QRS
: wide QRS
Ventricular tachycardia
ventricular fibrillation
: narrow QRS
Supra ventricular tachycardia
nodal rhythm



PR interval
PR << normally
3 5

39

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Dr. Shaf3y

ECG

first degree heart block

WPW

Variable PR interval
: QRS
wide QRS << complete heart block
narrow QRS << second degree heart block

QRS
V1
,, right bundle branch block

,,

V6
,, Left bundle branch block
,,
ST segment
right bundle branch block
ST segment depression T wave inversion V1 V2 V3

left bundle branch block
ST segment depression T wave inversion V4
secondary changes

V5 V6

Secondary changes

V1
V6

V1

R S
right ventricular enlargement

40

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Dr. Shaf3y

ECG

V6
R ,, left ventricular enlargement

QRS complex Leads
pathological Q
,,
old myocardial infarction
lead lead aVF Inferior
Lead aVL high lateral
,,

ST segment
ST segment elevation
leads pericarditis
Leads Myocardial infarction
Prinzmetals angina
Myocardial infarction

: ST segment depression
: Leads
Digitalis

hypokalemia

pericarditis

,, Digitalis
sagging
ST segment depression
leads
,, Angina
exclusion bundle branch block cardiac hypertrophy
ST segment elevation
hyper acute T

41

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Dr. Shaf3y

ECG

ST segment depression
inversion of T wave

rhythm strip
rhythm strip
ECG
lead ,,

rhythm strip
rhythm strip

,,

Rhythm Strip

,, rhythm strip
rhythm strip P
) (

P:

rhythm strip

P wave
P wave
P wave present

) (
,, ,,
,,
,,

regular long strip
rate tachycardia

42

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Dr. Shaf3y

ECG

QRS

deformed

Narrow normal

deformed

,,

ventricular tachycardia
Narrow normal
P

P wave

single

multiple

single sinus tachycardia

P wave QRS T
multiple P

Atrial flutter

Supra ventricular tachycardia

deformed QRS

ventricular tachycarida

sinus tachycardia

43

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Dr. Shaf3y

ECG

multiple P

Atrial flutter

P wave
Supra ventricular tachy cardia
Regular bradycardia

Sinus bradycardia

first degree heart block

Mobitz two

third degree heart block

Nodal rhythm

regular bradycardia
sinus bradycardia

first degree heart block
Just prolonged PR interval
Mobitz two
regular drop of QRS complex
third degree heart block
deformed QRS
AV dissociation

44

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Dr. Shaf3y

ECG

nodal rhythm
A.V. node peace maker
A.V. node peace maker
P
inverted
QRS absent

regular bradycardia
QRS
deformed
Narrow normal

deformed
third degree heart block
Narrow normal

P wave
P wave
single
Multiple

single sinus bradycardia first degree heart block

first degree heart block
just prolonged PR interval
P wave multiple
Mobitz two
Mobitz two Atrial flutter

45

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Dr. Shaf3y

ECG

Mobitz two bradycardia

atrial flutter tachycardia

Noda rhythm
diagnostic approach long strip

rhythm rate QRS

P


segmented
P
QRS
ST segment
Long strip

,,
ECG

,,
8
13 2013

www.facebook.com/dr.tafreegh

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Dr. Shaf3y

ECG

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