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ECG IN 10 DAYS
ECG
T
he only review book to offer full-sized ECGs
throughout (simulating how they appear on
NEW TO THE SECOND EDITION
tests and in actual practice), this sourcebook
• Inclusion of the latest American College of
is the most sought-after ECG review anywhere,
Cardiology (ACC) guidelines
trusted by cardiology fellows, internal medicine
• Selection of random ECGs after Day 10 for
residents, medical students, and health-related additional review
professionals alike. ECG IN TEN DAYS is based on the
• A brand-new glossary with key terms, which
author’s popular ten-day review course, and are also bolded within the text
features a unique step-by-step approach, crystal- • Short appendix that includes formal criteria 10.875
clear vector images, plus practice EDB strips to for various ECG diagnoses
build confidence and fine-tune clinical skills. • Consolidated chapters 2 and 3 for a more
cohesive look at super ventricular arrhythmias
In these pages, you’ll find essential information
• Reorganized chapters that streamline the
on everything from SA & AV nodal conduction content on Day 6, and help ensure a more
abnormalities, to mechanisms of arrhythmias and efficient, manageable review of the material
In 10 Days
electronic pacemakers. Also included is an answer
sheet similar to the one encountered on board
exams.
David R. Ferry
27/32 8.5
Softcover trim: 8-1/2 x 10-7/8 Color: 4 color process
final bulk: .842 (27/32 spine)
Lam: GBC Layflat glossy
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ECG
in 10 Days
Table of Contents
Preface vii
Acknowledgments ix
Suggestions for Using This Book xi
v
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Preface
This book originally arose from our commitment to teach senior medical
students how to interpret electrocardiograms in two weeks, or ten work-
ing days. The School of Medicine, in its wisdom, had chosen that interval
for us, and we were forced to adapt to its mandate. We had 10 to 15 stu-
dents in our class every four weeks for the entire academic year. We
quickly realized that we needed to establish specific topics for each day
so that, regardless of which faculty members were available, there was a
consistent method used. We also decided on a set of sample ECGs to use
each day.
I found myself repeatedly drawing the same illustrations, charts, and dia-
grams, so I eventually put together the rudiments of this text into a handout.
This effort was well received by medical students, residents from Internal
Medicine, Family Practice, and Preventive Medicine, and nurses and techni-
cians. I was subsequently encouraged to publish this material, and the editors
at McGraw-Hill were gracious enough to accommodate me.
Since publication of the first edition, several things have become obvi-
ous, particularly that I needed to provide many more sample ECGs for prac-
tice, both at the end of the chapters and a random sample at the end of the
text. Therefore, there are now 20 ECGs at the ends of Chapters 2–9 and 100
at the end, bringing the total practice tracings to 280, far more than any other
book. I needed to update several figures and add many more to accommo-
date advances in electrocardiography and make some concepts easier to
understand. It was obvious that I needed to divide the contents of Day 5 into
two chapters, therefore necessitating compression of Days 2 and 3 into one
chapter. I also decided to use full 12 lead ECGs instead of rhythm strips to
illustrate the majority of concepts, since it would be in this format that prac-
titioners would encounter these tracings. Finally, I decided to use a system I
call “call-outs” on the sample ECGs, in which key portions of the tracing are
identified by circles and are then enlarged and commented on in the top
margin.
There have also been major advances in computer imaging, processing,
and storage since the first text. In this edition, all of the illustrations were
drawn on an Apple Macintosh G5 computer using Adobe PhotoShop CS2
vii
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viii Preface
and a Wacom graphics tablet. The ECGs were scanned at 600 dpi for clarity
even when magnified in the call-outs.
It is my hope that my readers will enjoy this text as much as I did in
preparing it and in teaching the concepts.
David R. Ferry, MD
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Acknowledgments
ix
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Suggestions for
Using This Book
david.ferry@med.va.gov
xi
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Day 1
The Basics
I. Cardiac muscle has two unique properties that predispose it to the two
common types of arrhythmias
A. Automaticity
1. As opposed to skeletal muscle, all myocardial cells exhibit spontaneous
depolarization.
2. This is normally a beneficial property because:
a. It obviates the need for central nervous system initiation of
myocardial depolarization.
b. It allows for “backup” pacemakers to take over if there is sinus
node dysfunction or failure of propagation of depolarization.
3. Disorders of this property can result in automatic or ectopic
arrhythmias.
A. The conduction system consists of modified cardiac muscle cells that have
unique electrical properties.
1
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2 ECG in 10 Days
Left Atrium
SA node
Intra-atrial Fibers
Left Anterior Fascicle
Bundle of His
Left Ventricle
Right Ventricle
QRS duration
P wave T wave
U wave
PR interval QT interval
1.0 mv
A. There are six standard leads (the “limb leads”) that depict cardiac
electrical events from six angles in the frontal or vertical plane.
B. There are six precordial leads (the “chest leads”) that depict electrical
events in the horizontal plane.
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4 ECG in 10 Days
ELECTROCARDIOGRAPHIC LEADS
V. Genesis of the ECG wave forms in the various leads and the concept of axis
A. The P wave, QRS complex, and T wave for any lead can be derived from
the vector representation of electrical activity in the appropriate plane.
1. For instance, ventricular depolarization in the frontal plane can be
displayed by a series of vectors representing the mathematical sum of
all the electrical activity occurring at that instant.
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6 ECG in 10 Days
Classification of Fireworks.
The fireworks now being used by the American Army are divided
into the following classes:
1. Very Pistol cartridges.
2. VB cartridges (commonly called “Tromblons”).
3. Rockets.
4. Flares.
The complete directions for firing these various fireworks are
generally attached to the container or box in which they are packed.
They are fully discussed in Annex 14, Translation of the 1917
“Instruction on Liaison for Troops of all Arms, A. E. F.”
The Very pistol cartridges are made in two sizes, a 25-mm size,
which is issued to the companies of infantry, and a 35-mm size,
which is used by the airplanes. These Very pistols fire both signal
and illuminating cartridges.
2. VB Cartridges.
3. Rockets.
4. Flares.
Flares are used only in the front lines to mark the position of the
advanced troops when called for by an airplane.
Radio Equipment.
The Radio receiving sets, type SCR-53 and SCR-54-A form the
standard units for the reception on the ground of signals from
airplanes, and in general, of all damped wave signals or modulated
wave signals. The use for these sets may perhaps be said to be that
in connection with the work of the fire control airplanes in directing
the fire of the artillery. But in addition, they are used for so many
other classes of radio work, that they may indeed be considered
among the most important radio sets.
The type SCR-54 set is very similar to the French type A-1
receiving set. The SCR 54-A set is an improved American product,
designed along the same general lines as the type SCR-54 but
differing in some respects, both mechanical and electrical, to
improve the operating characteristics. The type A-2 and A-2-B
antennae are fully described in Radio Pamphlet No. 2. With their use
the receiving sets have a wave length range of approximately from
150 to 650 meters. If properly operated, they afford quite sharp
tuning. This feature and their compact, rugged and simple
construction have made them of very considerable value on the
Western Front.
As shown in the wiring diagram, Fig. 1, the type SCR-54A
receiving set comprises a primary (antenna) circuit and a secondary
circuit, both of which may be tuned by means of the variable
capacitance and variable inductance comprised in both circuits. The
secondary circuit may also be made aperiodic by placing the switch
M on the position marked “AP.” This connects the condenser in or
disconnects it from the circuit. A separate buzzer circuit is installed in
the cover of the box to excite the set when adjusting the crystal
detector.
The adjustable capacitance in each circuit is a variable air
condenser which is adjusted by means of an insulating handle,
marked “Primary” or “Secondary,” mounted directly on the rotating
shaft of the condenser. The relative amount of capacitance in the
circuit, corresponding to the various positions of these handles, is
indicated by a pointer fastened to the shaft, which moves over a dial
graduated from 0 to 90. The position 0 corresponds to the minimum
and the position 90 to the maximum capacitance of the condenser.
The two condensers are identical in design, and have a maximum
capacitance of 500 micro-mfd.
The primary and secondary inductances are varied by means of
two dial switches marked “P” and “S,” respectively. The primary
inductance comprises 60 turns of wire divided into six steps of 10
turns each, while the secondary inductance comprises 60 turns
divided into four steps of 15 turns each. These two inductance coils
are wound on separate wooden cylinders so arranged that their
relative positions may be readily varied. The coupling of the two
circuits, which is accomplished by the mutual induction effect of
these two coils, is varied by changing the relative mechanical
positions of the coils. The secondary coil may be rotated by means
of a handle marked “Coupling,” and a pointer moving over a scale
graduated from 0 to 90 indicates its position. When in the 0 position
the axes of the two coils are at right angles to each other, and the
degree of coupling is 0. When in the position “90” the axes are
parallel, and the coupling is a maximum.
The telephone and detector circuit shunts the secondary
condenser. This circuit consists of a crystal detector connected in
series with the telephone receiver which are shunted by so-called
stopping condensers. The latter is a .002 mfd. mica condenser. Two
crystal detectors are furnished with a set; one of them is enclosed in
a glass tube, which protects the crystal from dust or dirt. The other is
open, having no such protecting casing. Either one may be used by
screwing it to the two binding posts of the set marked “Detector.”
The buzzer is mounted in a compartment of set box cover, and
consists of a small buzzer connected in series with a dry battery type
BA-4, and a switch. The buzzer is energized when this switch is
closed. A spare dry for the buzzer, a screwdriver, the enclosed
detector, some spare wire and spare crystals are normally stored in
compartments or metal clips in the cover. Two type P-11 telephone
head sets are kept in a special compartment in the box. This set box
when closed may be carried by a leather strap attached to it.
Method of Operating.
The first step in putting the set in operating condition is to select a
suitable place and set up the antenna. The set box is then installed
in a dry and protected place, and the arial and ground (or
counterpoise) leads are connected to their respective terminals on
the operating panel, and the telephone head set plugged into the
jack with the installation thus completed the first step is to adjust the
crystal detector. To do this, place the “Coupling” handle near the
maximum position, and connect the short piece of wire from the
terminal clip in the buzzer circuit to the “Antenna” or “Ground”
terminal of the operating panel. Close the buzzer switch to energize
the buzzer, and carefully explore the surface of the crystal with the
spring contact point until a sensitive spot is found, as evidenced by a
good audible sound in the telephone receiver. The short wire running
from the buzzer to the panel is then removed and the buzzer
stopped by opening the buzzer switch. Care should be taken not to
disturb the crystal adjustment by mechanical vibration or shock. This
adjustment is very delicate, and if destroyed, it must be restored
before any signals can be received. With the crystal adjusted, the set
is then ready for tuning. The procedure varies somewhat according
to whether the wave length of the station it is desired to receive is
known or not.
(a) Wave Lengths of Signals Unknown.—The switch M in the
center of the panel is thrown to the position “AP” (aperiodic). This
disconnects the secondary condenser, and makes the secondary
circuit responsive to signals of any wave length. The coupling is
made a maximum, and the secondary inductance dial switch S
placed at the position “60.” The primary inductance switch P is then
placed successively at the positions marked 10, 20, 30, 40, 50 and
60, and, at each point, the handle of the primary condenser is slowly
turned over its full range, until the loudest signals are obtained in the
telephone. The station is then identified by its call letters, and if it is
the station desired, tuning of the set is completed as explained
below. It may happen however, that in this search for signals, several
stations are heard, simultaneously or for different positions of the
handles. The process of searching is kept up until the desired
station, as identified by its call letters, is heard with the greatest
intensity.
The coupling pointer is then moved toward the minimum position,
so that the signals will be just loud enough to be easily read. The
switch M is placed in the position T (tune), which connects the
secondary condenser in the secondary circuit. The secondary circuit
is then tuned by operating the secondary inductance dial switch S
and the secondary in the same way that was followed in tuning the
primary. The secondary circuit is in tune when the signals are heard
loudest. The set is then ready for operation.
If necessary, the strength of the signals may be increased by
increasing the coupling, but this should not be done unless the signal
become too faint to be read, since increasing the coupling increases
the likelihood of interference by other sending stations. When the
coupling is changed, some slight adjustments of the primary and
secondary condensers will be found to improve the signals.
(b) Wave lengths of Signals Known.—When the receiving
operator has been advised of the wave length of the signals he is to
pick up, the process of tuning in is somewhat facilitated by the use of
the table of wave lengths which is pasted in the cover of the box.
The primary circuit of the set is first tuned, as explained above,
with the switch on “AP,” the secondary inductance on “60” and with
maximum coupling. After the signals have been identified and the
primary has been tuned to give maximum loudness, the coupling is
reduced as before and the switch M moved to T. The secondary
inductance setting to be used is then given in the table. Thus, for a
wave length of 280 meters, the setting may be 30 or 45. It is best to
use the higher value 45. The final secondary adjustment is then
made as before by means of the secondary condenser.