BASIC ECG INTERPRETATION

CONDUCTION
SYSTEM
Sinoatrial Node (SA)
Primary pacemaker
Intrinsic rate 60-
100/min
Located in Rt. Atrium
Supplied by
sympathetic and para-
sympathetic nerve
fibers
Blood from RCA-60%
of people

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 CONDUCTION
SYSTEM
Three internodal
pathways

Anterior tract
 Bachmann’s Bundle
 Left atrium

Wenckebach’s Bundle

Thorel’s Pathway

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 ECG
Records electrical
voltage of heart cells
Orientation of heart
Conduction
disturbances
Electrical effects of
medications and
electrolytes
Cardiac muscle mass
Ischemia / Infarction

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 ECG
Leads
Tracing of electrical
activity between 2
electrodes
Records the Average
current flow at any
specific time in any
specific portion of time

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 ECG Leads
Leads are electrodes which measure the difference in
electrical potential between either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point

with zero electrical potential, located in the center of
the heart (unipolar leads)
 ECG Leads
The standard EKG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads

The axis of a particular lead represents the viewpoint from

which it looks at the heart.
ECG Leads:
Bipolar Leads:
Lead I: Right arm (RA) (–) to Left
arm (LA) (+), displays lateral
wall activity

Lead II: RA (–) to left leg (LL) (+),

displays Inferior wall activity

Lead III: LA (-) to LL (+) displays

a different angulation of inferior
wall activity

The right leg (RL) acts as the

ground or common
ECG Leads:
Unipolar:
 1) AVR: displays the cardiac impulse
detected from the right arm.
 In the normal heart, AVR displays as a
negative waveform because the cardiac
impulse is traveling away from the right
arm.
 It doesn’t display the electrical activity
of any single cardiac wall. Therefore, it
is called the “orphan lead”.

 2) AVL: displays the cardiac impulse

viewed from the left arm.
 AVL displays the electrical activity of the
lateral wall.

 3) AVF:displays the cardiac impulse as

viewed from the left foot.
 It displays the electrical activity in the
inferior wall.
Standard Limb Leads
Precordial Leads

Adapted from: www.numed.co.uk/electrodepl.html

Precordial Leads
 Summary of Leads

Limb Leads Precordial Leads

Bipolar I, II, III -

(standard limb leads)

Unipolar aVR, aVL, aVF V1-V6

(augmented limb leads)
Arrangement of Leads on the EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
HEXA- AXIAL

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 ECG PAPER
Graph Paper
Small boxes
 1mm wide; 1 mm high
Horizontal axis
 Time in seconds
 1 mm box represents
0.04 seconds
 ECG paper speed is
25 mm/second
 One large box is 5 (1 mm
boxes or 0.04 sec)=.20
seconds

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 ECG PAPER
Vertical Axis
Voltage or amplitude
Measured in millivolts
1mm box high is 0.1
mV
1 large box is (5 x
0.1=0.5 mV)
However, in practice
the vertical axis is
described in
millimeters.

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 ECG PAPER
Waveforms
Movement from
baseline
Positive (upward)
Negative (downward)

Isoelectric –along
baseline
Biphasic - Both
upward and
downward

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 ECG
P Wave
First waveform
Impulse begins in SA
Node in Right Atrium
Downslope of P wave –
is stimulation of left
atrium
2.5 mm in height (max)
O.11 sec. duration
(max)
Positive in Lead II

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 ECG
QRS Complex
Electrical impulse
through ventricules
Larger than P wave
due to larger muscle
mass of ventricles
Follows P wave
Made up of a
 Q wave
 R wave
 S wave

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 ECG
Q wave
First negative
deflection following P
wave
Represents
depolarization of the
interventricular septum
activated from left to
right

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 ECG
R wave
First upright
waveform following
the P wave
Represents
depolarization of
ventricles

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 ECG
S wave
Negative waveform
following the R wave

Normal duration of
QRS
0.06 mm – 0.10 mm

Not all QRS

Complexes have a Q, R
and S
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 ECG
T wave
Represents ventricular
repolarization
Absolute refractory
period present during
beginning of T wave
Relative refractory
period at peak
Usually 0.5 mm or
more in height
Slightly rounded

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 ECG

J Point
 Point where the QRS
complex and ST-segment
meet

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 ECG
PR Interval
Measurement where P
wave leaves baseline to
beginning of QRS
complex
Activation
 AV Node
 Bundle of His
 Bundle Branches
 Purkinje Fibers
 Atrial repolarization
0.12 - .20 sec.

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 ECG
QT interval
Begins at isoelectric
line from end of S
wave to the beginning
of the T wave - 0.44
sec.
Represents total
ventricular activity
Measured from
beginning of QRS
complex to end of T
wave
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 ECG
Analysis
Regularity
 Atrial Rate
 Measure distance
between P waves
 Ventricular Rate
 Measure distance
between R-R intervals
 0.04 mm ‘off’ is
considered regular

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 ECG
Analysis
Measure P wave length

Measure PR Interval

Measure QRS wave

duration

Measure QT interval

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 ECG
Analysis
ST segment
 Elevated?
 Depressed?

T wave
 Normal height
 Upright?

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 ECG
Normal Sinus Rhythm
Electrical activity
activity starts in SA
node
 AV Junction
 Bundle Branches
 Ventricles
 Depolarization of atria
and ventricles
Rate: 60-100 /Regular
PR interval / QRS
duration normal
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 ECG
Sinus Tachycardia
SA node fires faster than 100-180/minute
Normal pathway of conduction and depolarization
Regular rate
Why?
 Coronary artery disease Fear; anger; exercise;
 Hypoxia Fever
Treatment:
 Treat Cause
 Beta-Blockers

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 ECG
Sinus Arrhythmia
The SA node fires Irregularly / Rate 60-100/min.
Normal pathway of electrical conduction and
depolarization
PR and QRS durations are normal
Why?
 Respiratory- Increases with inspiration; decreases with
expiration
 Often in children; Inferior Wall MI; Increased ICP;
 Medications: Digoxin; Morphine
Treatment: Often None

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 ECG
Atrial Flutter
Irritable focus within the atrium typically fires at a rate of
about 300 bpm
Waveforms resemble teeth of a saw
AV node cannot conduct faster than about 180 beats/minute
Atrial vs ventricular rate expressed as a ratio
Why: Re-entry- Hypoxia Pulmonary embolism
MI Chronic Lung disease Pneumonia etc.
S & S: SOB; Weakness; Dizziness; Fatigue; Chest
discomfort
Treatment: Ca Channel Blocker; Beta Blockers;
Amiodarone; Cardioversion – anticoagulants; Corvert
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 ECG
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 ECG
Atrial Fibrillation
Irritable sites in atria fire at a rate of 400-600/minute
Muscles of atria quiver rather than contract
(fibrillate)
No P waves – only an undulating line
Only a few electrical impulses get through to the
ventricles – may be a lot of impulses or a few
A lot of impulses (ventricular rate high- then called
atrial fibrillation with rapid ventricular response)
A few impulses (ventricular rate slow – then called
atrial fibrillation with slow ventricular response)

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 ECG
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 ECG
AV Block
 Delay or interruption in impulse conduction
 Classified accordi8ng to degree of block and/or to site of
block

First Degree Block

 Impulses from SA node to the ventricles is DELAYED but
not blocked
 Why? Ischemia Medications
Hyperkalemia
o Inferior MI Increased Vagal Tone
 Treatment? Usually None
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 ECG
Second Degree Block Type I - Wenckebach
 Lengthening of the PR interval and then QRS wave is
dropped

 Why? Usually RCA occlusion (90% of population)

 Ischemia
 Increasein parasympathetic tome
 Medications
 Treatment
 If slow ventricular rate
o Atropine
o Pacing

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 ECG

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 ECG
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 ECG
Second Degree AV Block – Mobitz Type II
 Why
 Ischemia LCA – Anterior MI
 Organic heart disease
 Important:
 Ventricular Rate
 QRS duration
 How many dropped QRS’s in relation to P waves?
 What is the ratio?
 Treatment
 Atropine
 Pacing

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 ECG
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 ECG
Third Degree AV Block (Complete Block)
 No P waves are conducted to the ventricles
 The atrial pacemakers and ventricle pacemakers are firing
independently
 Why?
 Inferior MI; Anterior MI
 Serious
 Treatment
 Atropine 0.5 mg IV
 Epinephrine 2-10 mcg/kg or Dopamine 2-10 mcg/kg/min
 Pacing

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 ECG
Ventricular Rhythms
 Are the heart’s least efficient pacemakers
 Generate impulses at 20-40/min
 Assume pacemaking if:
 SA nodes fail, very slow (below 20-40) or are blocked
 Ventricles site(s) is irritable
 Irritable
due to ischemia
 Depolarization route is abnormal and longer, therefore
QRS looks different and is wider.
 T wave is opposite in direction to QRS

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 ECG
Premature Ventricular Contractions
May be from One Site and all look the same
 Called Unifocal (from one focus or foci)

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 ECG
Ventricular Fibrillation
 Chaotic rhythm of the ventricles
 Lethal if not treated
 Causes: MI; Electrolyte Imbalance; Drug OD’s; Trauma
Heart Failure; Vagal Stimulation; Increased SNS
Electrocutions etc.

 Treatment: Defibrillation and CPR; AICD

Defibrillation: 360 Joules (monophasic defibrillators)
150 Joules (biphasic defibrillators)

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 ECG
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