ECG INTERPRETATION

Presented by :- ROHINI RAI

M sc nursing part I, C.O.N,
N.B.M.C.H
 INTRODUCTION
The ECG is a graphic representation of the
electrical currents of the heart. The ECG is
obtained by placing disposable electrodes in
standard positions in the skin of the chest wall
and the extremities
 DEFINITION
• Electrocardiograph: ECG is defined as “the
recording of electrical activity of heart on a
graph paper.
• OR
• Graphical representation of electrical activity
of heart
 PURPOSE
• ECG gives information about rate and rhythm of heart
• It is a diagnostic tool for various heart conditions like
hypertrophies, ischemia, infarction, arrhythmias,
conduction problems and pace maker activity
• Chamber enlargement
• Myocardial ischemia injury or infarction.
• It can also suggest cardiac effects of electrolyte
disturbances ( high or low calcium and potassium
levels).
 
ELECTRICAL CONDUCTION OF THE
HEART
 MEANING OF POLARIZATION
Heart muscle cells are polarized when at
rest. This means that the net charge
density of the fluid inside and outside of
the cells is different, because ion
concentrations are different on either
side of the cell membranes. ... In muscle
cells, the action potential causes a
muscle contraction.
MEANING OF DEPOLARIZATION
Loss of polarization especially : loss of the
difference in charge between the inside and
outside of the plasma membrane of a muscle
or myocyte due to a change in permeability
and migration of ions across the cell
membranes.
 RHYTHM OF THE HEART

The word “rhythm” is used to refer to the part

of the heart which is controlling the activation
sequence. The normal heart rhythm with
electrical activation beginning in the SA node,
is called “sinus rhythm”
ECG PAPER
 ECG PAPER
• ECG graph paper is divided by light and dark
vertical and horizontal lines at standard
intervals.
• Time and rate are measured on the horizontal
axis .
• Amplitude or voltage is measured on the
vertical axis
• One square is 1mm wide and 1mm high
• On ECG paper there are thick lines, between
two thick lines there are 5 small squares
• The speed of ECG machine is 25mm per
second
• The time internal of each small square can be
calculated as :
• 25 small squares are equal to 1 second
• 1 small squares is equal to 1/25 second
• i.e. 0.04 seconds
• each large square ( 5 mm) represents 0.2
seconds, i.e. 200 miliseconds
• therefore there are 5 large squares per second,
and 300 per minute.
• Vertically the small square represent the
amount of electrical potential
• One small square represent the potential of
0.01 mv
• 10 small squares represent the potential of 1
mv
 
 ECG LEAD

A lead is an electrical picture of the heart

The ECG recorder compares the electrical
activity detected in the different electrodes,
and the electrical picture so obtained is called
a lead.
 THERE ARE 12 ECG LEADS
• 3 Bipolar limb leads
• 3 augmented limb leads ( unipolar)
• 6 chest leads
 BIPOLAR LIMB LEADS

• Lead 1= left arm + v e, right arm –v e

• Lead 2 = right arm –v e, left leg +v e
• Lead 3 = left arm -v e, left leg + v e
BIPOLAR LIMB LEADS
 AUGMENTED ( UNIPOLAR) LIMB LEADS
 

• AVR = Attach to right arm

• AVL = Attach to left arm
• AVF = Attach to left foot
 
AUGMENTED LIMB LEADS
 ECG ELECTRODE PLACEMENT
The standard left precordial leads are:
• V1 - fourth intercostals space, right sternal
border.
• V2 – fourth intercostals space, left sternal
border
• V3 – diagonally between V2 and V4
• V4- fifth intercostals space, left midclavicular
line
• V5 – same level as V4 , anterior axillary line
• V6- same level as V4 and V5, midaxillary line
PLACEMENT OF PRECORDIAL LEADS
 WAVE FORMS

• P Wave: Atrial depolarization

• QRS complex: Ventricular depolarization
• T wave: Ventricular repolarization
 
 CORELATION OF WAVE FORMS WITH THE
CARDIAC CYCLE

Cardiac cycle is the duration that represent

one complete heart beat consisting of
one contraction and relaxation of heart.
The duration of cardiac cycle is 0.8 seconds
• Atrial systole = P wave
• Ventricular systole = QRS wave
• Ventricular diastole = T wave
 BASIC TERMINOLOGIES

• Base line: flat, straight or isoelectric line

• Wave form: deviation or movement away from
the base line , may be upward or downward
• Segment: a line between two waves
• Interval: a wave form plus a segment this shows
time duration
• Complex: combination of several wave forms
without segment
 THE DIFFERENT PARTS OF ECG
 

• Contraction of atria is associated with the ECG

wave called the “P”.
• Ventricles are depolarized: this is called the QRS
complex
• The “T” wave of the ECG is associated with the
return of the ventricular mass to its resting
electrical state
• In some ECGs an extra wave can be seen on the
end of the T wave, and this is called the U wave.
 P WAVE
• P wave shows atrial depolarization
• Its duration is 0.1 sec (2 and half small
square)
• Height is 2.5 mv ( 2 and half small
square)
• Presence of p wave in the ECG strip
shows the sinus rhythm
 ABNORMALITIES OF P WAVE
 P. Pulmonale
 P. Mitrale
 Inverted P wave
P. Pulmonale and P.Pulmonale ECG strip
 QRS COMPLEX
• QRS represents the ventricular
depolarization
• The duration of QRS complex shows how
long excitation takes to spread through
the ventricles.
• If the conduction takes longer time due to
any abnormality it causes widened QRS
complexes.
 QRS COMPLEX
• QRS complex represent the ventricular
depolarization
• Its normal duration is 0.08 seconds ( less than
two small squares) and height is about 5 to
20 small squares
• It is a wide complex because it mask the
atrial repolarization
 Q - WAVE
• Q wave is the first wave of this complex but
often absent
• Q wave present the interventricular septal
depolarization
• It is the first wave in the ECG with negative
deflection
• Q wave greater than 1/3 the height of the R
wave, greater than 0.04 sec are abnormal and
may represent the old infarction.
 LOW VOLTAGE QRS COMPLEX
When the height of R and S wave is not
more than 5mm… it is seen in
• Hypothyroidism
• Pericardial effusion
• Thick chest wall
• Problem in ECG machine
LOW VOLTAGE QRS COMPLEX
 HIGH VOLTAGE QRS COMPLEX

•  This is present in ventricular hypertrophies

• The maximum voltage of QRS complex may be
35 mv ( 35 small square)
• V1 and v2 show high voltage QRS complex in
right ventricular hypertrophy ( s wave)
• V5 and V6 shows such QRS complex in left
ventricular hypertrophy ( r wave)
 R WAVE
The R wave represents the electrical
stimulus as it passes through the main
portion of the ventricular walls.
Tall R wave represents depolarization of
an enlarged ventricle.
 S WAVE
S wave and represents depolarisation in
the Purkinje fibres. The S wave travels in
the opposite direction to the large
R wave because, as can be seen on the
earlier picture, the Purkinje fibres spread
throughout the ventricles from top to
bottom and then back up through the
walls of the ventricles.
 T WAVE
• It represent the ventricular repolarization
• It is repolarizing wave but shows the upward
deflection because the part depolarised in the
last is the first to be repolarised, that is base of
the heart depolarised in the last but is the first
to be repolarised
• T wave should not be more than one third of R
wave
 ABNORMALITIES OF T WAVE
• T wave inversion represent ischemia of heart
• Tall and peaked T wave is present in
hyperkalemia
• Flattened T wave in pericarditis and
myocarditis
FLATTENED T WAVE
 PR INTERVAL
• This is from beginning of P wave to the beginning of Q
wave. It is the time taken for excitation to spread from SA
node, through the atrial muscle and the AV node, down the
bundle of His and into the ventricular muscle. Logically it
should be called the PQ interval, but common usage is PR
interval.

• The normal PR interval is 120-220 ms, and is represented by

3-5 small squares.

• Its normal duration is from 0.12 to 0.2 sec

• It represent the conduction time of impulse from SA node to

the ventricles and AV delay.
 Q T INTERVAL
The Q T interval is the time from the
beginning of the QRS complex, representing
ventricular depolarization, to the end of T
wave , resulting from ventricular
repolarization.

It is the time taken from when the ventricles

start to contract to when they finish relaxing.
 QT INTERVAL
QT interval varies with heart rate. It is
prolonged in patients with some electrolyte
abnormalities, and more importantly it is
prolonged by some drugs.
An abnormally long or abnormally short QT
interval is associated with an increased risk of
developing abnormal heart rhythms and
sudden cardiac death.
A prolonged QT interval may lead to ventricular
tachycardia
 ST SEGMENT
• This segment present between S wave and T
wave
• It represents the plateau phase
• Its duration is 0.04 secs
• Elevation of ST segment is seen in Myocardial
infarction and hyperkalemia
• Depression is seen in ischemia, digitalis therapy
and hypokalemia
 
S T DEPRESSION
 J POINT
• It is the exact point at which all parts of
ventricles are depolarized i.e. at the just end
of QRS complex and just at the beginning of ST
segment
• At the point potential of ECG is zero with no
current is flowing through heart.
J POINT
PROCEDURE OF ECG
 ECG INTERPERTATION AND RESULTS
Most often, the ECG assessment includes the following:
• determination of the rate,
• assessment of the rhythm,
• evaluation of the electrical conduction patterns.
Heart muscle that is irritated conducts electricity
differently than heart muscle that is normal.
Abnormal conduction may be apparent during
ventricular contraction and during ventricular
recovery.
 ASSESSMENT OF HEART RATE THROUGH ECG

When the cardiac rhythm is regular, the heart

rate can be determined by the interval
between two successive QRS complexes. On
standard paper with the most common tracing
settings, the heart rate is calculated by
dividing the number of large boxes (5 mm or
0.2 seconds) between two successive QRS
complexes in 300.
ECG STRIP WITH REGULAR RHYTHM
HEART RATE DETERMINATION BASED ON THE
NUMBER OF LARGE BOXES

NUMBER OF LARGE HEART RATE NUMBER OF LARGE HEART RATE

BOXES ( beats / min ) BOXES ( BEATS/MIN)

1 300
2 150
3 100
4 75
5 60
6 50
7 43
8 38
9 33
10 30
Look at the number of large boxes before two R
waves and :--
 Remember that two and half large boxes or
less is a critical value for tachycardia.
 7 or more large boxes is a critical for
bradycardia
 ASSESSMENT OF HEART RATE THROUGH
ECG
• When the cardiac rhythm is irregular, a quick
way to calculate heart rate is based on the entire
ECG being 10 seconds. By counting the number of
QRS complexes and multiplying by six, the number
per minute can be calculated, because 10 seconds
times six equals 60 seconds, or 1 minute. This is a
better method when the QRS complexes are
irregular, as during atrial fibrillation, in which case
the RR intervals may vary from beat to beat
Example #1 ( Irregular cardiac rhythm)
Note that the QRS complexes are about 5 1/2
large boxes apart. Referencing the above
image, it can be determined that the
ventricular heart rate is between 50 and 60
b/pm. This is a full 10-second rhythm strip,
and there are nine QRS complexes total.
Multiply the number of QRS complexes by six,
and the exact heart rate is 54 b/pm. There is
one P wave for each QRS complex, thus the
atrial rate is the same.
 PRACTICE: Calculate heart rate

Number of large boxes = 50

No of QRS Complex 17
NURSING RESPONSIBILITY IN ECG
 CONCLUSION

The electrocardiogram (ECG or EKG) is a

diagnostic tool that is routinely used to assess
the electrical and muscular functions of the
heart. While it is a relatively simple test to
perform, the interpretation of the ECG tracing
requires significant amounts of training.