BASIC ECG

A report by:
Clinical Clerk Mary Hazel Te
 Electrocardiogram
• ECG or EKG
• graphic recording of electric potentials generated by the
heart

• signals are detected by means of metal electrodes

attached to the extremities and chest wall

• records only the depolarization (stimulation) and

repolarization (recovery) potentials
 Pacemakers of the Heart
• SA Node - Dominant pacemaker
with an intrinsic rate of 60 - 100
beats/minute.

• AV Node - Back-up pacemaker

with an intrinsic rate of 40 - 60
beats/minute.

• Ventricular cells - Back-up

pacemaker with an intrinsic rate
of 20 - 45 bpm.
SA Node
What Does the ECG Measure?

V
O
L
T
A
G
E
TIME
ECG Paper
 Smallest squares are 1 mm wide and 1 mm high
 5 small squares between the heavier black lines
 25 small squares within each large square
 The ECG Paper (cont)
3 sec 3 sec

• Every 3 seconds (15 large boxes) is marked by

a vertical line
 Four Major ECG intervals
• R-R duration of ventricular cardiac cycle (an indicator of ventricular
rate)
• PR
measures the time (normally 120 to 200 ms) between atrial and
ventricular depolarization, which includes the physiologic delay in
AV node
• QRS
duration of ventricular depolarization.
• QT
both ventricular depolarization and repolarization times and varies
inversely with the heart rate
 Electrocardiographic Lead
System
• 12 Leads

– 3 bipolar leads (I, II, III)

– 3 modified unipolar leads (aVR, aVL, aVF)

– 6 precordial leads (v1, v2, v3, v4, v5, v6)

Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
 Why is this important?
• Recording cardiac electrical activity from
the six different angles gives as a much
greater and more accurate perspective.

• With this leads we can identify that

depolarization is toward the patient’s left
side and inferiorly toward the left foot
• All six limb leads meet to form six intersecting
lines that lie in a flat plane on the patient’s
chest.

• Each intersecting line form 30 degree angles

from each other.

• The flat plane formed is the FRONTAL PLANE.

• Each limb lead provides a different view of the

same cardiac activity.
All Limb Leads
 ECG Leads
The six chest leads are unipolar
recordings obtained by electrodes
in the following positions:
V1 - 4th intercostal space, just to the right of the
sternum
V2 - 4th intercostal space, just to the left of the
sternum
V3 - midway between V2 and V4
V4 - midclavicular line, 5th intercostal space
V5 - anterior axillary line, same level as V4
V6 - midaxillary line, same level as V4 and V5
Chest Leads
• For each chest leads, the suction cup electrode
that is placed on the chest is considered positive

• Each lead is oriented to the AV node and exits

through the patients back which is negative

• V1 and V2 – Right side of the heart

• V3 and V4 – interventricular septum
• V5 and V6 – Left side of the heart
 ECG Leads
• Two leads that look at neighbouring anatomical areas of the heart
are said to be contiguous

• Relevance of this is in determining whether an abnormality on the

ECG is likely to represent true disease or a spurious finding
 Anatomical Relations of Leads in a Standard ECG-12-
Leads

I, aVL High Lateral

II, III, aVF Inferior Wall

V1, V2 Septal Wall

V3, V4 Anterior Wall

V5, V6 Lateral Wall

ECG INTERPRETATION
• RATE

• RHYTHM

• AXIS

• HYPERTROPHY

• INFARCTION
 Determining the Rate

• 1500 ÷ # of small boxes within an RR

interval (regular rhythms)
• 10 x # of R complexes in 6 seconds
Calculate Heart Rate (QRS method)

R wave

Find a R wave that lands on a bold line.

Count the # of large boxes to the next R

wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes
- 100, 4 boxes - 75, etc.
 Determining Regularity
R R

• Look at the R-R distances (using a caliper or

markings on a pen or paper).

• Regular (are they equidistant apart)? Occasionally

irregular? Regularly irregular? Irregularly irregular?
 Determining PR interval

• Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)
 Determining QRS duration

• Normal: ≤ 0.10 seconds

(1 - 3 boxes)
 QRS Interval
• subdivided into specific deflections or waves

• Q wave - initial QRS deflection in a given lead is negative

• R wave - the first positive deflection

• S wave - negative deflection after an R wave

• QS wave - entirely negative QRS complex

• Subsequent positive or negative waves are labeled R´

and S´, respectively

• Lowercase letters (qrs) - used for waves of relatively

small amplitude
 Normal Sinus Rhythm (NSR)

• Etiology: the electrical impulse is formed

in the SA node and conducted normally.
• This is the normal rhythm of the heart;
other rhythms that do not conduct via the
typical pathway are called arrhythmias.
 NSR Parameters

• Rate 60 - 100 bpm

• Regularity regular
• P waves visible before QRS
• PR interval 0.12 - 0.20 s
• QRS duration ≤ 0.10 seconds
Any deviation from above is sinus
tachycardia, sinus bradycardia or an arrhythmia
• Sinus Bradycardia
– Sinus rhythm less than 60/min, regular
PQRST
– Most often caused by parasympathetic
excess
– Sometimes it may be slow enough to produce
syncope Rate = 48/min
• Sinus Tachycardia
– Sinus rhythm more than 100/min,
– Regular PQRST
Rate = 115/min
 Rhythm
• On the ECG there is a consistent
distance between similar waves
during a normal, regular cardiac
rhythm, because the automaticity
of the SA node precisely
maintains a constant cycle.
• SA node overdrive suppresses all lower
foci

• 3 levels of automaticity foci

– Atrial – 60-80/min
– Junctional – 40-60/min
– Ventricular – 20-40/min

• Should the highest pacemaking center fail,

it transfers to the next highest level
• “Arrhythmia” literally means without rhythm
 Sinus arrhythmia – physiologic, extremely
minimal increase in HR during inspiration and
extremely minimal decrease in HR during
expiration. Identical but irregularly occurring
PQRST . Longest PP or RR > the shortest by
0.16 sec or more

Rate = 94/min Rate = 71/min Rate = 79/min Rate = 94/min

 Arrhythmia
• Irregular Rhythms
• Escape
• Premature Beats
• Tachy-arrythmias
• Heart blocks
Irregular rhythm
IRREGULAR RHYTHM
Atrial Fibrillation

-due to continuous, rapid firing of

multiple atrial foci

-No true P waves, only rapid series of

tiny, erratic spikes on EKG

- Irregular ventricular response

ESCAPE
Junctional Rhythm

-Origin of impulse
at the AV node

-Decreased rate
(40-60)

-- QRS complex
normal

-Regular rhythm

--P waves may

not be seen
( activation of
atria occurs
retrograde)
ESCAPE
Premature Ventricular Contraction
-Origiinates suddenly in anirritable
automaticity focus in a ventricle

-Rate variable
-Irregular rhythm
-P waves absent
--QRS wide usually? 0.12s
TACHYARRHYTHMIA
Atrial Flutter
-Originates in an automaticty focus.

-Rate : 250-350
-Usually regular rhythm
--saw tooth pattern
-QRS usually narrow.
Tachy arrhythmia
-caused by many irritable atrial foci

-Rate: variable

--Rhythm: irregularly Irregular

-- absent P waves
Ventricular tachycardia

 due to a slower conduction in ischemic ventricular muscle  circular activation (re-entry)  activation of the
ventricular muscle at a high rate (over 120/min)

rapid, bizarre, and wide QRS-complexes;

ventricular tachycardia is often a consequence of ischemia and myocardial infarction.

 Ventricular Fibrillation
• Rapid rate discharges from many irritable
ventricular foci, producing an erratic, rapid
twitching of ventricles (350-450/min)
• “bag of worms” – lacking identifiable waves
Heart Blocks
First Degree AV Block

 Prolongation of the PR interval

on the electrocardiogram
(ECG) (>0.20 s in adults
- All atrial impulses reach the
ventricles in first-degree AV
block
- Conduction is delayed within
the AV node
** can be found in healthy
adults, and its incidence
increases with age.
Heart Block
2nd Degre AV Block
(Wenckebach phenomenon)

2nd degree AV block, Mobitz I

- PR interval progressively
becomes longer from cycle to cycle
until the AV node will no longer
conduct a stimulus from above.
Heart Block
 Mobitz II second-degree AV block
(His bundle or lower)

- Constant PR interval followed by

sudden failure of a P wave to be
conducted to the ventricles,

- Either an occasional dropped P

wave or a regular conduction
pattern of 2:1 (2 conducted and 1
blocked), 3:1 (3 conducted and 1
blocked)
** rare in healthy individuals
Heart Block
Third degree Heart block (V node
or the His-Purkinje system)

-when a complete AV block occur

below the AV junction, a ventricular
focus escapes overdive
suppression to pacethe ventricles
at its slow inherent rate of20-40 per
minute
BUNDLE BRANCH
BLOCK
This is caused by a block,
of conduction, in the Right
or in the Left Bundle
Branch.

The blocked Bundle branch

delays depolarization to the
ventricle it supplies
 widenedQRS appearance on ECG : 3 small squares (0.12s or
BUNDLE BRACH BLOCK greater)

Left Bundle Branch – Left ventricular depolarization is delayed,

Right ventricle depolarizes earlier than the Left
usually seen in V5 and V6 Chest leads

Right Bundle Branch – Right ventricular depolarization id delayed.

V1 and V2 Chest leads
 AXIS
- Refers to the direction of the movement of
depolarization, which spreads through out
the heart to stimulate the myocardium to
contract.

- If we add up all the vectors of ventricular

depolarization we have one large “MEAN
QRS VECTOR”
 MEAN QRS VECTOR
• Because the depolarization vectors are
larger in the thicker LV the vectors point
toward the left (Vector =
Direction+Magnitude)

• The LIMB LEADS are used to determine

the axis.
 LEAD I
• Uses the right and left arm for recording
• It is negative on the right arm and positive
on the left.
• QRS complex is positive it signifies that
the vector points to the left, and to the right
if it is negative (Right axis deviation)
• The BEST lead to determine RAD
 AVF
• For AVF the upper half is negative and the
lower half is positive

• So in determining deviation one should

check Lead I and AVF
Lead I AVF RESULT

Normal range

+ + (“Double thumbs
sign”)
RAD

- +
LAD

+ -
Extreme RAD

- -
 Hypertrophy
• Usually pertains to an increase in
size, but when relating to the
myocardium the term refers to an
increase in mass.

• Implies an increase in thickness

and some dilation
• Examine the P wave for signs of atrial
enlargement. Lead V1 is directly over
the atria so this is the best source of
information

• With atrial enlargement there is

usually a DIPHASIC P WAVE – both
positive and negative
 Right Atrial Hypertrophy
• If the initial component of a diphasic P
wave is the larger

• Note: if the height of the P wave of the

limb leads exceeds 2.5mm even not
dipahsic, RAH should be suspected
 Left Atrial Hypetrophy
• If the terminal portion of the diphasic
P wave is wide then there is Left
Atrial Enlargement

• This is usually caused by systemic

hypertension but can also be caused
by a narrowed mitral valve
 Right Ventricular Hypertrophy
• In lead V1, there is usually a larger R wave than
the S wave
• The R wave gets progressively smaller (V1-V4)
 Left Ventricular Hypertrophy
• V1 S wave is usually deeper, very tall R wave in
lead V5 – (Depth of S wave in V1 + Height of R
wave in V5 = >35mm)
• There is usually LAD and an Inverted T WAVE
 Infarction
• Results from the complete occlusion of a
coronary artery. The area supplied
becomes non-viable and cannot contract.

• The resulting cardiac hypoxia also causes

irritability in one or more ventricular foci,
producing deadly arrhythmia.
 Classic triad of MI = III
–Injury

–Ischemia

–Infarction
Ischemia
• Characterized by
inverted T-waves
 Ischemia
• Since the chest leads are nearest the
ventricles always run down V1-V6 for T-
wave inversion
 Injury
• May be acute or recent
• Elevation of the ST
segment – earliest sign of
infarction to record on ECG
• If the ST segment is
elevated without associated
Q waves, this may
represent a non-Q wave
infarction that may herald
an impending larger infarct
• The ST segment may also be depressed
under certain conditions

– DIGITALIS

– A subendocardial infarction

– A patient with narrowed coronary

arteries undergoing a stress test
 Infarction
• The Q wave makes
the diagnosis of
infarction
 Infarction

• A significant Q wave is at least one small

square wide (0.4 sec) or one-third of the
entire QRS amplitude
• Omit lead AVR in noting the significant Q
waves – unrelaiable, like an upside down
lead II

• Locating INFARCT
– Posterior – large R in V1 and V2, may be a Q
in V6, and a mirror test
– Inferior – Q in II, III and AVF
– Lateral – Q in I and AVL
– Anterior – Q in V1, V2, V3, and V4
 Regions of the
Myocardium:

Lateral
I, AVL,
V5-V6

Anterior /
Inferior Septal
II, III, aVF V1-V4
THANK YOU