BASIC 12 LEAD ECG READING

Jonathan M. Paghubasan, MD, DPBEM

BASIC THINGS TO LOOK AT ON ECG
➤ Rate
➤ Rhythm
➤ Axis
➤ Morphology and intervals
THE NORMAL ECG
➤ Rate
➤ Start with a QRS complex that occurs on
a thick line. Assuming that the rhythm is
regular, simply count the number of thick
lines to the next complex. Because each
thick line represents 0.2 sec, there are
300 such lines in 1 minute. Divide 300 by
the number of thick lines, and the
quotient will be the rate in beats per
minute.
➤ The second method of calculating the
rate is to count the number of complexes
in 6 seconds and multiply by 10.
 RHYTHM
➤ The SA node is the normal pacemaker of the
heart. As the automaticity of the SA node
causes atrial depolarization, a P wave is
generated on the ECG.
➤ To describe the cardiac rhythm, one must
determine both the location of the pacemaker
and its rate.
➤ The rhythm of the normal heart is therefore
designated normal sinus rhythm (NSR)
because it originates in the sinus node.
➤ A rapid rhythm originating in the SA node is
called sinus tachycardia, whereas a slow
rhythm originating in the SA node is called
sinus bradycardia.
AXIS
➤ The term axis refers to the direction of
these impulses in both the coronal and
the transverse planes. In general, the
QRS axis is the most commonly
considered, but it is useful also to inspect
the axes of the P and T waves.
MORPHILOGY AND INTERVALS
➤ P wave- The normal P wave lasts less
than 0.12 sec (3 mm). The P wave is
normally less than 0.25 mV.
➤ PR segment- The normal PR interval is
between 0.12 and 0.20 sec. This interval
increases with age.
➤ QRS complex- The duration, or width, of
the QRS reflects the time expended
during ventricular depolarization.
Although there is no lower limit for the
duration of the QRS, it is usually
completed in less than 0.12 sec.
➤ ST segment- Many studies have been
performed to define the normal range of
the QT interval, with most arriving at a
QT Cless than 0.44 sec.
➤ As a rough assessment of QT
prolongation at heart rates between 60
and 100 bpm, the QT interval should be
no more than half the preceding R-R
interval.
DYSRHYTHMIAS AT NORMAL RATES
➤ Regular rhythm, narrow QRS complex
➤ Normal Sinus Rhythm with First Degree
Atrioventricular Block.
➤ Ectopic Atrial Rhythm.
➤ Accelerated Junctional Rhythm
➤ Paroxysmal Atrial Tachycardia with Block.
➤ Atrial Flutter with Block
➤ Regular rhythm, wide QRS complex
➤ Accelerated Idioventricular Rhythm
➤ Hyperkalemia
➤ Drug Toxicity
➤ Irregular rhythm, narrow QRS complex
➤ Normal Sinus Rhythm with Premature Atrial,
Junctional, or Ventricular Contractions.
➤ Sinus Dysrhythmia
➤ Sinus Pause.
➤ Sinoatrial Block.
➤ Wandering Atrial Pacemaker.
➤ Second Degree Atrioventricular Block.
➤ Paroxysmal Atrial Tachycardia with Variable
Block
➤ Atrial Fibrillation with Normal Ventricular
Response.
➤ Atrial Flutter with Variable Block
➤ Irregular rhythm, wide QRS complex
➤ All of the rhythms mentioned in the
previous section may exhibit wide QRS
complex morphology if there is
coexistent bundle branch block,
preexcitation, or aberrant conduction.
BRADYDYSRHYTHMIAS
➤ Regular rhythm, narrow QRS complex
➤ Sinus Bradycardia.
➤ Junctional Rhythm.
➤ Third Degree (Complete)
Atrioventricular Block.
➤ Regular rhythm, wide QRS complex
➤ Idioventricular Escape Rhythm.
➤ Sinoventricular Rhythm.
➤ Irregular rhythm, narrow QRS
complex
➤ Second Degree/Mobitz Type I
Atrioventricular Block.
➤ Second Degree/Mobitz Type II
Atrioventricular Block.
➤ Atrial Fibrillation/Flutter with Slow
Ventricular Response.
➤ Sinoatrial Exit Block.
➤ Irregular rhythm, wide QRS complex
➤ Second-degree/Mobitz type I AV block,
second degree/Mobitz type II AV block
(Fig. 7-7B), atrial fibrillation/flutter with
slow ventricular response, and SA exit
block may present with a wide QRS
complex owing to coexistent bundle
branch block; alternatively, the site of the
escape focus may also be associated with
a widened QRS complex.
 TACHYDYSRHYTHMIAS
➤ Regular rate, narrow QRS complex
➤ Sinus Tachycardia.
➤ Inappropriate Sinus Tachycardia
➤ Sinus Node Reentry Tachycardia
➤ Atrial Tachycardias.
➤ Atrial Flutter.
➤ Junctional Tachycardia.
➤ Atrioventricular Nodal Reentry Tachycardia.
➤ Atrioventricular Reentry (Reciprocating)
TachycardiaOrthodromic.
➤ Fascicular Tachycardias.
➤ Regular rate, wide QRS complex
➤ Ventricular Tachycardia—Monomorphic
➤ Ventricular Flutter.
➤ Supraventricular Tachycardia with
Aberrancy or Bundle Branch Block.
➤ Tachycardia with Preexcitation
➤ Atrioventricular Reentry (Reciprocating)
TachycardiaAntidromic
➤ Pacemaker Tachycardia.
➤ Accelerated Idioventricular Rhythm.
➤ Irregular rate, narrow QRS complex
➤ Tachycardias with Premature Beats
➤ Atrial Fibrillation.
➤ Atrial Flutter with Variable Block
➤ Atrial Tachycardias with Variable Block
➤ Multifocal Atrial Tachycardia,
➤ Irregular rate, wide QRS complex
➤ Polymorphic Ventricular Tachycardia.
➤ Torsades de Pointes.
➤ Ventricular Fibrillation
➤ Irregular Atrial or Supraventricular
Tachycardias with Aberrancy or Bundle
Branch Block.
➤ Tachycardia with Preexcitation
➤ Preexcited Atrial Fibrillation and Flutter
with an Accessory Pathway.