Tutorial in ECG

Dr. Chew Keng Sheng

Emergency Medicine
Universiti Sains Malaysia

http://emergencymedic.blogspot.com
 The Basics
• Standard calibration
– 25 mm/s
– 0.1 mV/mm

• Electrical impulse that

travels towards the
electrode produces an
upright (“positive”)
deflection relative to the
isoelectric baseline
 Vertical and horizontal
perspective of the ECG Leads
Leads Anatomical

II, III, aVF Inferior surface

of heart

V1 to V4 Anterior surface
of heart

I, aVL, V5, and Lateral surface

V6 of heart

V1 and aVR Right atrium

 Location of MI and Affected
Coronary Arteries
Location of MI Affected Artery
Lateral Left circumflex
Anterior LAD
Septum LAD
Inferior RCA
Posterior RCA
Right Ventricle RCA
Right Sided & Posterior Chest
Leads
 Sinus Rhythm

• The P wave is upright in leads I and II

• Each P wave is usually followed by a Q
• The heart rate is 60­99 beats/min
Normal Sinus Rhythm
Instant Recognition of Axis
Deviation
 Cardiac Axis
Normal Right Axis Left Axis
Axis deviation Deviation

Lead I Positive Negative Positive

  
Lead II Positive Positive Negative
  
Lead III Positive Positive Negative
Calculating Cardiac Axis
P wave
• Always positive in lead
I and II in NSR
• Always negative in lead
aVR in NSR
• < 3 small squares in
duration
• < 2.5 small squares in
amplitude
• Commonly biphasic in
lead V1
• Best seen in leads II
 Right Atrial Enlargement
• Tall (> 2.5 mm), pointed P waves (P
pulmonale
 Left Atrial Enlargement
• Prominent terminal P negativity (biphasic)
in lead V1 (i.e., "P-terminal force")
duration >0.04s, depth >1 mm
 Left Atrial Enlargement
• Notched/bifid (‘M’ shaped) P wave (P
‘mitrale’) in limb leads with the inter-peak
duration > 0.04s (1 mm)
P Pulmonale and P Mitrale
 RAH and LAH

Right Atrial Hypertrophy

Left Atrial Hypertrophy
Short PR Interval
• WPW (Wolff-
Parkinson-White)
Syndrome
• Accessory pathway
(Bundle of Kent)
allows early activation
of the ventricle (delta
wave and short PR
interval)
 QRS Complexes
• Non­pathological Q waves are often
present in leads I, III, aVL, V5, and V6
• The R wave in lead V6 is smaller than the
R wave in V5
• The depth of the S wave, generally, should
not exceed 30 mm
• Pathological Q wave > 2mm deep and >
1mm wide or > 25% amplitude of the
subsequent R wave
QRS In Hypertrophy
 RVH Changes
• A tall positive (R) wave
– instead of the rS complex normally seen in
lead V1
– an R wave exceeding the S wave in lead V1
– in adults the normal R wave in lead V1 is
generally smaller than the S wave in that lead
• Right axis deviation (RAD)
• Right ventricular "strain" T wave inversions
Conditions with Tall R in V1
Right Atrial and Ventricular
Hypertrophy
COPD
 Left Ventricular Hypertrophy
• Sokolow & Lyon Criteria (Am Heart J,
1949;37:161)
– S in V1+ R in V5 or V6 > 35 mm
• An R wave of 11 to 13 mm (1.1 to 1.3 mV)
or more in lead aVL is another sign of LVH
• Others: Cornell criteria (Circulation, 1987;3:
565-72)
– SV3 + R avl > 28 mm in men
– SV3 + R avl > 20 mm in women
Hypertrophy Strain Pattern vs
ACS
 ST Segment
• Normal ST Segment is flat (isoelectric)
– Same level with subsequent PR segment
• Elevation or depression of ST segment by
1 mm or more, measured at J point IS
ABNORMAL
• “J” (Junction) point is the point between
QRS and ST segment
 Variable Shapes Of ST Segment
Elevations in AMI

Goldberger AL. Goldberger: Clinical Electrocardiography: A Simplified Approach.

7th ed: Mosby Elsevier; 2006.
 T wave
• The normal T wave is asymmetrical, the
first half having a more gradual slope than
the second half
• The T wave should generally be at least
1/8 but less than 2/3 of the amplitude of
the corresponding R wave
• T wave amplitude rarely exceeds 10 mm
• Abnormal T waves are symmetrical, tall,
peaked, biphasic or inverted.
 T wave
• As a rule, the T wave follows the direction
of the main QRS deflection. Thus when
the main QRS deflection is positive
(upright), the T wave is normally positive.
• Other rules
– The normal T wave is always negative in lead
aVr but positive in lead II.
– Left-sided chest leads such as V4 to V6
normally always show a positive T wave.
 QT interval
• QT interval decreases when heart rate increases
• A general guide to the upper limit of QT interval.
For HR = 70 bpm, QT<0.40 sec.
– For every 10 bpm increase above 70 subtract 0.02
sec.
– For every 10 bpm decrease below 70 add 0.02 sec
• As a general guide the QT interval should be
0.35­0.45 s, and should not be more than half of
the interval between adjacent R waves (R­R
interval).
QT Interval
Long QT Syndrome
 QT Interval
• The QT interval increases slightly with age
and tends to be longer in women than in
men.
• Bazett's correction is used to calculate the
QT interval corrected for heart rate (QTc):
QTc = QT/ Sq root [R­R in seconds]
 U wave
• Normal U waves are small, round, symmetrical
and positive in lead II, with amplitude < 2 mm
(amplitude is usually < 1/3 T wave amplitude in
same lead)
• U wave direction is the same as T wave direction
in that lead
• More prominent at slow heart rates and usually
best seen in the right precordial leads.
• Origin of the U wave is thought to be related to
afterdepolarizations which interrupt or follow
repolarization
 Calculation of Heart Rate
• Method 1: Count the number of large (0.2-
second) time boxes between two successive R
waves, and divide the constant 300 by this
number OR divide the constant 1500 by the
number of small (0.04-second) time boxes
between two successive R waves.
• Method 2: Count the number of cardiac cycles
that occur every 6 seconds, and multiply this
number by 10.
Calculation of Heart Rate
 Question
• Calculate the heart rate
RBBB and LBBB

• RBBB = MaRroW
• LBBB = WiLLiaM
Rhythm Disturbances
 Cardiac Arrest & Peri-arrest
Rhythms
• Cardiac Arrest • Peri arrest rhythms
– Shockable – Tachyrrhythmias
• VF, Pulseless VT – Bradyarrhythmias
– Non Shockable  Drugs to control
• Asystole, PEA rate
 Drugs to revert the
rhythms
The drugs to be given at this Note that by this
stage are vasopressors time, if 3rd shock
is required, it is
the DRUG
→SHOCK→
CPR sequence. It
is the same
sequence
thereafter

Cardiac
Arrest
 Cardiac
Arrest

After the 3rd sequence and giving

adrenaline/vasopressin, consider giving
antiarrhythmics like amiodarone for VF or magnesium
for torsades de pointes. The sequence is still the same
DRUG→SHOCK→ CPR. At any time, if rhythm
becomes non-shockable, follow the non-shockable
algorithm
For cardiac arrest, the first thing to know is whether the
rhythm is shockable or not shockable. In periarrest
rhythms (bradyarrhythmias and tachyarrhythmias, the
first thing to know is whether it STABLE or NOT
 When The Arrhythmias Is
Unstable
Four main signs
1. Signs of low cardiac output – systolic
hypotension < 90 mmHg, altered mental
status
2. Excessive rates: <40/min or >150/min
3. Chest pain
4. Heart failure
• If unstable, electrical therapy: cardioversion
for tachyarrhythmias, pacing for
bradyarrhythmias
Atropine 0.5
mg each bolus
up to 3 mg.
Atropine as
temporizing
measure only.
Needs
transcutaneous
/transvenous
pacing
 Four Rhythms At Risk Of
Developing Asystole
1. Recent asystole
2. Mobitz II 2nd degree AV Block
3. Complete Heart Block (especially with
broad QRS or initial heart rate <40/min)
4. Ventricular standstill more than 3 sec

For these, consider also electrical therapy

– Only mentioned in European Resuscitation Council
Guidelines 2005
 Bradyarrhythmias
• 2nd degree Mobitz type 1
• the block is at AV Node
• Often transient
• Maybe asymptomatic
• 2nd degree Mobitz type 2
• Block most often below AV node, at
bundle of His or BB
• May progress to 3rd degree AV block
* For polymorphic VT – if patients become unstable, perform
defibrillation rather than cardioversion. If ever in doubt whether to
perform cardioversion or defibrillation, then perform
DEFIBRILLATION
Rule of thumb – if your eye cannot synchronize to each QRS complex,
neither can the machine!
 Tachyarrhythmias
• For stable tachyarrhythmias, we need to further
decide whether it is NARROW QRS or WIDE QRS
• For each type, further divide into
– Regular
– Irregular
 Tachyarrhythmias
• Narrow QRS tachyarrhythmias
– Regular
• Sinus Tachycardia, PSVT, atrial flutter with regular AV
conduction
– Irregular
• Atrial Fibrillation, Atrial flutter with variable AV Block
• Wide (Broad) QRS tachyarrhythmias
– Regular
• Ventricular Tachycardia, SVT with BBB
– Irregular
• Polymorphic VT, AF with BBB
Narrow complexes and regular – attempt vagal maneuver and
adenosine;
Narrow complexes but not regular- likely AF. Don’t give
adenosine. May attempt rate control using beta blocker or
diltiazem
Amiodarone can be given for
both regular and irregular
broad complexes
 Recommended Resources
• ABC of Clinical Electrocardiography
– www.bmj.com
• Goldberger: Clinical Electrocardiography:
A Simplified Approach, 6th edition.
– Access via www.mdconsult.com
• ECG Learning Center
– http://medstat.med.utah.edu/kw/ecg/index.html
• ECG Library
– http://www.ecglibrary.com/ecghome.html
 Thank You
Contact me:
Dr. K.S. Chew
cksheng74@yahoo.com
http://emergencymedic.blogspot.com