ECG diagnosis

Lead Position

A typical ECG report shows the cardiac cycle from 12

different vantage points (I, II, III, aVR, aVL, aVF, V1-V6), like
viewing the event electrically from 12 different locations (like
a 3D perspective).BUT only 10 electrodes are used.

Lead I represents activity that is going from the right arm to

the left arm
Lead II represents activity that is going from the right arm to
the left leg
Lead III represents activity that is going from the left arm to
the left leg

aVL is placed on the left arm (or shoulder)

aVF is placed on the left leg (or hip)
aVR is placed on the right arm (or shoulder)
V1- 4th intercostal space to the right of sternum
V2- 4th intercostal space to the left of sternum
V3- halfway between V2 and V4
V4- 5th intercostal space in the left mid-clavicular line
V5- 5th intercostal space in the left anterior axillary line
V6- 5th intercostal space in the left mid axillary line

NSR

Aims

10 ECG rules
Heart Rate
ECG signs of M.I.
Evolution of changes in M.I.
Classical Appearences

QRS waveform nomenclature

qR

qRs

Qrs

QS

Qr

Rs

rS

qs

rSr

rSR

The 10 rules for a normal ECG

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

.2

Rule 1

1.0

Millivolts

0.5

R
PR
interval

PR interval should be 120 to

200 milliseconds or 3 to 5 little
squares

T
P
Q

-0.5

200

400

Milliseconds

600

Rule 2

1.0

The width of the QRS complex

should not exceed 110 ms, less
than 3 little squares

Millivolts

0.5

T
P
Q

-0.5

QRS
0

200

400

Milliseconds

600

Rule 3

I II III

aVR aVL aVF

The QRS complex should be

dominantly upright in leads I and II

Rule 4

I II III

aVR aVL aVF

QRS and T waves tend to have the

same general direction in the limb
leads

Rule 5

All waves are negative in lead aVR

T
Q

Rule 6

V1

V2

V3

V4

V5

V6

The R wave in the precordial leads must grow from V1 to at least V4

Rule 7

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

The ST segment should start isoelectric except in V1 and

V2 where it may be elevated

Rule 8

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

The P waves should be upright in I, II, and V2 to V6

Rule 9

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

There should be no Q wave or only a small q less than

0.04 seconds in width in I, II, V2 to V6

Rule 10

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

The T wave must be upright in I, II, V2 to V6

What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm

What is the heart rate?

www.uptodate.com

(300 / ~ 4) = ~ 75 bpm

What is the heart rate?

(300 / 1.5) = 200 bpm

10 Second Rule
As most EKGs record 10 seconds of rhythm per page,
one can simply count the number of beats present on the
EKG and multiply by 6 to get the number of beats per 60
seconds.

This method works well for irregular rhythms.

What is the heart rate?

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

33 x 6 = 198 bpm

Characteristic changes in AMI

ST segment elevation over area of damage

ST depression in leads opposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves

ST elevation

Occurs in the early stages

R
ST
P

Occurs in the leads facing the

infarction
Slight ST elevation may be
normal in V1 or V2

Deep Q wave

Only diagnostic change of

myocardial infarction

R
ST

At least 0.04 seconds in duration

P
T
Q

Depth of more than 25% of

ensuing R wave

T wave changes

Late change
R

Occurs as ST elevation is
returning to normal

ST

Apparent in many leads

T
Q

Bundle branch block

Anterior wall MI
I II III

aVR aVL aVF

Left bundle branch block

V1 V2 V3

V4 V5 V6

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Sequence of changes in evolving AMI

R

R
T

ST

ST

P
Q S

P
T

1 minute after onset

1 hour or so after onset

A few hours after onset

R
ST

ST

P
T

A day or so after onset

P
T

Later changes

A few months after AMI

Anterior infarction
Anterior infarction

I II III

Left anterior descending artery (LAD)

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Inferior infarction
Inferior infarction

I II III

Right
coronary
Artery( RCA) OR Circumflex (LCX)

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Lateral infarction
Lateral infarction

I II III

Left
circumflex
coronary
Artery OR DAIAGONAL branch of LAD

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Location of infarct combinations

aVR

LATERAL OR HIGH
II

aVL
LATERAL

V1

V4

SEPTAL
ANT
V2
V5
ANT
V3

III

INFERIOR

aVF

V6

LAT

Diagnostic criteria for AMI

Q wave duration of more than 0.04

seconds
Q wave depth of more than 25% of
ensuing r wave
ST elevation in leads facing infarct (or
depression in opposite leads)
Deep T wave inversion overlying and
adjacent to infarct
Cardiac arrhythmias

Hay..
wake up we are
done