Abnormal ECG

By Fadhly Shariman Bin Hj Yahaya

INTERVALS/DUR
ATION
 P wave
When studying the P
wave, always look at
I, II, avF and V1

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

o 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)?
o 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?
o YES: Left Atrial
Enlargement (LAE)
 PR interval
Normal:
o 0.12-0.20 secs.
 PR interval
Look at your
measurements

Is the PR interval
short (<0.12
sec)?
o YES: Bypass of
the AV node
 PR interval
Look at your
measurements

Is the PR interval
long (>0.20 sec)?
o 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?
o If:
> 2 small squares deep
> 25% of the height of the
following R wave
> 1 small square wide

o YES: Infarction
 Q wave
If:
o Pathological Q wave
o No ST segment depression
o Normal T wave

o YES: Old Infarction/

Fibrosis/ Previous
documented MI Leads Location
I, avL High Lateral
Where is the location? II, III, avF Inferior
Identify the leads. (right coronary artery)

V1, V2 Septal
V3, V4 Anterior
(left main artery)

V5, V6 Lateral
 Q wave
If:
o Pathological Q wave
o ST segment depression
o T wave inversion

o YES: New Infarction

(MED EMERGENCY!)
Leads Location
Where is the location? I, avL High Lateral
Identify the leads. 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?
o YES: Left
ventricular
hypertrophy

Check using:
o Sokolow-Lyon index:
SV1 + (RV5 or RV6) >3.5
mV
o 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:
o R wave increases in height from V1 to V6
o 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)?
o YES: Poor R wave progression
 R and S waves
Look at leads V1 to V6
Are the S waves persistent in sizes?
o YES: Persistent posterobasal forces
 QRS complex
Normally varies in
different ECG leads

Normal:
o < 0.12 sec
o < 3 small squares

o 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?
o YES: Premature
ventricular
complex (PVC)
 QRS complex
Are any QRS
complexes too wide
(> 0.12 secs)?
o YES: Bundle
Branch Block
 QRS complex
Look at V1, V2 and
V5, V6

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

o Wide QRS complex

o Deep S in V6
YES: Complete BBB
 QRS complex

Look at V1, V2 and

V5, V6

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

o Wide QRS complex

o Deep S in V6
YES: Complete BBB
 QRS complex
Look at V1, V2 and
V5, V6

If:
o Normal QRS complex
o BBB morphology
YES: Incomplete BBB
 ST segment
Isoelectric ( Lies at
the same level as the
baseline)

Normal:
o Deviate between -0.5 and +1
mm from the baseline
 ST segment
Are the ST segments
elevated (raised
above level of
baseline)?
o YES: Acute MI to normal
variant
ST segment
 ST segment
Are the ST segments
depressed ( > 2 small
squares below level of
baseline)?
o YES: Myocardial ischemia
ST segment
 ST segment
Does the J point ensue early at repolarization?
o YES: Early Repolarization Pattern
 ST segment
Is there flattening of T waves?
o YES: Non-specific ST wave changes (NSSTWC)
 T wave
Normal:
o Not clearly defined
o 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)?
o YES: Peak T waves (Hyperkalemia or AMI)
 T wave
Is the T wave inverted
(> 1 mm)?
o YES: Myocardial Ischemia
 U wave
Prominent in V3

Normal:
o Not >1 mm amplitude
 U wave
Do the U waves
appear too
prominent?
o YES: Prominent U waves
(Hypokalemia,
Hypercalcemia,
Hyperthyroidism)
RHYTHM
 Sinus Rhythm

Presence of P wave
Followed by QRS complex
Regular rate

Normal:
o 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 Irregular

No P-QRS P wave but

P wave No P wave No P wave
relation abn PR

Sinus Narrow 3rd degree Group

Wide QRS Slow AF
Bradycardia QRS AV Block beating

Idio- 2nd degree

Junctional ventricular AV Block
BRADYCARDIA

Sinus Bradycardia
BRADYCARDIA

3rd degree AV Block

 BRADYCARDIA
2nd degree AV Block
Type 1

Type 2
 TACHYCARDIA
RR > 100 bpm

Narrow QRS Wide QRS

Regular Irregular V tach

Flutter waves;
P wave; 100-140 No P wave; 150
No P wave saw tooth; >300
bpm bpm
bpm

Sinus
SVT AF Atrial flutter
tachycardia
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
o > -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
THANK
YOU!