randommomentsdevida

LeadI+leadIII=LeadII(EinthovensLaw)

LeadILARA

LeadIILLRA

LeadIIILLLA
KirchoffsLawThesumofthepotentialsofAVR+AVL+AVF=0

NORMAL

Pwave

Amplitudenormally0.5to2.5mm(2.5squares)(inlimb
leads)

Durationnotover110msec(3squares)(inlimbleads)

Insinusrhythms,PwaveisuprightinLeadIIandinvertedin
aVR.Ifnot,SAnodeisnotpacemaker

Normalaxis(frontalplane)is0to+90,usually+30to+60

Leftaxis0to30

Rightaxisbeyond+75

PRinterval

Normalvalueinadultsis0.12secto0.20sec(ventricularpreexcitation<35squares<1stdegreeAV
block)

QRS

60100ishms(1.52.5squares)

STsegment

Usuallyisoelectric,butmaynormallydeviatebetween0.5and+1.0mmfrombaselineinstandardand
unipolarextremityleads

Upwarddisplacementof2or3mmmaybenormalparticularlyinrightprecordialleads

Twave10%ofamplitudeofQRSisnormal.

Uwave

PolarityusuallysameasTwave

MostprominentinleadV3

Maximumamplitudeshouldnotexceed1mm

AlterationsinautomaticityoftheSAnode

Sinustachycardiasinusrhythm>100beats/min

Sinusbradycardiasinusrhythm<60beats/min
Sinusarrhythmiaincreasedsinusratewithinspiration.

withdrawalofparasympathetictoneduringinspiration

Sinusarrestpause.SAnodefailstofire.

canbecausedbyincreasedparasympathetics,hypersensitivecarotidsinus,damagetoSAnode,digitalis
IrregularRhythms

WanderingPacemakerpacemakeractivitywandersfromSAnodetonearbyatrialautomaticityfoci

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2

Pshapevaries

Atrialrate<100(if>100thenbecomesmultifocalatrialtachycardia)

Irregularventricularrhythm
MultifocalAtrialTachycardiaChaoticAtrialRhythm

Pwaveshapevaries(ThreeormoreectopicPwaveswithdifferentconfigurations/morphologiesbecauseP
wavescomefromdifferentareasintheatrium.)

IsoelectriclinebetweenPPintervals

FrequentoccurrenceofvaryingPRintervals

Atrialrate>100(100250bpm)

Irregularventricularrhythm

SeeninCOPD
AtrialFibrillation

Irregularrhythmandirregularventricularrhythm

Chaoticatrialspikes
Escapebeatanautomaticityfocustransientlyescapesoverdrivesuppressiontoemitonebeat(Abeatoriginatingfromasite
otherthantheSAnode).Longpausefollowedbyescapebeat(versusprematurebeatwherethereisnopausebefore)
EscapeRhythmanautomaticityfocusescapesoverdrivesuppressiontopaceatitsinherentrate(anothernormalpacemaker
takesover)asequenceofsimilarectopicbeats(manyectopicbeats).WhenSAnodepacemakeractivityisimpaired

Atrialescaperhythm6080/min

PwavesarenotidenticaltopreviousPwaveswhicharefromtheSAnode.(Thesameisfortheescape
beat)
Junctionalescaperhythm4060/min

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3

ConductsmainlytoventriclesseriesofloneQRScomplexes.
RetrogradeatrialdepolarizationleadstoaninvertedP

canbeimmediatelybeforetheQRS

canbeburiedintheQRS

canbeaftertheQRS
Ventricularescaperhythm2040/min

largeventricularcomplexes

canbesoslowthatitcausesStokesAdamsSyndromewherenotenoughbloodreachesthebrain.
PrematureBeatsirritablefocusspontaneouslyfiresasinglestimulus

PrematureatrialbeatearlyPwavewhichcanbehiddenintheTwavewithnormalQRSfollowing.

PcandepolarizetheventriclesleadingtoawideQRSinthePACbeatonly.
Ifnotconducted,lonePwavewithnoQRSfollowing.
Irritatedby(sameforprematurejunctionalbeat)epi,increasedSNSstimulation,caffeine,amphetamines,
cocaine,otherbeta1stimulants,excessdigitalis,toxins,etoh(sometimes),hyperthyroid,stretch
PrematurejunctionalbeatprematureirritablestimulationfromAVjunctionwhichdepolarizestheventriclesand
sometimesinaretrogradefashion,willdepolarizetheatria.

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4

Pwavecanbebefore,duringoraftertheQRS.
UpperAVJunctionalRhythm

AVnodenotpacemaker.

Retrograde/invertedPwavesprecedetheQRScomplexesbyshortPRintervals(startpacemaker
nearAVnodetravelsfasterbecauseshorterdistance)inleadsII,III,andaVF

MiddleAVJunctionalRhythm

PwavescannotbeidentifiedsincetheyareburiedintheQRScomplexes.Atrialfibrillationisruled
outsincethebaselineshowsnooscillations.

LowerAVJunctionalRhythm

RetrogradePwavesfollowQRScomplexes.TheyarebestseeninleadsII,III,andaVF

AtriadepolarizedAFTERtheventriclesdepolarize.
Prematureventricularbeatirritatetheventricles

WideandtallQRSwithoppositepolarityofthenormalQRS
Onlydepolarizestheventricles,nottheSAnode.
Irritatedbyairwayobstruction,hypoxia,reducedCO,lowpotassium,mitralvalveprolapse,stretch,
myocarditis

VentricularParastolefromanentranceblockbutnotirritablePVCscoupledtolongseriesofnormalcycles

MultifocalPVCseachfocusisownuniqueidentifiablePVC

RonTPVCfallsonaTwave/fallsonavulnerableperiodandstartsshit

fromhypoxiaandlowserumpotassium.
Tachyarrhythmiasrapidventricularrhythmsoriginatinginaveryirritableautomaticityfoci

Paroxysmal(sudden)tachycardia150250(sinustachycardiaisnotsuddenlikeparoxysmal)

ParoxysmalAtrialTachycardia(PAT)

rapidrate,spikePwaves
2:1ratioP:QRS
(suspectdigitalisexcessortoxicitydigitaliscaninhibittheAVnode)

randommomentsdevida
5

PATwithAVblockmorethanonePwaveforeveryQRSresponse

ParoxysmalJunctionalTachycardia(PJT)suddenrapidpacingofaveryirritableautomaticityfociinthe
AVjunction

invertedPbefore,during,oraftertheQRScandepolarizetheatriainaretrogradefashionfrom
below

WideQRSfromdepolarizingleftbeforeright
JunctionalTachycardiaAVnodalreentrytachycardia

randommomentsdevida
6

continuousreentrycircuitrapidlypacestheatriaandventricles.Eachpacingstimulusrecordsin
anoriginnearthecoronarysinus.
Supraventriculartachycardiairritableautomaticityfocithatproducebothparoxysmalatrialand
junctionaltachycardia(abovetheventricles)

ParoxysmalVentricularTachycardiaresemblesaseriesofPVCs

SAnodestillpacesatriaindependentpacingoftheatriaandventricles(AVdissociation)

IndicatescoronaryinsufficiencyleadingtopoorO2totheheart.
DistinguishingwideQRSinsufficiencycomplexSVTfromVTach.

SVT

VTach

Ptwithcoronarydiseaseorinfarction

uncommon

verycommon

QRSwidth(duration)

<0.14s

>0.14s

AVdissociationshowingcapturesor
fusions

rare

yes

AxisextremeRAD

rare

yes

TorsadesdePointes(250350)

causedbylowpotassium,medsthatblocktheK+channels,congenitalabnormalities,
long/lengthenedQTsegment.
Possiblyfromtwoirritablefociindifferentventricularareas.

Flutter250350

Atrialfluttersawtoothshape

randommomentsdevida
7

Originatesintheatrialautomaticityfocus
VentricularFlutter

singleventricularautomaticityfocus

Sinewavesofsimilaramplitude

TendstogotoVFib.
Fibrillation350450(multiplefocidischargerapidly)

atrialfibrillation

manyirritableparasystolicatrialfoci

causesmanyirregularspokesontheEKG

NoidentifiablePorPwaveswithirregularQRSresponse.
VentricularFibrillation

Manyirritableparasystolicventricularautomaticityfocipacingrapidly(entranceblock)
WolffParkinsonWhiteSyndrome

randommomentsdevida
8

Deltawave=areaofpreexcitation
Canhaveparoxysmaltachycardia

rapidconductionSVT(atrialflutterandafib)canberapidlyconductedthroughthe
accessorypathway

somebundleshaveautomaticityfocithatcaninitialparoxysmaltachycardia

Reentryventriculardepolarizationmayimmediatelyrestimulatetheatriaina
retrogradefashionviatheaccessorypathwaycausingatheoreticalcircusreentryloop
LownGanongLevineSyndrome(LGL)

AVnodeisbypassedbyanextensionoftheanteriorinternodaltract(JamesBundle)which
conductsatrialdepolarizationsdirectlytotheBundleofHiswithoutdelay
NosignificantPRintervaldelay
PwavesareadjacenttotheQRSsonEKG.

SinusBlock

SAnodemaytemporarilyfailtopaceforatleastonecyclethenresumespacing

Thepausecaninduceanescapebeatfromanautomaticityfoci

SickSinusSyndrome

seenintheelderlywithheartdisease

Markedsinusbradycardiawithoutnormalescapemechanismsoratrialandjunctionalfoci

candevelopbradycardiatachycardiasyndromeintermittentepisodesofSVT(aflutterorafib)
AVBlock

FirstDegreeAVblock

randommomentsdevida
9

lengthenedPRinterval>0.2s(1largesquare)

NowideQRS
SeconddegreeAVblock

WenckebachlengtheningofPRintervaluntilQRSisdropped.

Mobitz21normalcycleprecededbyaseriesofpacedPwavesthatfailtoconductthroughthe
AVnode

ThirddegreeAVblock

blockoftheconductionofatrialstimulitoventricles.

Atriaandventriclespaceatdifferentrates.
BundleBranchBlock/IntraventricularConductionDelay

blockofonebundlebranchwhichproducesadelayofdepolarizationoftheventricleitsupplies.

WideQRSwithrabbitears(>0.12s)(3squaresormoreinanylead)RSR

RBBBrabbitearsinV1,V2

randommomentsdevida
10

DeepandroundSwavesinI,aVLandV46

SecondaryST,TwavechangeinV13

abnormaldepolarizationandrepolarization

CompleteRBBBwithRVH>15mm.CanDxonlywithRBBB.
LBBBrabbitearsinV5,V6

AbsenceofseptalqwavesinV46(smallqfromseptalactivationnotseen)

RSRorMpatternofQRSinI,aVLandV46

SecondaryST,TwavechangeinI,aVLandV46

Septalactivationinoppositedirection(RL)
IfRSRofnormalQRSdurationincompleteBBB
IntermittentmobitzoccasionaldroppedQRSduetopermanentBBBwithintermittentBBBofotherside.

Hemiblock

randommomentsdevida
11

AnteriorHemiblock

LADusuallyassociatedwithanMI(orotherheartdz)

NormalorslightlywidenedQRS(0.100.12s)

Q1S3QinIorwise/deepSinIII)

LeftAnteriorblock

MeanandterminalQRSvectorsaredirectedtotheleftof30infrontalplane

Initial0.02secondQRSvector

Directedrightandinferiorlyandproducesasmall0.02secondQwaveinLeadIand
AVL

Small0.02secondRwaveinLeadsII,IIIandAVF

Othercausesofabnormalleftaxisdeviationareruledouti.e.,inferiorwallmyocardialinfarction
AnteriorhemiblockwithRBBB

RBBBmeanQRSvectoriswithinnormalrangeorshowsminimalRAD

RBBB+LAD=anteriorhemiblock
Posteriorhemiblock

RAD(usuallyassociatedwithanMI)

normalorslightlywidenedQRS

S1Q3WideSinIandQinIII

Posteriorblock

Thisconditionisverydifficulttodiagnoserightventricularenlargementandlateralinfarctions

MeanandterminalQRSvectorsinfrontalplaneshowrightaxisdeviation

Initial0.02secondQRSvector

Directedslightlyleftwardandsuperiorlyandproducesasmall0.02secondRwavein
LeadIandAVL(r/oanterolateralinfarction)

Small0.02secondQwaveinLeadsII,IIIandAVF
Bifascicularblock

RBBB+anteriorhemiblock

RBBB+posteriorhemiblock
Intermittentblock

continuousEKGpatternwithintermittentwideQRScharacteristicofintermittentBBBorwithintermittent
changesofQRSaxis.
IncompleteTrifascicularBlock

FirstdegreeAVblockplusarightbundlebranchblockpluseitheraleftanteriorhemiblockorposterior
hemiblock

Axisdirectionofdepolarizationasitpassesthroughtheheart

originofmeanQRSvectoristheAVnode=tailofthe
vector.090isnormal

MeanQRSvectorwillpointtowardhypertrophyandaway
frominfarct

V1,V2=rightwardrotation

V5,V6=leftwardrotation

Hypertrophy

Diphasicwave=atrialenlargement

RightatrialenlargementinitiallargedeflectioninV1.Tall
Pwave

randommomentsdevida
12

ifheight>2.5mminIIand>0.12s,suspectrightatrialenlargement
pointedPwavegreaterthan2.5mm,whichisbestseeninleadsperpendiculartotheheartbottomwall(II,
III,aVF)andchestleadsV1andV2
LeftatrialenlargementlargeterminaldeflectioninV1.LongPwave

Pwaveisaprolongedandbiphasic(bifid).ItisbestseeninleadsI,IIandaVLandsometimespossiblyin
leadsV5andV6.(http://www.healthtutor.com/pmitraleecg.html)
Rightventricularhypertrophy

randommomentsdevida
13

LargeRwaveinV1,Swaveismuchsmaller

ThelargeRwaveinV1progressivelybecomessmallerinV2,V3,V4

RVHcausesRAD+rightwardshift.
Leftventricularhypertrophy

QRScomplexesareexaggeratedinamplitudeeps.inchestleads.
VerytallRwavesinV5
Height/depthofSinV1+heightofRinV5>35mmLVH.

randommomentsdevida
14

CanseeanasymmetricalinvertedTwave(idealleadsV5/V6)
ventricularstrain
V1providesthemostinformationregardinghypertrophydiphasicwaves,RwaveinV1,SwaveinV1,R
waveinV5

Accompaniedby

leftatrialabnormality

>0.11s

Leftaxisdeviation030

STsegmentTwavechangesleftventricularstrainpattern(systolicoverload)

Extremityleads

AmplitudeofRwaveinLeadIand/orAVL>15mm

AmplitudeofRwaveinAVF>21mm

SumofRwaveinLeadIplusSwavein

LeadIII>25mm

Precordialleads

SV1+RV5orSV1+RV6>35mm

RwaveinV5orV6>26mm

RwaveinV6tallerthanRwaveinLeadV5
Infarction

Ischemiareducedbloodsupply

characterizedbysymmetricinvertedTwaves
LeadsV2V6ispathological
MarkedTwaveinversioninleadsV2,V3isWellensSyndromeStenosisofanteriordescending
artery.
Injuryacuteorrecent

ifnoQwaves,canbenonQwaveinfarction

STelevationisinfarct.Depressioninreciprocalchanges.
Pericarditis

randommomentsdevida
15

STsegmentiselevated(diffuse)andusuallyflatorconcave(middlesagsdown).

EntireTwavemaybeelevatedoffbaseline
Subendocardialinfarction

randommomentsdevida
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Necrosisdeadtissue

QwaveindicatesnecrosiscanDxinfarction
InsignificantQwaves<0.04s(1mm)
SignificantQwaves>0.04s(orQRSamplitudeoldcriterion)

AnteriorInfarct

randommomentsdevida
17

elevatedSTsegmentsandQwavesinV1,V2,V3,V4anteriordescendingofleftcoronary
artery
PosteriorInfarct

Mirrorimageofanteriorinfarct

STdepressioninV1,V2

LargeRwaves,maybeQinV6
Lateralinfarct

randommomentsdevida
18

I,AVLQwaves

Circumflexleftcoronaryartery
InferiorInfarct

II,III,AVFQwaves

right/leftcoronaryartery
CannotDxinfarctionwithLBBB

randommomentsdevida
19

hyperkalemia

wide,flatP

peakedT

wideQRS
Hypokalemia

T/Uwavefusion.

FlatTwave

ProminentUwave
Hypercalcemia

shortQTinterval

randommomentsdevida
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Hypocalcemia

prolongedQTinterval
Digitalis

positiveinotropeImprovecontractilityofthefailingheart(mechanicaleffect)

ProlongtherefractoryperiodoftheAVnodeinpatientswithsupraventriculararrhythmias(electricaleffect)

inhibitsthecellmembranesodiumpotassiumATPasepump

TherapeuticusefortreatingAtrialfibrillation

SalvadorDalismustache

ToxicitySinusbradycardia,AVblock,VTachsecondarytoectopicbeats
Quinidine

ClassIAantiarrhythmic(blocksNaandKchannels)
retardsandrepolarizes
LongQTintervalcanleadtoTorsades
Wide,notchedP
WideQRS
depressionST
Uwave