Electrocardiograms

James Lamberg
Electrical System Overview

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Action Potentials

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12-Lead Positioning

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Values To Memorize
• Inherent Rates
– SA: 60 to 100
– AV: 40 to 60
– Ventricles: 20 to 40
• Normal PRI: 0.12 to 0.20
– 3 to 5 small boxes
• Normal QRS: < 0.12
– Less than 3 small boxes
• Normal QTc: 0.35 to 0.45
– QT < 1/2 RR; QTc = QT / sqrt(RR)

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Calculating Rates

• Count R waves in 6 seconds x 10

– R waves between 2 sets of 3s marks
• Large boxes between R waves / 300
– Small boxes between R waves / 1500

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Standard ECG

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Precordial Leads

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Determining Axis & Rotation
• Axis: Look at Lead I and aVF
– QRS complexes
• Positive: Normal
• “Leaving”: Left
• “Reaching”: Right
• Negative: Indeterminate
– Perpendicular to isoelectric lead
• Rotation: Look at V1 to V6
– V1 or V2 isoelectric: Right
– V3 or V4 isoselectric: Normal
– V5 or V6 isoelectric: Left

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Axis: Leads I, II, III

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Determining Axis: An Example

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Normal Sinus Rhythm

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Sinus Bradycardia

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Sinus Tachycardia

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Sinus Arrhythmia

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Congestive Heart Failure Causes

• FAILURE
– Forgot medication
– Arrhythmia, Anemia
– Ischemia, Infarction, Infection
– Lifestyle (too much salt)
– Upregulation of cardiac output
(pregnancy, hyperthyroidism)
– Renal failure
– Embolism (PE)

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First Degree Heart Block

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Second Degree Block Type I

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Second Degree Block Type II

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Third Degree Heart Block

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Premature Atrial Contraction

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Premature Junctional Contraction

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Premature Ventricular Contraction

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Atrial Fibrillation

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Atrial Fibrillation Causes
• THE ATRIAL FIBS
– Thyroid – Atrial enlargement
– Lone (idiopathic)
– Hypothermia
– Fever, anemia,
– Embolism (PE) high-output states
– Alcohol (“holiday – Infarct
heart”) – Bad values (mitral
– Trauma (cardiac stenosis)
contusion) – Stimulants
– Recent surgery (cocaine,
(post-CABG) theophylline,
amphetamine,
– Ischemia caffeine)

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Atrial Flutter

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Atrial Tachycardia

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Atrial Bigeminy & Trigeminy

• Bigeminy
*

• Trigeminy

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Supraventricular Tachycardia

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Junctional Escape Rhythm

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Junctional Tachycardia

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Ventricular Fibrillation

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Ventricular Tachycardia

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Torsade de Pointes

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Ventricular Bigeminy & Trigeminy

• Bigeminy

• Trigeminy

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Ventricular Asystole

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Bundle Branch Blocks
• Characteristic
QRS pattern in
lead I, V1, and V6

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The Turn Signal Rule
• Turn-Signal Rule
– QRS >0.12 everywhere • Triangle pointing up
– Look V1 QRS indicates RBBB
– Find J point • Triangle pointing down
– Draw a horizontal line indicates LBBB

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William Marrow (V1-V6)
• LBBB • RBBB

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Left Bundle Branch Block

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Right Bundle Branch Block

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Wolff-Parkinson-White

• Pre-excitation
– Bundle of Kent
– Delta wave
• Slurred QRS
• Lown-Ganong-Levine
– Bundle of James
– Short PR Interval
• < 0.12s

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Sick Sinus Syndrome

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Atrial Hypertrophy

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Atrial Hypertrophy

• P Pulmonale: Right (RAH)

• P Mitrale: Left (LAH)

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Ventricular Hypertrophy
• Right (RVH) • Left (LVH)
– Right axis – Left axis deviation
deviation and and rotation
rotation – Tall QRS on left
– Tall QRS on right (V4, V5, V6)
side leads
• (V1, V2, V3)

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Left Ventricular Hypertrophy

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Significant Q Waves

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Myocardial Infarction

• Significant Q wave = Necrosis

• ST elevation = Injury
• T wave inversion = Ischemia

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MI Location

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MI Location

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Anterior Leads

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Lateral Leads

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Inferior Leads

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Pericarditis
– Diffuse ST Elevation
– PR Depression

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Pericarditis Causes
• CARDIAC RIND
– Collagen vascular – Rheumatic fever
disease – Injury
– Aortic aneurysm – Neoplasms
– Radiation – Dressler syndrome
– Drugs (MI or surgery)
(hydralazine)
– Infections
– Acute renal failure
– Cardiac infarction

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Non-STEMI versus STEMI
• Non-STEMI • STEMI

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STEMI Progression

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STEMI Progression

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ST Segment Elevation
• ELEVATION
– Electrolytes
– Left bundle branch block
– Early repolarization
– Ventricular hypertrophy
– Aneurysm
– Treatment (pericardiocentesis)
– Injury (acute MI, contusion)
– Osborne waves (hypothermia)
– Nonocclusive vasospasm

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ST Segment Depression
• DEPRESSED ST
– Drooping valve (mitral valve prolapse)
– Enlargement or LV with strain
– Potassium loss (hypokalemia)
– Reciprocal ST depression (inferior MI)
– Embolism (PE)
– Subendocardial ischemia
– Subendocardial infarct
– Encephalon hemorrhage
– Dilated cardiomyopathy
– Shock
– Toxicity of digitalis, quinidine

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Abnormal T Waves

• Subarachnoid
hemorrhage
• Cerebral
hemorrhage
• Cerebral *
thrombosis

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Electrolytes & Drugs
• Hyperkalemia • Hypokalemia
– High K+ – Low K+
– Peaked T – Flat T, U Wave

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Electrolytes & Drugs
• Hypercalcemia
– Short QT
• Hypocalcemia
– Long QT
• Dititalis
– Sloping ST
• Quinidine
– Long QT
– Notched P

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Brudada Syndrome

• Asian Males
• ST Elevation in V1, V2, V3

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Interpretation Example #1

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Interpretation Example #2

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Right Sided ECG

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Interpretation Example #3

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Interpretation Example #4

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Interpretation Example #5

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Interpretation Example #6

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Tools of the Trade

• Recommend
– Calipers
• Useful
– Magnifier
• Avoid
– Rulers

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Questions?

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