BASIC ABNORMAL ECG

BY TANYA TULLAO
INTERVALS/DURATION
P WAVE
When studying the P
wave, always look at I, II,
avF and V1

Normal:
How tall? 0.5-2.5 mm
How wide? 0.10 sec

P wave is upright in all
leads except sometimes it
is biphasic in V1
P WAVE
Look at leads I, II,
avF

Are there any P
waves too tall
(>2.5 mm)?
YES: Right Atrial
Enlargement (RAE)
P WAVE
Look at leads I, II,
avF

Are there any P
waves too wide
(>0.10 sec)? Any
bifid P waves?
YES: Left Atrial
Enlargement (LAE)
PR INTERVAL
Normal:
0.12-0.20 secs.

PR INTERVAL
Look at your
measurements

Is the PR interval
short (<0.12 sec)?
YES: Bypass of the
AV node

PR INTERVAL
Look at your
measurements

Is the PR interval
long (>0.20 sec)?
YES: First degree AV
Block

Q WAVE
Q wave is present when
the first QRS deflection is
downward
Observed in each lead

Are there any
pathological Q waves?
If:
> 2 small squares deep
> 25% of the height of the
following R wave
> 1 small square wide

YES: Infarction

Q WAVE
If:
Pathological Q wave
No ST segment
depression
Normal T wave

YES: Old Infarction/
Fibrosis/ Previous
documented MI

Where is the location?
Identify the leads.

Leads Location
I, avL High Lateral
II, III, avF Inferior
(right coronary artery)
V1, V2 Septal
V3, V4 Anterior
(left main artery)
V5, V6 Lateral
Q WAVE
If:
Pathological Q wave
ST segment depression
T wave inversion

YES: New Infarction
(MED EMERGENCY!)

Where is the location?
Identify the leads.

Leads Location
I, avL High Lateral
II, III, avF Inferior
(right coronary artery)
V1, V2 Septal
V3, V4 Anterior
(left main artery)
V5, V6 Lateral
R AND S WAVES
Are any R or S waves too
big?
YES: Left ventricular
hypertrophy

Check using:
Sokolow-Lyon index:
SV1 + (RV5 or RV6) >3.5 mV
Cornell voltage criteria:
SV3 + RavL 2.8 mV (men)
SV3 + RavL 2.0 mV (women)

R AND S WAVES
Look at leads V1 to V6
Normal:
R wave increases in height from V1 to V6
S wave decreases in depth from V1 to V6


R AND S WAVES
Look at leads V1 to V6
Are the R waves persistent in sizes (<5 mm)?
YES: Poor R wave progression


R AND S WAVES
Look at leads V1 to V6
Are the S waves persistent in sizes?
YES: Persistent posterobasal forces


QRS COMPLEX
Normally varies in
different ECG leads

Normal:
< 0.12 sec
< 3 small squares

QRS is upright in all leads
except in avR
QRS COMPLEX
Is there any bizarre
looking QRS with deep S
wave?
Premature, wide,
aberrant, notched QRS, >
0.12s in duration?
YES: Premature
ventricular complex
(PVC)

QRS COMPLEX
Are any QRS complexes
too wide (> 0.12 secs)?
YES: Bundle Branch
Block

QRS COMPLEX
Look at V1, V2 and V5,
V6

If:
Wide QRS complex
M sign or rSR in V1
YES: Right Bundle Branch
Block (RBBB)

Wide QRS complex
Deep S in V6
YES: Complete BBB


QRS COMPLEX
Look at V1, V2 and V5,
V6

If:
Wide QRS complex
srS in V1
M sign in the peak of R
YES: Left Bundle Branch
Block (LBBB)

Wide QRS complex
Deep S in V6
YES: Complete BBB


QRS COMPLEX
Look at V1, V2 and V5,
V6

If:
Normal QRS complex
BBB morphology
YES: Incomplete BBB


ST SEGMENT
Isoelectric ( Lies at the
same level as the
baseline)

Normal:
Deviate between -0.5 and
+1 mm from the baseline
ST SEGMENT
Are the ST segments
elevated (raised above
level of baseline)?
YES: Acute MI to normal
variant

ST SEGMENT
ST SEGMENT
Are the ST segments
depressed ( > 2 small
squares below level of
baseline)?
YES: Myocardial
ischemia

ST SEGMENT
ST SEGMENT
Does the J point ensue early at repolarization?
YES: Early Repolarization Pattern


ST SEGMENT
Is there flattening of T waves?
YES: Non-specific ST wave changes (NSSTWC)


T WAVE
Normal:
Not clearly defined
Guide:
Should not be > size of
the preceding QRS complex
T wave is usually not above
10 mm in any precordial
leads
T WAVE
Look at V2, V3, V4
Are the T waves too tall (>10 mm)?
YES: Peak T waves (Hyperkalemia or AMI)

T WAVE
Is the T wave inverted (>
1 mm)?
YES: Myocardial
Ischemia
U WAVE
Prominent in V3

Normal:
Not >1 mm amplitude
U WAVE
Do the U waves appear
too prominent?
YES: Prominent U
waves (Hypokalemia,
Hypercalcemia,
Hyperthyroidism)
RHYTHM
SINUS RHYTHM
Presence of P wave
Followed by QRS complex
Regular rate

Normal:
60-100 bpm
SINUS ARRHYTHMIA
Presence of P wave
Followed by QRS complex
Irregular sinus rhythm at rate <100 bpm
Cycle vary by 10% or more
PREMATURE ATRIAL COMPLEX
(PAC)

Premature P wave which results from a premature
ectopic, supraventricular impulse that originates
somewhere in the atria outside of the SA node
CARDIAC RATE
BRADYCARDIA
RR <60 bpm
Regular
P wave
Sinus
Bradycardia
No P wave
Narrow
QRS
Junctional
Wide QRS
Idio-
ventricular
No P-QRS
relation
3
rd
degree
AV Block
Irregular
No P wave
Slow AF
P wave but
abn PR
Group
beating
2
nd
degree
AV Block
BRADYCARDIA

Sinus Bradycardia
BRADYCARDIA

3
rd
degree AV Block
BRADYCARDIA
2
nd
degree AV Block
Type 1




Type 2
TACHYCARDIA
RR > 100 bpm
Narrow QRS
Regular
P wave; 100-
140 bpm
Sinus
tachycardia
No P wave;
150 bpm
SVT
Irregular
No P wave
AF
Flutter waves;
saw tooth;
>300 bpm
Atrial flutter
Wide QRS
V tach
BRADYCARDIA

Sinus Tachycardia
BRADYCARDIA

SVT
BRADYCARDIA

AF
BRADYCARDIA

Atrial flutter
BRADYCARDIA

V-tach
AXIS
LEFT ANTERIOR FASCICULAR
BLOCK (LAFB)
Mean QRS axis of -45 to -90 degrees
> -30 degrees is the hallmark
rS pattern in II, III and avF
qR pattern in I and avL
Normal QRS duration (<0.12 sec)
LEFT ANTERIOR FASCICULAR
BLOCK (LAFB)
LEFT POSTERIOR FASCICULAR
BLOCK (LPFB)
Mean QRS axis of 120 degrees
rS pattern in I and avL
qR pattern in II, III, avR
Normal QRS duration ( <0.12 sec)
LEFT ANTERIOR FASCICULAR
BLOCK (LAFB)
RIGHT VENTRICULAR HYPERTROPY
(RVH)
Mean QRS axis of >90 degrees
qR in V1 or R wave in V1 7 mm or R/S ratio of 1 or
rSR in RBBB