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ECGs

AILSA & ELLIE

Waves, segments and intervals

• What is under each box? 2
2
• What do they represent?
• Why do we care about them?
• P waves – sinus rhythm
• PR interval – heart block 3 5
1
• Q wave – pathological Q waves
• R wave – ventricular hypertrophy
• QRS complex – narrow (normal) or broad 1 3
• ST segment – ischaemia
4
• QT interval – electrolyte imbalance /use of drugs (antipsychotics) 4

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Learn where the electrodes go

• Comes up in OSCEs
• Easy to fumble about when nervous

????

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Interpretation

OSCE land (and probably good practice)

• Confirm patient details
• Date and time ECG was performed
• ‘I’d like to compare this ECG to any previous ECGs the patient has’

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STEP 1:
Heart rate

1. REGULAR = 300 / number

of big squares between 2
R waves
2. IRREGULAR = Number of
QRS complexes on the
rhythm strip * 6

STEP 2: Rhythm
• Regular
• Irregular:
– Regularly irregular
– Irregularly irregular
– Can use paper method if unsure

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STEP 3: Axis
• Key principle = understanding deflections
• Look at leads I, II and III

LEFT axis deviation = LEAVING

RIGHT axis deviation = RETURNING

1 2

Which is which?

LEFT axis deviation = LEAVING RIGHT axis deviation = RETURNING

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Normal

LAD

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RAD

RAD

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Why do we care about cardiac axis?

RAD = associated with LAD = associated with

right ventricular left ventricular
hypertrophy (pulmonary hypertrophy and
conditions that put strain conduction abnormalities
on the heart) (BBB/fascicular blocks)

STEP 4: P waves

• Present

• Absent
– Flutter
– Fibrillation
– SVT

True or false?
Presence of P waves = sinus
rhythm

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Normal sinus rhythm

1. HR 60-100 beats per minute

2. P waves – normal shape, size and
present before every QRS complex
(at a ratio of 1:1)
3. Normal PR interval

STEP 5: PR interval
• Should be between 3-5 small squares
• Prolonged PR (>5 small squares) suggests AV
block (heart block)
– 1st degree – fixed, prolonged PR
– 2nd degree
• Mobitz I – progressive prolongation of the PR interval
until eventually a QRS complex is dropped
• Mobitz II – consistent PR interval with intermittently
dropped QRS complexes
– 3rd degree – complete dissociation

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Mobitz I

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1st degree

Mobitz II

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Complete heart block

STEP 6: QRS complex

• Width
– Narrow <0.12 (normal)
– Wide >0.12 (pathological)

• Height
– Small – obesity, fluid, loss of viable myocardium
– Tall – ventricular hypertrophy, or slim people

• Morphology
– Delta wave (WPW)
– Bundle branch blocks
– Rlly weird – VF, VT etc

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Bundle branch blocks

• Interruption of the normal His-Purkinje system leading to
aberrant conduction and an abnormal QRS morphology
• Prolonged QRS >3 small squares
• Changes are best seen by looking in V1 & V6
• Right
– Indicates right sided heart disease
• Left
– Indicates left sided heart disease
– Can indicate an acute MI

Left vs Right

• Right - MarroW
– Can be a normal variant
– Indicates right sided heart disease (cor pulmonale, PE)

• Left - WilliaM
– Always pathological
– Indicates left sided heart disease (IDH)
– Can also indicate an acute MI

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RBBB

LBBB

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• Depression

STEP 7: ST segment • Elevation

• Reciprocation

STEP 8: T waves
• Tall – hyperkalaemia, hyperacute STEMI
• Inverted – SHOULD be inverted in V1
(sometimes III too). If in other leads:
– Ischaemia
– BBB
– PE….. Lots of reasons
– New T-wave inversion = always abnormal

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STEP 9: QT interval
• Congenital prolongation
– Syndromes
• Acquired prolongation
– Drug-induced
(antipsychotics,
antiarrhythmics,
antibiotics…)
– Electrolyte imbalances
(hypokalaemia,
hypomagnesaemia,
hypocalcaemia)
– Hypothermia

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CASE 1: Muriel

• A 75 year old women presents to ED with a one-

day history of feeling like she’s missing a heartbeat
every now and then. She also reports feeling like
her heart is racing. Otherwise Muriel has no other
symptoms and is normally fit and healthy

• PMHx: HTN, hypothyroidism

• Drug Hx: amlodipine 10mg, levothyroxine 100
micrograms
• Social Hx: lives with her partner Greg

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Case 2: Darren
• Darren, a 37 year old DJ, presents to A+E feeling
distressed. He has a sense of impending doom and reports
feeling unable to catch his breath. His mum died of a heart
attack at the age of 65 when she was reportedly fit and
healthy. He was out gigging last night when he said he
started feeling shaky. Upon further questioning he tried
cocaine “for the first time last night’.
• PMHx: appendectomy, anxiety
• Drug Hx: sertraline
• Social Hx: smokes 10 a day, reportedly drinks daily, denies
past recreational drug use

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Case 3: Graham
• Graham, a 55-year-old lorry driver presents to ED via
ambulance after prolonged chest pain. Graham looks
visibly clammy and after an excellent SOCRATES history
you discover he has crushing chest pain radiating to his left
jaw,. It is not relieved by position, but by something the
paramedics helped him.
• PHMx: GORD, HTN, Diabetes type 2, hypercholesteremia
• Drug Hx: omeprazole, metformin, atorvastatin, ramipril
• Social Hx: non-smoker, has 5 cans of beer every other day
and is currently in the midst of a messy divorce

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Case 4: Bella
• Bella, a 26-year-old model presents with repeated bouts of
dizziness. She presented to her GP a month ago, but her GP
played it off as anemia. Anyway, Bella goes private to get her
demands heard. Upon further investigation at this
appointment, including an ECG, a possible cause for Bella’s
dizziness is clear.
• PHMx: Lyme disease
• Believes in holistic medicine
• Social Hx: vapes, occasionally drinks

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Case 5: Larry

• Larry, a 62-year-old financial advisor, comes into ED via

ambulance after collapsing at work. Upon performing an A-E
assessment Larry is found be extremely tachycardic. The ED
doctors place a 12 lead ECG on Larry which shows an
arrythmia. Vagal maneuvers are performed which fail to resolve
Larry's arrhythmia. A decision is made to administer adenosine,
but unfortunately Larry’s arrhythmia fails to cease. However,
they look at the ECG and it has changed.
• What is the abnormality?

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Arrythmias
• Broad complex QRS
– Regular
• Assume VT (unless previously confirmed SVT with bundle branch block)
– Irregular
• AF with BBB
• Polymorphic VT (torsade de pointes)

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Narrow complex
• Narrow complex
– Regular
• SVT
• Atrial Flutter
– Irregular
• Probably atrial fibrillation

SVT vs VT

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Supraventricular tachycardias
• Narrow complexes
• Heart rate >100
• Regular (unless AF)
• Depending on type p wave may or may not be present

Ventricular tachycardia
• VT is characterised on ECG by:
• Fast rate >200bpm

• Regular rhythm
• No p waves - obscured
• Broad QRS

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Torsades de Pointes

Torsades de pointes

• Polymorphic ventricular tachycardia

• Irregular
• Precipitated by QT prolongation
• Can deteriorate into ventricular fibrillation

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Ventricular Fibrillation
- Tachycardia

- Irregular rhythm

- No P waves

- Broad QRS with abnormal

morphology

VF cont

• Ventricular fibrillation (V-fib or VF) is when the

heart quivers instead of pumping due to
disorganized electrical activity in the ventricles -
it is a type of cardiac arrhythmia

• Ventricular fibrillation results in cardiac arrest

with loss of consciousness and no pulse. This is
followed by death in the absence of treatment.

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Asystole

Non-shockable rhythm

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