- There are two main types of fibers in the heart - myocardial contractile fibers and pacemaker/conducting fibers.
- The conducting system includes the sinoatrial node, atrioventricular node, bundle of His, and Purkinje fibers which generate and conduct electrical impulses.
- The sinoatrial node has the highest automaticity and initiates each heartbeat, while the other nodes and fibers conduct the impulse through the atria and ventricles.
Definition:
Also known as Hypoplastic Right Heart Syndrome (HRHS)
It is a rare congenital cardiac lesion characterized by heterogeneous right ventricular development, an imperforate pulmonary valve, and possible extensive ventriculocoronary connections.
It is a type of congenital cyanotic heart disease, a severe form of Tetralogy of Fallot (TOF)
Newborn patients present cyanotic with high desaturation and pulmonary blood flow that depend on patent ductus arteriosus
Pulmonary atresia with intact interventricular septum management Ramachandra Barik
The goals of early palliation of pulmonary atresia with intact ventricular septum (PA-IVS) include the relief of cyanosis and ductal dependence by providing a reliable source of pulmonary blood flow, and the relief of right ventricular outflow tract (RVOT) obstruction to encourage forward flow and growth of right-sided
Definition:
Also known as Hypoplastic Right Heart Syndrome (HRHS)
It is a rare congenital cardiac lesion characterized by heterogeneous right ventricular development, an imperforate pulmonary valve, and possible extensive ventriculocoronary connections.
It is a type of congenital cyanotic heart disease, a severe form of Tetralogy of Fallot (TOF)
Newborn patients present cyanotic with high desaturation and pulmonary blood flow that depend on patent ductus arteriosus
Pulmonary atresia with intact interventricular septum management Ramachandra Barik
The goals of early palliation of pulmonary atresia with intact ventricular septum (PA-IVS) include the relief of cyanosis and ductal dependence by providing a reliable source of pulmonary blood flow, and the relief of right ventricular outflow tract (RVOT) obstruction to encourage forward flow and growth of right-sided
Pulmonary atresia with intact interventricular septum Ramachandra Barik
PA/IVS is a rare congenital cardiac defect that consists of atresia of the pulmonary valve resulting in an absent connection between the right ventricular outflow tract (RVOT) and pulmonary arteries, and an intact ventricular septum that allows no connection between the right and left ventricles
TGA is a complex congenital heart disease.Understanding the anatomy,physiology,surgery and anaesthetic management is very important for patient's better outcome.This ppt explains all these points in detail.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Pulmonary atresia with intact interventricular septum Ramachandra Barik
PA/IVS is a rare congenital cardiac defect that consists of atresia of the pulmonary valve resulting in an absent connection between the right ventricular outflow tract (RVOT) and pulmonary arteries, and an intact ventricular septum that allows no connection between the right and left ventricles
TGA is a complex congenital heart disease.Understanding the anatomy,physiology,surgery and anaesthetic management is very important for patient's better outcome.This ppt explains all these points in detail.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
An electrocardiogram (ECG or EKG) records the electrical signal from your heart to check for different heart conditions. Electrodes are placed on your chest to record your heart's electrical signals, which cause your heart to beat. The signals are shown as waves on an attached computer monitor or printer
This presentation covers few basic things about ECG, especially for UG Medical students like ECG leads, normal ECG waves, axis of ECG and how to look for common ECG misplacements.
assessing neonatal systolic and diastolic cardiac function by echo. also assessing how PDA influences cardiac and systemic flow in neonates.
a new unique modility in NICU
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
4. Myocardial fibers
• MYOCARDIAL CONTRACTILE FIBERS –
• are Non-automatic in atria and ventricle.
• These are Na+ driven tissues, usually cannot generate own electric
impulse.
5. Pacemaker & conducting fibers
All of the cells in the heart have the ability to
initiate an action potential.
However, only some of these cells are designed to routinely trigger
heart beats. These cells are found in the conduction system of the
heart - the SA node, AV node, Bundle of His and Purkinje fibers.
6. Conducting system
Automatic conducting fibers are Ca++ driven tissues and can
generate own impulse - PACEMAKER.
It consist of -
1.The nodal system- consists of two nodes –
- The sinoatrial node (also called the S-A node or the sinus
node). Is situated in right atrium close to svc.
-The atrioventricular node (also called the A-V node).
8. Conducting system
CONDUCTING FIBERS
3. The Purkinje system
(also called the His-Purkinje system):
The atrioventricular bundle
(also called the A-V bundle or the bundle of His).
The right and left bundle branches.
The Purkinje fibers.
9.
10. What is the automaticity of SA,AV &
ventricular system ?
11. The sinoatrial node is a single specialized node located in
the right atrium; which has a higher automaticity (a faster
pacemaker) than the rest of the heart and therefore is
usually responsible for setting the heart rate and initiating
each heart beat.
12. What are the factors which
influences myocardial contractility?
13. FACTORS THAT INFLUENCE
MYOCARDIAL CONTRACTILITY
• Sympathetic stimulation has a +ve inotropic effect
• Parasympathetic stimulation has a –ve inotropic effect on
the atrial myocardium only because the vagus nerves
enervation is upto atria.
* The preload (EDV): -
* Heart rate: -
14. •Sympathetic stimulation has a +ve inotropic effect on both atria
and ventricle.
• Activation of β1 receptors
• Augmentation of L-type Ca2+ current
• Phase 4 AP more steeper
15. Current always flow from negative to positive direction.
When Lead is parallel to the vector, that lead will have Positive deflection
When lead is perpendicular to the vector, that lead will have no deflection or
Negative or biphasic deflection
16. ECG LEAD NEONATAL
(NON - TRAUMATIC LEADS)
Standard Limb Leads :
Lead I
Lead II
Lead III
Augmented limb leads
aVR
aVL
aVF
Chest leads : V1 to V6
17. ECG LEAD - INFANCY
Einthoven's triangle is an imaginary formation
of three limb leads in a triangle used in
electrocardiography, formed by the two
shoulders and the pubis. The shape forms an
inverted equilateral triangle with the heart at
the center. It is named after Willem Einthoven
Einthoven's law:
That lead I + lead III = lead II
or
I+(-II)+III = 0
Thus, the deflection in one lead can be
predicted from the deflections in the other
two.
18. AUGMENTED ECG LEAD
aVR, aVL and aVF and V1-V6 leads are not unipolar, but bipolar leads, with
the indifferent pole carrying a very low negative potential.
aVR is recorded the GCT consists of a connection of left arm and
left leg; when aVL is recorded the GCT consists of a connection of
right arm and left leg; when aVF is recorded the GCT consists of a
connection of right arm and left arm.
Thus the GCT is variable, consisting of the mean of the potentials
of the 2 (different for the 3 recordings) limb leads, in contrast to
the WCT which is unvariable.
This modification of Goldberger leads to the augmentation of the
recorded limb leads by 50%, as can be shown mathematically, and
thus the aVR, aVL, and aVF came into being
RA
FF
LA
aVR aVL
aVF
+
+
_
_
_
_
+
+
+
+
19. SURFACE
ELECTRO-CARDIOGRAPHY
The hexaxial reference system is made up by
the six limb leads And provide information
about Supero-inferior and right –left
relationship of electromotive forces in frontal
plane.
The bipolar limb leads I,II & III are clockwise
With angle between them of 60 degree.
Positive inferiorly.
Augmented limb leads aVL positive at left
shoulder, aVF positive inferiorly at foot end
& aVR positive superiorly at right shoulder
The lead I and aVF at right angle at the
electric center
20. CHEST LEADS
The horizontal chest leads or precordial
leads V1-V6 ,V3R,V4R provide information
about antero-posterior (V2) and
Left to right ( V6) relationship.
V3R is mirror image of V3
V4R is mirror image of V4
R wave in V6 - left ward force
S wave in V6 – Right ward force
R wave in V1, V3R & V4R – right & anterior force
S wave in V1, V3r & V4R - left ward & posterior
force
21.
22. Anatomical Relation of leads in a Standard 12 Lead ECG :-
Lead II , III & aVF :- View inferior surface of heart
Lead I & V4 :- View of the Anterior surface
Lead I, aVL, V5 & V6 :- View lateral surface
Lead V1 & aVR :- look through the Right atrium directly into the cavity of left
ventricle
. Leads V1 and V2 :- The QRS complexes are predominantly negative with small R waves and
relatively deep S waves because the more muscular left ventricle produces
depolarization current flowing away from these leads.
26. ECG paper : One large box have total 25 squares, with five vertical and horizontal lines.
In height 10 segments are equal to 1mm volt.
One segment in length is equal to time interval 0.04 sec and five segment are equal to 0.2 sec
Normal speed of ECG paper is 5 big segment per second.
If tachycardia, for better depiction ECG tracing, particularly “P” wave paper speed is
increase to 10 Big second per second
5x5 mm
10 seg = 1 mV
27. ECG paper : Height 10 segments are equal to 1mm volt and 5seg are equal to 0.5 mvolt
10 seg = 1 mV
1mV is for lead I,II.II, aVR, aVL aVF
0.5 mV is for chest leads
When chest leads volts is very high
28. ECG paper : Height 10 segments are equal to 1mm volt and 5seg are equal to 0.5 m volt
ECG is of normal voltage or half voltage
10 seg = 1 mV
1mV is for lead I,II.II, aVR, aVL aVF
0.5 mV is for chest leads
When chest leads volts is very high
29. ECG VOLTAGE
After assessing paper speed and ECG voltage caliberation
ECG voltage should be assessed as per Calibration –
Normal
Low - Cardiac tamponade
High - Cardiac hypertrophy
33. • Simple rule:
• 1500/number of small squares
• 300/number of large squares
• Rule of ten second : Take ECG for 10 sec,
• Count Heart rate and multiply by 6 will give
• Heart rate per minute.
34. Rhythm is regular or irregular -
Rhythm irregularly irregular - complete AV block
35. 10 seg = 1 mV
Negative “P” in aVR suggest heart Situs Solitus
( normal )
Positive “P” wave in aVR suggestive of abnormal
situs – Situs Inversus or Ambiguous
38. “P” in aVR
The morphology of the P wave in lead aVR can be used to differentiate atrial tachyarrhythmias.
A positive P wave in aVR during tachycardia favours atrioventricular nodal re-entry tachycardia.
A negative P wave in aVR suggests a focal right atrial tachycardia
41. •Atrial depolarisation proceeds sequentially from right to left, with the right atrium activated before the
left atrium.
•The right and left atrial waveforms summate to form the P wave.
•The first 1/3 of the P wave corresponds to right atrial activation,
the final 1/3 corresponds to left atrial activation; the middle 1/3 is
a combination of the two.
•In most leads (e.g. lead II), the right and left atrial waveforms move in the same direction, forming a
monophasic P wave.
•However, in lead V1 the right and left atrial waveforms move in opposite directions. This produces a
biphasic P wave with the initial positive deflection corresponding to right atrial activation and the
subsequent negative deflection denoting left atrial activation.
•This separation of right and left atrial electrical forces in lead V1 means that abnormalities affecting each
individual atrial waveform can be discerned in this lead. Elsewhere, the overall shape of the P wave is used
to infer the atrial abnormality.
RA LA
42. The P wave is the first positive deflection on the ECG and represents atrial depolarisation
•The P wave is the first positive deflection on the ECG
•It represents atrial depolarisation
•Duration: < 0.12 s (<120ms or 3 small squares)
Morphology
•Smooth contour
•Monophasic in lead II
•Biphasic in V1
Axis
•Normal P wave axis is between 0° and +75°
•P waves should be upright in leads I and II, inverted in aVR
Duration
•< 0.12 s (<120ms or 3 small squares)
Amplitude
•< 2.5 mm (0.25mV) in the limb leads
•< 1.5 mm (0.15mV) in the precordial leads
“P” wave abnormalities are most easily seen in the inferior leads (II, III and aVF) and lead V1, as the P waves
are most prominent in these leads.
43. In NSR, the P wave is less than 120 milliseconds in duration and less than 0.15 mV to 0.25 mV in height
in lead II. The permissible maximum varies based on the lead. If there is a biphasic P wave in lead V1,
the terminal component should be less than 40 milliseconds in duration and 0.10 mV in depth.
The P wave should also have a normal axis (0 degrees to more than 90 degrees) and constant
morphology.
The normal axis is indicated by P waves that are:
1.upright in leads I, II, and often aVF
2. “P” wave Inverted in lead aVR, Positive “P” wave in aVR suggest situs inversus
3.Upright, inverted, or biphasic in leads III and aVL
4.Upright or biphasic in leads V1 and V2, “P” is positive in V1 if chest lead is placed UP
5.Upright in leads V3 through V6.
44. The location of “P” wave axis determine the origin of an atrial derived rhythm.
It is determined by measuring net positive or negative P-wave deflections on all six limb leads
and calculating the net direction of electrical activity using the hexaxial reference system.
Abnormal P-wave axis is defined as any value outside 0–75°
0 to 90 degree Normal sinus rhythm
90-180 degree Left axis deviation
180-270 degree low left axis deviation
270 to 0 degree low right axis deviation
49. •In right atrial enlargement, right atrial depolarisation lasts longer than normal and its waveform
extends to the end of left atrial depolarisation.
•Although the amplitude of the right atrial depolarisation current remains unchanged, its peak now falls
on top of that of the left atrial depolarisation wave.
•The combination of these two waveforms produces a P waves that is taller than normal (> 2.5 mm),
although the width remains unchanged (< 120 ms).
50. In right atrial enlargement, right atrial depolarisation lasts longer than normal and its waveform extends to the
end of left atrial depolarisation, summation of both results in tall and peaked “P” wave , that is “P” pulmonale
51. •In left atrial enlargement, left atrial depolarisation lasts longer than normal but its amplitude remains unchanged.
•Therefore, the height of the resultant P wave remains within normal limits but its duration is longer than 120 ms.
•A notch (broken line) near its peak may or may not be present (“P mitrale”).
52. •A notch (broken line) near its peak may or may not be present (“P mitrale” “M” shape ).
•Ventricular inversion
•Both A-V attached to Left Atrium
53. P wave may be absent – Atrial fibrillation, SVT - AVNRT,
Negative “P” wave in I,
Wandering Atrial Pacemaker
WAP is not pathologic and is often seen in young, healthy individuals. It results from a change in the
dominant pacemaker focus from the sinus node to ectopic atrial foci.
There must be at least three dominant ectopic atrial foci to meet the diagnostic criteria for WAP.
This can be seen on ECG by a variation in P wave morphology and the PR interval. Each variation in P wave
morphology represents a different ectopic focus. The closer the ectopic focus is to the AV node, the
shorter the PR interval will be. Because WAP is not considered pathologic and often asymptomatic, there is
no indication for treatment. (WAP < 100 bpm, MAT ≥ 100 bpm)
54. •First degree: With first-degree SA nodal exit block, there is impulse exit slowing with normal 1:1
conduction. A body surface EKG is not able to recognize this.
•Second degree: Like second-degree AV nodal blocks, there are two types second-degree SA nodal exit
blocks –
• type I (Wenckebach) and type II.
•With type I (Wenckebach), the P-P intervals progressively shorten in duration until a dropped P wave
occurs. The dropped P wave results in a pause that is less than two P-P intervals in duration.
• While type II also has a pause from a dropped P wave, it is a multiple of the SA nodal pacemaker input.
Therefore, the P-P intervals should remain constant and compensatory in nature.
•Third-degree: With third-degree SA nodal exit block, the SA node impulse is unable to reach the right
atrium. Thus, the atrial will not depolarize, and there will be no P wave. For this reason, it cannot be
distinguished from sinus arrest.
56. Subsidiary Atrial Pacemakers
Subsidiary atrial pacemakers have been identified in the atrial myocardium, especially in the crista
terminalis, at the junction of the inferior right atrium and inferior vena cava, near or on
the eustachian ridge, near the coronary sinus ostium, in the atrial muscle that extends into
the tricuspid and mitral valves, and in the muscle sleeves that extend into the cardiac veins (venae
cavae and pulmonary veins).
57. Age PR interval sec
0-1 day 0.08-0.16
1-3 days 0.08-0.14
3-7 days 0.08-0.14
7-30days 0.07-0.14
> 1 months 0.07-0.13
58.
59.
60. COMMON IRREGULAR NARROW QRS TACHYCARDIA
Ectopic atrial tachycardia with
variable conduction
Except the above 3 conditions, all other SVTs are regular
Atrial fibrillation- Variable conduction across
AV node.
extremely rare in infants
Atrial flutter – usually fixed
conduction
61. When the QRS complex is clearly positive, it means that the electric impulse flows towards the lead.
if the QRS complex is negative, the impulse flows away from the lead.
if the QRS complex is biphasic it means the direction of the impulse is perpendicular to the lead.
The most efficient way to estimate axis is to look at LEAD I and LEAD aVF.
Step I - Determine QRS – A positive or negative in Lead I that is in lead I net deflection R-S =
- Determine QRS - A positive or negative in Lead aVF that is lead aVF net deflection R-S =
Step II - Join both mark by perpendicular line to get final axis in degree.
QRS COMPLEX
I aVF AXIS
+ + NORMAL -30 TO +90
+ - LEFT AXIS -30 TO - 90
- + RIGHT AXIS +90 TO +180
- - RIGHT SUPERIOR AXIS
_90--180
62. The most efficient way to estimate axis is to look at LEAD I and LEAD aVF.
Step I - Determine QRS – A positive or negative in Lead I that is in lead I net deflection R-S =
- Determine QRS - A positive or negative in Lead aVF that is lead aVF net deflection R-S =
and determine the quadrant
Step II - Find out biphasic or equiphasic lead, axis is perpendicular to it, in determined quadrant .
QRS COMPLEX
I aVF AXIS
+ + NORMAL -30 TO +90
+ - LEFT AXIS -30 TO - 90
- + RIGHT AXIS +90 TO +180
- - RIGHT SUPERIOR AXIS
_90--180
63. AGE AXIS
0-1 DAY 60-120
1-3 DAY 64-197
3-7 DAYS 75-185
7-30 DAYS 65-160
1-3 MONTHS 31-115
Find out lead of maximum positive QRS
Than look for lead which perpendicular to it, what is difference between R-S; suppose 2 mm
Than axis is; axis of Maximum QRS -/+ 10degree per mm
77. R = - 4 mm
V6 S = -3 mm
Axis = + 125
+I
-aVF
V1= R 7, T upright
V2
I R = - 5
aVf = 4
78. R = - 4 mm
V6 S = -7 mm
Axis = + 125
RAD
aVR= qR
R 5+S 9
= 14
+I
-aVF
V1= equiphasic, T upright
II= P - Pulmonale
I R = - 5
aVF = +7
aVR = qR
79.
80. The “T” wave axis is determined by the same method as used to determine the QRS axis.
In the normal newborn, children and adults the mean T axis is + 45 degree ( 0 to + 90 degree)
T wave must be upright in lead I and aVF.
The T wave axis outside normal quadrant is seen in
During the 1st day of life, right axis deviation, large “R” wave and upright T wave in right precordial
leads v3R,v4Rand V1. T wave become negative with in 72 hours of birth, if persist beyond 7 days
Suggestive of right ventricular strain.
Severe ventricular hypertrophy with strain
Ventricular conduction disturbance
Metabolic disorder – popmes disease
81. S POTASSIUM ECG CHANGES
2.5 ST seg depression
Round “T” wave
Prominent U wave
3.5 – 5.5 Normal
5.5- 6.5 Peaked Tall “T” Wave
Prolonged PR
6.5 -8 Loss of “P” wave
Wide QRS
ST seg. Elevation
Ectopic beat /escape rhythm
>8 Wide QRS, SIGN wave
VT
Asystole
Bundle branch block
Fascicular Block
82.
83. Angle between QRS & T axis.
The median value for QRS-T angle was 20°, and the median
values for QRS-axis and T-axis were 40 and 30°, respectively.
QRS-T angle did not differ between genders, with a mean
QRS-T angle being 29° in men and women, or in different age
groups.
A QRS/T angle of ≥ 100 degrees is nothing more than a mathematical representation of a general pattern of
T-wave discordance. Generally speaking, it means the T-waves on the ECG are deflected opposite the majority
of the QRS complex, which is a normal finding in left bundle branch block, paced rhythm, and left ventricular
hypertrophy with strain.
84.
85. The 'U' wave is a wave on an electrocardiogram (ECG). It comes after the T wave of ventricular
repolarization and may not always be observed as a result of its small size. 'U' waves are thought
to represent repolarization of the Purkinje fibers and IVS. It is observed in chest leads. Direction of U
wave is same as of T wave.
Prominent “U” wave
Hypokalaemia
Hypomagnesemia
Hypocalcaemia
Hypothermia
Digoxin
LVH OR HCM
Raised ICH
86. Left Ventricular Hypertrophy (LVH)
• Limb lead criteria –
Axis – LAD
• Augmented Limb-lead voltage criteria:
• R in aVL ≥ 11 mm or, if left axis deviation
• R in aVL ≥ 13 mm plus S in III ≥ 15 mm
• R in I + S in III > 25 mm
Cornell criteria: Add the R wave in aVL and the S wave in V3. If the sum is greater than 28 millimeters in
males or greater than 20 mm in females, LVH is present.
Modified Cornell Criteria: Examine the R wave in aVL. If the R wave is greater than 12 mm in amplitude, LVH
is present.
• Chest lead voltage criteria
Sokolow-Lyon Criteria: Add the S wave in V1 plus the R wave in V5 or V6. If the sum is greater than 35
mm, LVH is present.
87. General ECG features include:
• Leftward shift in frontal plane QRS axis
•≥ QRS amplitude (voltage criteria; i.e., tall R-waves in LV leads, deep S-waves in RV leads)
•Delayed intrinsicoid deflection in V6 (i.e., time from QRS onset to peak R is ≥ 0.05 sec)
(Intrinsicoid deflection: time between QRS complex onset & R wave peak (in leads that begin with R wave
& have no Q wave).The intrinsicoid deflection reflects the depolarization vector from the endocardium to
the epicardium.)
•Widened QRS/T angle (i.e., left ventricular strain pattern, or ST-T oriented opposite to QRS direction)
•Evidence for left atrial enlargement (LAE)
88. Left Ventricular Hypertrophy (LVH) - summarty
Limb lead criteria – LAD Left Axis Deviation
• Augmented Limb-lead voltage criteria:
• R in aVL ≥ 11 mm , R in I, II, III, aVL, aVF
• Chest lead voltage criteria
R in V1 + S in V5 or V6 ≥ 10 mm
• R/S ratio in V1 or V2 < 1
• R in V5 or V6 < 5 mm
• S in V1 or V2 > 7 mm
• Q wave in V5,V6
• T wave negative in lateral leads
•ST segment depression and T wave inversion in left precordial leads that is opposite to R wave deflection
• QRS-T Axis angle >100
89. +ECG Criteria Points
•Voltage Criteria (any of):
•R or S in limb leads ≥ 20 mm
•S in V1 or V2 ≥ 30 mm
•R in V5 or V6 ≥ 30 mm
3 points
•ST-T Abnormalities : Without digitalis
•ST-T abnormalities With digitalis
3 points
1 point
Left Atrial Enlargement in V1 3 points
Left axis deviation 2 points
QRS duration 0.09 sec 1 point
Delayed intrinsicoid deflection in V5 or V6 (>0.05 sec) 1 point
ESTES Criteria for LVH
("diagnostic", ≥ 5 points; "probable", 4 points)
90. R = - 4 mm
V6 S = +24 mm
Axis = - 30 LAD
aVL, aVF = R
SV1+RV6 = >35
+I
aVF aVL = R
V1= S 23
II= P - Pulmonale
I R = + 5
aVR = S
V6 - -T
91. Right Ventricular Hypertrophy (RVH)
Limb lead criteria – RAD Right Axis Deviation
• Augmented Limb-lead voltage criteria:
• R in aVR ≥ 11 mm or qR in aVR
• Chest lead voltage criteria
R in V1 + S in V5 or V6 ≥ 10 mm
• R/S ratio in V5 or V6 < 1
• R in V1 or V2 < 5 mm
• S in V5 or V6 > 7 mm
•ST segment depression and T wave inversion in right precordial leads that is opposite to R wave deflection
•Upright “T” in v1, v2 after 3 days of life .
92. R = - 4 mm
R = +4 mm
Axis = 80
Normal
+I
-aVF
V1
V2
“P” Pulmonale
aVR = qR
V1= R wave, upright “T” wave in V1,2,3,
V6= “S”
RAD
95. Specific ECG features RVH (assumes normal calibration of 1 mV = 10 mm):
•Any one or more of the following (if QRS duration < 0.12 sec):
• Right axis deviation (> 90 degrees) in presence of disease capable of causing RVH
• R in aVR ≥ 5 mm, or
• R in aVR > Q in aVR
•Any one of the following in chest lead V1:
• R/S ratio > 1 and negative T wave
• qR pattern
• R gt; 6 mm, or S < 2mm, or rSR' with R' > 10 mm
•Other chest lead criteria:
• R in V1 + S in V5 (or V6) 10 mm
• R/S ratio in V5 or V6 < 1
• R in V1 or V2 < 5 mm
• S in V5 or V6 > 7 mm
•ST segment depression and T wave inversion in right precordial leads that is opposite to R wave
deflection
96. Biventricular Hypertrophy (difficult ECG diagnosis to make)
In the presence of LAE any one of the following suggests this diagnosis:
•R/S ratio in V5 or V6 < 1
•S in V5 or V6 > 6 mm
•RAD (> 90 degrees)
Other suggestive ECG findings:
•Criteria for LVH and RVH both met
•LVH criteria met and RAD or RAE present
Katz-Wachtel phenomenon.
Tall diphasic QRS complexes (>50 mm in height) in the mid-precordial leads (leads V2, V3 or V4) typically
associated with Biventricular Hypertrophy.
97. The ECG criteria for a left bundle branch block include:
1.QRS duration greater than 120 milliseconds
2.Absence of Q wave in leads I, V5 and V6
3.Monomorphic R wave in I, V5 and V6
4.ST and T wave displacement opposite to the major deflection of the QRS complex
5.Dominant S wave in V1
6.Prolonged R wave peak time > 60ms in leads V5-6
98. Complete RBBB
1.QRS duration greater than or equal to 120 ms in adults, greater than 100 ms in children ages 4 to 16
years, and greater than 90 ms in children less than 4 years of age.
2.rsr′, rsR′, or rSR′ in leads V1 or V2. The R′ or r′ deflection is usually wider than the initial R wave. In a
minority of patients, a wide and often notched R wave pattern may be seen in lead V1 and/or V2.
3.S wave of greater duration than R wave or greater than 40 ms in leads I and V6 in adults.
4.Normal R peak time in leads V5 and V6 but greater than 50 ms in lead V1.
101. 9y male RAD, R in V1 + S in V6 = 20+5= 25; aVR = qR
102. Corrected QT interval
Bazett formula: QTC = QT / √ RR
Fridericia formula: QTC = QT / RR 1/3
Framingham formula: QTC = QT + 0.154 (1 – RR)
Hodges formula: QTC = QT + 1.75 (heart rate – 60)
Normal QTc values
QTc is prolonged if > 440ms in men or > 460ms in women
QTc > 500 is associated with an increased risk of torsades de pointes
QTc is abnormally short if < 350ms
A useful rule of thumb is that a normal QT is less than half the preceding RR interval
103. Morphologic alteration of the cardiac silhouette and levo position of the heart with an overlap of the right
cardiac border to the vertebral column (black arrows), increase of the aortic knob, and of the main
pulmonary artery convexity with interposition of lung tissue between them (*), and a band of lucency
between the heart and left hemidiaphragm is also seen (white arrow)
Absence of R-wave growth in precordial, and growth data of right cavities. In
addition, the presence of the phenomenon of swinging heart in right precordial
104. Echocardiographic investigation which was performed on the 1 st day of life, revealed
marked hypertrophy of RV free wall (8, 9 and 11 mm in diastole, respectively),
interventricular septum (7, 8 and 8.5 mm in diastole, respectively) and a small RV cavity
(1.85, 1.63 and 1.69 cm 2 in diastole, respectively)