ECG Handouts

ECG…EASY?…G?
ANATOMY AND PHYSIOLOGY
Positive Vector
• Left
• Down
SEQUENCE OF ACTIVATION OF THE CARDIAC

CONDUCTING SYSTEM
Standard and Augmented Limb Leads

PR INTERVAL
 Conduction of depolarization from SA node to
AV node
 Measure in the limb lead with the longest PR
interval
QRS COMPLEX
6 MAJOR WAVES IN ECG  Ventricular contraction
 Normal: <0.10 sec
 Q wave
 Lead II & avF
○ <0.04 sec wide
○ <2mm deep
○ <25% of succeeding R wave
P WAVE
 Atrial contraction
 Upright in Lead I, II and avF
 Normal: 0.12 – 0.20 sec
NORMAL R WAVE PROGRESSION

ST SEGMENT
 Plateau phase of ventricular contraction ECG READING RATE
 Normally deviates between 0.5 – 1mm from CARDIAC PACEMAKERS
baseline  SA Node : 60 – 100 bpm
 Isoelectric  AV Node : 40 – 60 bpm
 Ventricular : 20 – 40 bpm
 Purkinje : 15 - 40 bpm
REGULAR RHYTHM
 RATE/MIN = 1500/# of small squares
• RATE/MIN = 1500/23 = 65 beats/min
QT INTERVAL  RATE/MIN = 300/# of big squares

Normal :
 Male < 0.48
 Female < 0.44
• RATE/MIN = 300/5 = 60 beats/min
IRREGULAR RHYTHM
 RATE/MIN = # QRS COMPLEXES X 10
 30 BIG BOXES (6 second strip)
QT Corrected
QT Actual
• RATE/MIN = 12 X 10 = 120
√ R − R Interval
ECG READING RHYTHM
Normal : REGULAR SINUS RHYTHM
Male < 0.48
Female < 0.44
T WAVE
 Rapid phase of repolarization
 Usually not >10mm in the precordial leads
P to P and R to R interval are regular (Cycle length do

not vary by 10%)
Rate = 60 to 100 bpm
Presence of a P wave followed by a QRS complex in a
regular rate
LEFT BUNDLE BRANCH BLOCK
Sudden absence of PQRST complex

Drop beat is not in exact multiple of the preceding
interval
Complete: QRS >0.12 sec
Broad, notched R in I, V5 and V6 SINOATRIAL BLOCK
Small R, deep S in V1 – V2
RIGHT BUNDLE BRANCH BLOCK
Complete: QRS >0.12 sec

rSR pattern in V1 Sudden absence of PQRST complex
Wide S in V6 Drop beat is in exact multiple of the preceding interval
FIRST DEGREE ATRIOVENTRICULAR BLOCK
Prolonged PR interval
SINUS ARREST/PAUSE 2nd DEGREE AV BLOCK – TYPE 1 WENCKEBACH

Progressive lengthening of the PR interval
Rate < 60 bpm
Drop beats after 3 or 4 P waves
Regularly occurring PQRST
Progressive shortening of RR interval
Cycle repeated after the drop beat
SINUS TACHYCARDIA
2nd DEGREE AV BLOCK – MOBITZ TYPE II
Regularly occurring PQRST

Sudden and unexpected drop beat without changes in Rate > 100 bpm
the preceding PR interval
Usually 2:1 AV conduction ratio SUPRAVENTRICULAR TACHYCARDIA
COMPLETE HEART BLOCK
Regularly occurring Narrow QRST

Absence of P-waves
P wave not related to QRS complex
SINUS BRADYCARDIA
SUPRAVENTRICULAR TACHYCARDIA (AVNRT)
ATRIAL FLUTTER
Regularly occurring Narrow QRST

Absence of P-waves
Atrial rate = 220-300
SINUS ARRHYTHMIA Biphasic, saw toothed flutter waves which is regular
Irregular RR interval
QRS complex narrow
ATRIAL FIBRILLATION
Identical but irregularly occurring PQRST
PREMATURE ATRIAL CONTRACTION

No discernible P wave
Irregular R-R interval
QRS complexes usually normal
FREQUENT PREMATURE ATRIAL CONTRACTIONS
Discernible P wave
Prematurely occurring PQRST complex
Irregular R-R interval
P wave different in configuration in sinus beat
QRS complexes usually normal
PR interval often long
QRS narrow
VENTRICULAR TACHYCARDIA
Rapid, bizarre wide QRS complex
No P wave (ventricular impulse) No P wave (Ventricular impulse origin)
Wide QRS complex
VENTRICULAR FIBRILLATION Pacemaker spike precedes the wide QRS complex
INTRAVENTRICULAR CONDUCTION DELAY
Associated with coarse or fine chaotic undulations

No P wave
No true QRS complexes
Indeterminate rate Supraventricular rhythm with associated bundle branch
block
VENTRICULAR FIBRILLATION (Torsades de Pointes) Wide QRS complex
VENTRICULAR PREMATURE CONTRACTION
Associated with chaotic undulations with varying

amplitudes
No P wave
No true QRS complexes
Indeterminate rate
Prematurely occurring complex

Wide bizarre looking complex
Usually no preceding P wave
T wave opposite in deflection to the QRS complex
Complete compensatory pause following premature
beat
PACEMAKER RHYTHM ECG READING AXIS

AXIS
ECG READING CHAMBER ENLARGEMENTS
LEFT ATRIAL ABNORMALITY
Increased P terminal forces in V1 > 0.04 sec wide and 1

mm tall
Notched P wave in lead II
P wave duration >0.12 sec
RIGHT ATRIAL ABNORMALITY
Peaked P waves in leads II, III, avF > 2.5 mm

Increased in the initial P wave in V1 > 0.08 sec
ST depression & T wave inversion in V1 to V3
ECG READING ISCHEMIA AND INFARCTION
LEFT VENTRICULAR HYPERTROPHY CONTIGUOUS LEADS
SERIAL CHANGES IN MYOCARDIAL INFARCTION
RIGHT VENTRICULAR HYPERTROPHY
R/S ratio in V6 < 1

R/S ratio in V1 > 1 ECG FINDINGS IN STEMI
Right axis deviation
Absence of significant q wave
EARLY REPOLARIZATION PATTERN
INFERIOR WALL MYOCARDIAL INFARCTION ST segment elevation NOT fulfilling criteria for ST-
Elevation MI
ECG READING ELECTROLYTE ABNORMALITIES

HYPERKALEMIA
Wide & deep Q in II, III and avF

ST segment elevation and/or T wave inversion in II, III
and avF
POSTERIOR WALL MYOCARDIAL INFARCTION Tall, narrow and peaked T waves

Intraventricular conduction defects
Decrease amplitude of p waves
HYPOKALEMIA
Tall R in V1
ST depression & upright T waves in V1 to V4
Wide & deep Q with ST elevation in V7 to V9
MYOCARDIAL ISCHEMIA
Prominent u waves especially in chest leads (As tall as T

in V2-V3)
T wave flattening & ST depression
Cardiac arrhythmias & AV block
New or persistent deep T wave inversion
ST depression HYPERCALCEMIA
Reduction of R wave voltage
Short QT segment with early peak & gradual descent of
the T wave Diffuse ST elevation (concave) with upright T waves in
Best seen in chest leads most leads
Absent pathologic q waves
HYPOCALCEMIA No reciprocal changes
PERICARDIAL EFFUSION
Modest reduction: QT prolongation

Severe Reduction
Further QT prolongation
Electrical Alternans
Horizontal ST segment & t wave depression
Low Voltage Complexes (< 5 mm Limb Leads; < 10 mm
Chest Leads)
ECG READING SPECIAL CASES

ACUTE PULMONARY EMBOLISM
S1Q3T3
PERICARDITIS

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ECG…EASY?…G?

ANATOMY AND PHYSIOLOGY

SEQUENCE OF ACTIVATION OF THE CARDIAC

Standard and Augmented Limb Leads

NORMAL R WAVE PROGRESSION

• RATE/MIN = 1500/23 = 65 beats/min

QT INTERVAL  RATE/MIN = 300/# of big squares

• RATE/MIN = 300/5 = 60 beats/min

P to P and R to R interval are regular (Cycle length do

Sudden absence of PQRST complex

RIGHT BUNDLE BRANCH BLOCK

Complete: QRS >0.12 sec

FIRST DEGREE ATRIOVENTRICULAR BLOCK

SINUS ARREST/PAUSE 2nd DEGREE AV BLOCK – TYPE 1 WENCKEBACH

Regularly occurring PQRST

COMPLETE HEART BLOCK

Regularly occurring Narrow QRST

P wave not related to QRS complex

Regularly occurring Narrow QRST

Identical but irregularly occurring PQRST

PREMATURE ATRIAL CONTRACTION

FREQUENT PREMATURE ATRIAL CONTRACTIONS

INTRAVENTRICULAR CONDUCTION DELAY

Associated with coarse or fine chaotic undulations

VENTRICULAR PREMATURE CONTRACTION

Associated with chaotic undulations with varying

Prematurely occurring complex

PACEMAKER RHYTHM ECG READING AXIS

Increased P terminal forces in V1 > 0.04 sec wide and 1

RIGHT ATRIAL ABNORMALITY

Peaked P waves in leads II, III, avF > 2.5 mm

ECG READING ISCHEMIA AND INFARCTION

LEFT VENTRICULAR HYPERTROPHY CONTIGUOUS LEADS

SERIAL CHANGES IN MYOCARDIAL INFARCTION

RIGHT VENTRICULAR HYPERTROPHY

R/S ratio in V6 < 1

EARLY REPOLARIZATION PATTERN

ECG READING ELECTROLYTE ABNORMALITIES

Wide & deep Q in II, III and avF

POSTERIOR WALL MYOCARDIAL INFARCTION Tall, narrow and peaked T waves

Prominent u waves especially in chest leads (As tall as T

Modest reduction: QT prolongation

ECG READING SPECIAL CASES

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