1) basic ecg
TRANSCRIPT
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THE
ELECTROCARDIOGRAM(ECG / EKG)
By: Dr Yasir Mansour i
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How To Interpret ECG?
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Highlights
Always interpret the ECG in clinical
context
Always read the ECG systematically
Put the data together & try to find pathology
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Objectives
To recognize the normal ECG of the heart
To recognize the most common ECG
Abnormalities
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The QRS Complex
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ECG ANALYSIS
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Normal ECG with normal QRS transition from V1V6
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ECG ANALYSIS
RATE
RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
U WAVE
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ECG Paper
Speed Amplitude and
Deflection
Calibration
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Standardisation
10mv
Paper Speed
1 small square
= 1mv (mm)
1 big square
= 5 small squares
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ECG ANALYSIS
RATE
Dividing
300 by the number of big squares,
OR
1500 by the number of small squares
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THE RATE
NORMAL (60100 beats / min)
FAST (>100 beats / min) = TACHYCARDIA
SLOW (< 60 beats / min) = BRADYCARDIA
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Pacemakers of the Heart
SA Node - Dominant pacemaker with an
intrinsic rate of 60 - 100 beats/minute.
AV Node - Back-up pacemaker with anintrinsic rate of 40 - 60 beats/minute.
Ventricular cells - Back-up pacemaker with
an intrinsic rate of 20 - 45 beats/minute.
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HR > 150/minNote Paper Speed12.5mm/sec
Same ECG: HR 75/minat Paper Speedof 25mm/sec
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THE RHYTHM
REGULAR or IRREGULAR
There may be a combination of :
Abnormal Rate + Abnormal Rhythm e.g.
Atrial Fibrillation (fast and irregular)
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REGULAR RHYTHM
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IRREGULAR RHYTHM
InspirationExpiration
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NORMAL SINUS RHYTHM
Regular P-P interval
Regular R-R interval ( Rate between 60100/m )
Each P wave is followed by a QRS complex
P T
R R R
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ECG ANALYSIS
RATE
RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
U WAVE
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Determination of Electrical Axis of the Heart
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NORMAL AXIS
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LEFT AXIS DEVIATION
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RIGHT AXIS DEVIATIONRIGHT
AXIS DEVIATION
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THE AXIS
LADEXTREME
RAD
RADNORMAL
I
aVF
I
aVF
I
aVF
I
aVF
0
-90
+90
180
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Normal AxisPositive R in I
Positive R in II
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Right Axis DeviationDeep S in I (Small R )
Tall R in II
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Left Axis DeviationTall R in I
Deep S in AVF
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ECG ANALYSIS
RATE
RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
U WAVE
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P Wave
- Duration
- Amplitude
- Shape
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P Wave
Duration: 0.080.12sec(2-3 small squares)Amplitude: 2 - 2.5mm(22.5small squares)
Shape:Roundedand upright, in Leads I, II, aVF, V4-V6.
Inverted in aVR.
Flat, inverted or biphasicin III, V1, V2
P
P
P
Normal
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ECG ANALYSIS
RATE
RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
U WAVE
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PR Interval
P
R
T
PR Interval
Normal - 0.120.20sec
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PR Interval
Normal Short Prolonged
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ECG ANALYSIS
RATE
RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
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QRS Complex
1. Duration ( Normal 0.060.11sec)
2. Components ( Q, R, S )
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QRS Complex - Duration
Narrow - Normal (0.060.11sec)
Wide - Abnormal (> 0.11sec)
Causes of Wide QRS Complex
1. PVC
2. Intraventricular Conduction Delay (IncompleteBBB)3. BBB
4. Paced Beat
5. W-P-W Syndrome
6. Aberrant Conduction
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QRS Complex - Duration
Causes of Wide QRS Complex
Premature Ventricular Contraction (PVC)
PVC
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Intraventricular Conduction Delay -
(Incomplete) Bundle Branch BlockQRS = 0.11sec
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Left Bundle Branch
Block QRS > 0.12 QRS 4x0.04
= 0.16
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(Complete) Right Bundle
Branch Block QRS > 0.12 QRS 4x0.04
= 0.16
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RBBB - Wide QRS complex Deep wide S in I, II, V5, V6
Prominent R / RsR in V1, V2
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QRS Complex - Duration
Causes of Wide QRS Complex
Paced Beat
Pacemaker Impulse
Paced Ventricular Beat
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Type A W-P-W: Short PR Interval Wide QRS complex (Delta Wave)
Prominent R in V1, V2
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QRS Complex - Components
Q Wave
R Wave
S Wave
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Q WAVE
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QRS Complex - Components
Normal Q Wave
Narrow (1mm duration)
Amplitude less than of the accompanying R wave
Q wave
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QRS Complex - Components
Abnormal Q Wave
Wide (> 1mm duration) and / or
Amplitude > than of the accompanying R wave
Q
R
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R WAVE
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R Wave
Normal R Wave
R wave
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R Wave -Amplitude
Abnormal R Wave:
Low - Causes: i. Emphysemaii. Pleural Effusion
iii. Pericardial Effusion
iv. Dilated Cardiomyopathy
Tall - LVH- RVH
- Biventricular Hypertrophy
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LVH
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RVH - Prominent R in V1 and V2
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Biventricular Hypertrophy ( LVH + RVH )
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Differential Diagnosis of Prominent
R or rsR in V1
RVH
RBBB
True Posterior Myocardial Infarct
Type A Wolffe Parkinson White (WPW)
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RVH
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RBBB - Wide QRS complex Deep wide S in I, II, V5, V6
Prominent R / RsR in V1, V2
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True Posterior MI - Prominent R / Rsr in V! and V2
Rsr
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Type A W-P-W Short PR Interval Wide QRS complex (Delta Wave)
Prominent R in V1, V2
ECG ANALYSIS
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ECG ANALYSIS
RATE RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
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S-T Segment Changes
ST segment Elevation
ST Segment Depression
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May be due to -
i. Myocardial Infarction- Convexupwards
- Related to the area of infarct
- Abnormal Q wave may be present- Reciprocal ST depression may be present
ii. Early Repolarisation
(Elevated J Junction)
iii. Acute Pericarditis- Concave upwards
- Generalised ( in all the leads )
- No abnormal Q wave
Q
R
(i)
(ii)
J junction
(iii)
S-T Segment Elevation
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S-T Segment Depression
May be due to:
1. Myocardial Ischaemia
2. LVH with strain3. Unstable Angina
4. Non-ST segment Elevation Myocardial Infarction
5. Digoxin Effect / Toxicity6. Hypokalaemia
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QT Interval
Measured from the beginning of Q to the end of T
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Measured from the beginning of Q to the end of T
QT Interval
QT Interval
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QT Interval
Measured from the beginning of Q to the end of T
QTinterval < 50% preceding R-R interval
QTc( corrected QT interval)
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ECG ANALYSIS
RATE RHYTHM
AXIS
P WAVE
P-R INTERVAL
QRS COMPLEX
ST SEGMENT
T WAVE
T W
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T Wave
Normal T Wave
Abnormal T Wave - Tall T wave
- Inverted T wave
Tall T waveInverted T wave
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Normal ECG with normal QRS transition from V1V6
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