When you see an ECG paper

Relax and take a deep breath ☺

Don’t forget to comment on 8 points
1. Rhythm
Sinus or not ??
Regular or not ??

2. Rate
If regular rhythm >> the heart rate equates 300 / n ( which n the number of big
squares between RR interval).
Or 1500 /n ( which n the number of small squares between RR interval ), more
accurate.
If irregular rhythm >> count the number of R waves in 30 big squares and
multiply the result by 10.
Or, 300 / n ( which n the average number of RR interval)
3. Axis
Lead one and two ( aVF ) positive >> normal axis
Lead one ( positive ) and lead two ( aVF) negative >> left axis deviation
Lead one ( negative ) and lead two ( aVF) positive >> right axis deviation

4. P wave
Normally >> 2.5 X 2.5 small squares
˃ 2.5 small squares ( tall ) and peaked >> right atrial strain
˃ 2.5 small squares ( width ) broad >> left atrial strain

5. P-R interval
From the beginning of the P wave to the beginning of the complex, measuring 3 to 5
small squares

6. QRS complex
Q wave >> first negative wave in the complex
R wave >> first positive wave in the complex
S wave >> the negative wave following R

Q wave >> less than 1 small square width and less than one fourth of the next R
R wave >> between 2 and 3 small squares width and between 1 to 5 big squares tall
S wave >> has a special relation with R wave

7. ST segment
From the end of S wave to the beginning of T wave ( important in MI )
 8. T wave
Never absent, less than 6 small squares width and less than one third of the preceding R
(Tall)

First look at the rhythm, it may be :

Regular
Irregular (better )

! "# "$
Why irregular rhythm is better ?
As they are usually one of three
Atrial fibrillation
Extra systole
Mobitz one

Atrial fibrillation
How to differentiate ?
Irregular
Usually tachycardia
Absent P wave

AF is usually rapid, but Slow AF in

certain cases :
Patient on digitalis
Patient on Beta blocker
Associated with Heart block
Lone AF

Irregular ECG with absent P wave >> AF however, tachy or not

.

Extra systole
Extrasystoles are essentially ally
extra beats, or contractions, ns,
which interrupt the normal al
regular rhythm of the heart.
They occur when there is
electrical discharge from
om
somewhere in the heart other her
than the SA node. They are re
classified as atrial or ventricular
lar
extrasystoles (VEs) according to
their site of origin.

Extrasystoles can occur frequently

ntly in people with completely normal hearts ts and
an often do not
cause any problems. However,, the
they can also be a feature of certain cardiacc diseases.
dis

Atrial extrasystoles are prem

premature P waves which look different fromm a normal P wave.
They may be hidden in the ST segm
egment or T wave of the preceding sinus beat.
eat. They may be
followed either by a normal QRSS co
complex, or the PR interval may be prolonged
nged, or the impulse
may not be conducted at all.

Ventricular extrasystoles (VEs)) are wide, abnormally-shaped QRS complexes. xes. Extrasystoles
occurring at every second or third
ird beat are called bigeminy or trigeminy respe
spectively.

Mobitz one
How to differentiate it ?
Progressive prolongation of
PR interval until dropped QRS
.

! "# "$
Look at the rate :
Tachycardia
Bradycarida
Normocardia as tachycardia ☺

Regular tachycardia
Sinus tachycardia
Ventricular tachycardia
Supra ventricular tachycardia
Atrial flutter

Sinus Tachycardia
Sinus tachycardia is a rhythm
in which the rate of impulses
arising from the sinoatrial (SA)
node is elevated.
Each sinus P wave is followed
by a QRS complex, indicating
sinus rhythm with 1:1 AV
conduction.

Ventricular tachycardia
Ventricular tachycardia is
defined as a sequence of three or
more ventricular beats. The
frequency must by higher than
100 bpm, mostly it is 110-250
bpm. Ventricular tachycardias
often origin around old scar
tissue in the heart, e.g. after
myocardial infarction.
Also electrolyte disturbances and ischemia can cause ventricular tachycardias. The
cardiac output is often strongly reduced during VT resulting in hypotension and loss of
conciousness. VT is a medical emergency as it can deteriorate into Ventricular fibrillation and
thus mechanical cardiac arrest.
Ventricular tachycardia can be catechorized as follows:
Non-sustained VT: three or more ventricular beats with a maximal duration of 30
seconds.
Sustained VT: a VT of more than 30 seconds duration (or less if treated by
electrocardioversion within 30 seconds).
Monomorphic VT: all ventricular beats have the same configuration.
Polymorphic VT: the ventricular beats have a changing configuration. The RR interval is
180-600 ms (comparable to a heart rate of 100-333 bpm).
Biphasic VT: a ventricular tachycardia with a QRS complex that alternates from beat to
beat. Associated with digoxin intoxication andlong QT syndrome.

Supra ventricular tachycardia

Is a condition presenting as a
rapid heart rhythm originating
at or above the AV node.

It may be originating from :

Atrium
A.V. node

If it is originated from the

atrium the P wave will be
deformed. ( reversal of
electric current )

If it is originated from the ventricle the P wave may ( inverted or absent or deformed )

Note
Supra ventricular tachycardia :
May be associated with absent P, inverted P or deformed P
Although "SVT" can be due to any supraventricular cause, the term is most often used to
refer to a specific example, paroxysmal supraventricular tachycardia (PSVT)
Atrial flutter
Is an abnormal heart rhythm thatat
occurs in the atria of the heart.
rt.
AV node makes reduction of the
atrial beats in a mathematical
fashion ( AV node transmit one of 2
or 3 or 4 beats )

Has a characteristic feature of

Sawtooth appearance

What is the differences between en

atrial flutter and atrial fibrillation
on ?
Atrial flutter >> is re
regular
Atrial fibrillation >> iis
irregular
Summary
I have a regular long strip, I found
und there is
tachycardia :
1. Look at the QRS :
deformed
Narrow
normal
If deformed >> ventricular tachyca ycardia

If narrow normal >>

Look at P wave
single
multiple
Others

Single >> sinus tachycardia

Multiple ( sawtooth ) >> atrial flutt
flutter
Others >> supra ventricular tachyc
hycardia
Regular bradycardia
Sinus bradycardia
first degree heart block
Mobitz two
third degree heart block
Nodal rhythm

Sinus bradycardia
Is a heart rhythm that
originates from the sinus
node and has a rate of
under 60 beats per minute.

First degree heart block

What is meant by first
degree heart block
Just prolonged PR interval
Mobitz two
What is meant by Mobitz two ?
Regular drop of QRS complex

Third degree heart block

What is meant by 3rd degree heart
eart
block ?
Deformed QRS with AV dissociation
ation

Nodal rhythm
What is meant by nodal rhythm ?
The AV node is the peace maker
ker of
the heart, hence the P wave will
ill be
inverted or absent
Summary
I have a regular long strip, I found
nd tthere is bradycardia :
1. Look at the QRS :
Deformed
Narrow normal

If deformed >> third degree heart

art b
block

If narrow normal >> Look at P wav

wave
Single
Multiple
Others

Single >>
Sinus bradycardia ( normal ECG with heart 60)
al EC
First degree heart block ( just prolonged PR interval)

Multiple >> Mobitz two

Others >> Nodal rhythm

How to differentiate between atria

atrial flutter and Mobitz two ?
Mobitz two >> bradycarycardia
Atrial flutter >> tachycar
ycardia