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+ Medical Student
Survival Skills

ECG
 + Medical Student
Survival Skills

ECG
Philip Jevon RN BSc(Hons) PGCE
Academy Manager/Tutor
Walsall Teaching Academy, Manor Hospital, Walsall, UK

Jayant Gupta FRCP

Consultant Cardiologist, Senior Academy Tutor
Walsall Healthcare NHS Trust, Manor Hospital, Walsall, UK

Consulting Editors

Jonathan Pepper BMedSci BM BS FRCOG MD

FAcadMEd
Consultant Obstetrics and Gynaecology, Head of Academy
Walsall Healthcare NHS Trust, Manor Hospital, Walsall, UK

Jamie Coleman MBChB MD MA(Med Ed)

FRCP FBPhS
Professor in Clinical Pharmacology and Medical Education / MBChB Deputy
Programme Director
School of Medicine, University of Birmingham, Birmingham, UK
This edition first published 2020
© 2020 by John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as
permitted by law. Advice on how to obtain permission to reuse material from this title is available at
http://www.wiley.com/go/permissions.
The rights of Philip Jevon and Jayant Gupta to be identified as the authors in this work has been asserted in
accordance with law.
Registered Office(s)
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial Office
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, customer services, and more information about Wiley products visit us at
www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears
in standard print versions of this book may not be available in other formats.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and
are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or
treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in
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devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for
each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage
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Library of Congress Cataloging‐in‐Publication Data
Names: Jevon, Philip, author. | Gupta, Jayant, author.
Title: Medical student survival skills. ECG / Philip Jevon, Dr Jayant Gupta.
Other titles: ECG
Description: Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index. |
Identifiers: LCCN 2018060335 (print) | LCCN 2018061637 (ebook) | ISBN 9781118818152
(Adobe PDF) | ISBN 9781118818169 (ePub) | ISBN 9781118818176 (pbk.)
Subjects: | MESH: Electrocardiography | Handbook
Classification: LCC RC683.5.E5 (ebook) | LCC RC683.5.E5 (print) | NLM WG 39 | DDC 616.1/207547–dc23
LC record available at https://lccn.loc.gov/2018060335
Cover Design: Wiley
Cover Image: © T VECTOR ICONS/ Shutterstock
Set in 9.25/12.5pt Helvetica Neue by SPi Global, Pondicherry, India
Printed in Great Britain by TJ International Ltd, Padstow, Cornwall
10 9 8 7 6 5 4 3 2 1
 + Contents

Preface vii
About the companion website ix

1 Introduction to ECG monitoring 1

2 Principles of ECG monitoring 3
3 Six stage approach to ECG interpretation 9
4 Sinus tachycardia 13
5 Sinus bradycardia 15
6 Sinus arrhythmia 17
7 Atrial ectopic beats 19
8 Atrial tachycardia 21
9 Atrial flutter 23
10 Atrial fibrillation 27
11 AV junctional ectopics 31
12 AV junctional escape rhythm 33
13 Junctional tachycardia 35
14 Ventricular ectopics 37
15 Idioventricular rhythm 41
16 Ventricular tachycardia 43
17 Torsades de pointes 47
18 First degree AV block 49
19 Second degree AV block Mobitz type I (Wenckebach phenomenon) 51
20 Second degree AV block Mobitz type II 53
21 Third degree (complete) AV block 55
22 Ventricular fibrillation 59
23 Ventricular standstill 61
24 Asystole 63

v
 25 Recording a 12 lead ECG 65
26 What the standard 12 lead ECG records 71
27 Interpretation of a 12 lead ECG 75
28 ECG changes associated with myocardial infarction 81
29 ECG changes associated with myocardial ischaemia 87
30 ECG changes associated with bundle branch block 91
31 Wolff–Parkinson–White syndrome 97

Appendix A: Resuscitation council (UK) bradycardia algorithm 99

Appendix B: Resuscitation council (UK) tachycardia algorithm 101
Appendix C: R
 esuscitation council (UK) advanced life support (ALS)
algorithm 103
Appendix D: Vagal manoeuvres 105
Appendix E: Synchronised electrical cardioversion 107
Appendix F: External (transcutaneous) pacing 111
Appendix G: Procedure for transcutaneous pacing 113
Appendix H: Definitions 115
References 117
Index 119

vi
 + Preface

A
n electrocardiogram (ECG) is a recording of electrical waveforms pro-
duced by the electrical activity of the heart. ECG monitoring is probably
one of the most valuable diagnostic tools in modern medicine. It is
essential if cardiac arrhythmias are to be identified. It can help with diagnosis
and can alert clinical staff to changes in the patient’s condition. ECG
­monitoring must be meticulously undertaken. Potential consequences of poor
­technique include misinterpretation of cardiac arrhythmias, mistaken diagno-
sis, wasted investigations, and mismanagement of the patient.

The purpose of this guide is to provide a structured approach to the recogni-

tion and treatment of cardiac arrhythmias as well as providing guidance to the
interpretation of the 12 lead ECG.

Philip Jevon
Jayant Gupta

vii
About the
companion website

Don’t forget to visit the companion website

for this book:
www.wiley.com/go/jevon/medicalstudent
There you will find checklists to enhance
your learning.

Scan this QR code to visit the companion website.

ix
 Introduction to ECG
1 monitoring

Conduction system of the heart (figure 1.1)

Sinoatrial node
Electrically inert
atrioventricular
Left
Right region
atrium
atrium
Left bundle
branch
Atrioventricular
node
Left Left anterior
m hemifascicle
ventricle

Left posterior
hemifascicle
Right bundle branch
Figure 1.1 Conduction system of the heart.

PQRST complex (figure 1.2)

P T

QRS

Figure 1.2 PQRST complex.

Medical Student Survival Skills: ECG, First Edition. Philip Jevon and Jayant Gupta.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/jevon/medicalstudent

1
 Chapter 1 Introduction to ECG monitoring

• P wave: atrial depolarisation

• PR interval: atrial depolarisation and the impulse delay in the atrioventricular
(AV) node prior to ventricular depolarisation
• QRS complex: ventricular depolarisation
• T wave: ventricular repolarisation

Sinus rhythm (figure 1.3)

Figure 1.3 Sinus rhythm.

• Normal rhythm of the heart

• Impulse originates in the sinoatrial (SA) node (i.e. ‘sinus’), regular rate of
60–100 beats per minute (bpm)
• No abnormal conduction delays

Sinus rhythm: Identifying ECG features

• Electrical activity: present
• QRS rate: 60–100 bpm
• QRS rhythm: regular
• QRS width: normal width and morphology
• P waves: present and of constant morphology
• Relationship between P waves and QRS complexes: P waves associated
to QRS complexes; PR interval normal and constant

NB Sinus rhythm can occasionally be seen in a cardiac arrest:

pulseless electrical activity (PEA).

2
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