Electrocardiography

Bernardo D. Morantte Jr.M.D.

Department of Medicine
College of Medicine
Pamantasan Ng Lungsod Ng Maynila
 Electrocardiography (EKG)
 The electrical activation of the muscle
cells and the conduction system of the
heart is the basis for electrocardiography.

 The EKG is the recording of the electrical

activation of the heart.
 Action potential
Electrical stimulus

 Na, Ca Phases of repolarization

extracellular
1
40
2
0 Cell Membrane
3
- 40 0
K Intracellular
4
- 80

-100
threshold
mV
1 msec
ARP
RRP
Resting
membrane ARP = absolute refractory period
potential
RRP = relative refractory period
Electrical activation of the heart

SA
LA
node
RA AV node
EKG LV
RV
LBB
P

RBB
Q
RS

T
 EKG
R T QRS
R on T
R pattern

Hyper-repolarized

T (vulnerable period )
p
U
0
PR ST
Q
S
ARR RRP
 Electrode placement
-90 0
-600
- 120 0

Posterior

aVR aVL
I -300 aVL
aVR - 150 0

P
4th v1
RICS V2 +1800 QRS
00 I
V3 V6 V6
II V4 V5 III

+150 P V5
+300
Frontal plane QRS
Hexaxial V4
reference
+1200 +600 II
aVF Anterior0 V3
III + 90
V1 V2 R/S
aVF
progression
Horizontal plane hexaxial reference
P and QRS vector frontal plane

SA
LA
node
RA
AV node LV
EKG
Left axis
deviation
RV -90
P

-60

-30
Q

+180 0
RS

+150 +30
Right axis
+60
deviation +120 +90
T
QRS axis determination
-90 0

- 1200 -600
Frontal Plane
-300 aVL
R aVR - 1500

P
* T 1800
00 I

1500
300
EKG

*Tallest R wave 120 0

600 II

III 900
aVF
 EKG Time Measurements
at 25 mm / second paper speed
Time intervals
R

T 10 mm
p = 1mV

PR QT
QRS
40 msec. calibration
signal
200 msec.

1 second
 Voltage Measurements
Time intervals
R

T 10 mm
P = 1mV

S
= 0.1 mV
40 msec. calibration
signal
200 msec.

1 second
 EKG
V5
V1 LVH= S V1 +R V5
> 35 mm +
RAH= P > 2.5 mm LAD or
R V5 > 26 mm
RVH= R/S > 1 :
RAD
or R V1 LAH = broad
>7.5 notched P inV5
or biphasic P in
V1 with deep
negative
component

RVH and RAH

LVH and LAH

 Atrial (AR) and ventricular rates (VR) at paper
speed of 25 mm per second for regular rhythm

Time intervals Ex: 300/5 = 60

R R

T
P P

Formula:
300
40 msec. 1. VR =
No. of large
200 msec. squares

1 second 1500
2 VR =
No. of small
squares
Caution before reading the EKG
Make sure that the paper speed is at 25 mm
per second
Make sure that the calibration is 10 mm =
1mV
Make sure that the electrodes have been
placed properly
 Non-standard EKG recordings
Be aware !
R
P T 5 mm =1mV

Calibration signal

12.5 mm / sec. paper speed

PR interval QRS QT interval

50 mm / sec paper speed.
 Inversion of right and left limb leads
-900
-600
- 120 0

aVR aVL
I -300 aVL
aVR - 150 0

P
v1
V2 +1800 00 I
V3 V6 QRS V6
V4 V5 III QRS
II
+150 V5
+300
Frontal plane P
V4
aVF +1200 +600 II
III + 900 V3
V1 V2
aVF
Horizontal plane hexaxial reference
 Dextrocardia
-900
-600
- 120 0

Posterior
aVR aVL
I -300 aVL
aVR - 1500
P
v1
V2 +1800 P
V3 V6 V6
V4 V5 III QRS
II
+150 V5
QRS +300
Frontal plane
V4
aVF +1200 +600 II
V2R Anterior V3
III + 900
V1 V2
aVF
Horizontal plane hexaxial reference
 Inversion of right arm and left foot
leads- 120 -90
-60 0
0
0

aVR aVL
I -300 aVL
aVR - 1500
P
v1
V2 +1800 00 I
V3 V6 QRS V6
V4 V5 III QRS
II
+150 V5
+300
Frontal plane P
V4
aVF +1200 +600 II
III + 900 V3
V1 V2
aVF

Horizontal plane hexaxial reference

 Inversion of left arm and left foot
leads
- 120
-90
-60 0
0
0

aVR aVL
I -300 aVL
aVR - 1500
P
QRS
v1
V2 +1800 00 I
V3 V6 V6 V6

90
II V4 V5 III
QRS V5
+150 +300
Frontal plane P
V4
aVF +1200 +600 II
III + 900 V3
V1 V2
aVF
Horizontal plane hexaxial reference
EKG
EKG