BASIC ECG
By Mohammed Alrasheed
Faculty Of Medicine
University Of Khartoum
1
EKG Basics
Definition
▪ ECG is the recording of the electrical activity of the heart.
▪ It is the vector summation of the depolarization and
repolarization potentials of all myocardial cells
❑
Uses of ECG:
1. Ischemic heart disease.
2. Arrhythmias
3. Chamber enlargement
4. Conduction abnormalities
5. Electrolyte disorders
Key Principles
- EKGs have 12 leads
- Each lead watches the same thing, but from different
vantage point
- Electrical activity toward lead = upward deflection
- Electrical activity away from lead = negative deflection
Definition
Key Principles
❑ Unipolar recording:
❑ Three unipolar limb leads; AVR, AVL, AVF
❑ Six uniplar chest leads V1-V6
❑ Bipolar recording using bipolar electrodes
❑ Standard limb leads; lead I, lead II, lead III
Key Principles
EKG Electrical Activity
Key Principles
❑ V1-V2: Right ventricle
❑ V3 -V4: Interventricular septum
❑ V5-V6: Left ventricle
❑ aVR, V1 are oriented towards the cavity of the heart.
❑ II, III, aVF: Inferior surface
❑ I, aVL, V6: Lateral wall
EKG Electrical Activity
EKG Electrical Activity
❑
2
ECG Action Potential
ECG Action Potential
❑ P wave—atrial depolarization.
❑ PR interval—time from start of atrial depolarization to start of
ventricular depolarization (normally 120-200 msec).
❑ QRS complex—ventricular depolarization (normally < 100 msec).
❑ QT interval—ventricular depolarization, mechanical contraction of the
ventricles, ventricular repolarization.
❑ T wave—ventricular repolarization. T-wave inversion may indicate
ischemia or recent MI.
❑ ST segment—isoelectric, ventricles depolarized.
❑ U wave—prominent in hypokalemia (think hyp“U”kalemia),
bradycardia
❑
Normal values:
- P duration < 0.12 sec (less than 3 small boxes)
- P amplitude < 2.5 mm
- PR Interval: 0.12 - 0.20 sec (3 – 5 small boxes)
- QRS Duration: 0.06 - 0.12 sec (less than 3 small boxes)
- QT Interval: QTc < 0.44 sec (< 1/2 R-R interval)
3
EKG Interpretation
❑ Step 1: Calculate the Rate:
❑ Step 2: Calculating the cardiac axis:
❑ Step 3: Find the p waves
❑ Step 4: determine QRS wide or narrow
❑ Step 5: Check the intervals
❑ Step 6: ST segments
Step 1: Calculate the Rate
- When the rhythm is regular & the paper speed is 25 mm / sec,
the heart rate can be calculated by either
1. Small square method: counting the number of small
squares between 2 consecutive R waves & dividing the
number by 300
2. Large square method: counting the number of large
squares between 2 consecutive R waves & dividing the
number by 300
❑ For example, in the pic. Below the rhythm is regular, and the RR
interval is about 4, so the HR = 300/4 = 75 beat/min
❑ When the rhythm is irregular, the heart rate/min can be
calculated by counting the number of intervals between QRS
complexes in 6 seconds (30 large boxes) & multiplying by 10 or
3 seconds (15 large boxes) multiplied by 20
Normal values:
❑ For example, in the pic. Below the number of QRS complex
during 6 second is 10, so the heart rate = 10 X 10 = 100
Normal values:
❑ Normal QRS axis is -30 and +90 degrees
❑ Left axis dedication: -30° and – 90°: occurs in LVH, LBBB,
Ventricular Rhythm
❑ Right axis deviation: +90° and +150: occurs in RVH, RBBB,
pulmonary hypertension and PE
EKG Electrical Activity
Normal Axis
Normal values:
- To determine the axis
First: Look at aVR:
▪ Make sure its negative
▪ If upright → limb leads are reversal (should correct it
position)
Normal values:
Look at I, II: If both positive, axis is normal
▪ If lead II is negative: LAD
▪ If lead I is negative: RAD
RXD
LAX
Step 3: Find the p waves
❑ P wave should be present
❑ Positive in lead I & II
o Best seen in lead II & V1
o Commonly biphasic in V1
❑ Less than 3 small squares in duration
❑ < 2.5 small squares in amplitude.
❑ P wave should be followed by QRS complex (sinus rhythm)
- Cardinal Features of Sinus Rhythm:
1. The p wave is upright in lead I & II
2. Each P wave is followed by QRS complex
3. The heart rate is 60 – 100 beats/min
o Sinus arrhythmia is the variation in the heart rate that
occurs during inspiration & expiration
4. The rate increases with inspiration & is vagally mediated
- P waves present, regular rhythm
o Sinus rhythm
o Rare: atrial tachycardia, atrial rhythm
- No p waves, irregular rhythm
o Atrial fibrillation – irregularly irregular
o Atrial flutter with variable block
- P waves present, irregular rhythm
o Sinus rhythm with PACs
o Multifocal atrial tachycardia
o Sinus with AV block
- No p waves, regular rhythm
o Hidden p waves: retrograde in AVNRT
o Supraventricular tachycardias (SVTs)
o Ventricular tachycardia
- Bifed P wave (P mitral)
o Occurs with Left atrial hypertrophy
• Mitral stenosis
• Mitral regurgitation
- Peaked P wave (P pulmonale)
o Occurs with Right atrial hypertrophy
• tricuspid stenosis
• Pulmonary hypertension
• Cor pulmonal
Step 4: determine QRS wide or narrow
- Normal duration ≤ 0.12s (3 small boxes)
- Narrow QRS (< 120 ms;)
o His-Purkinje system is working =
1. No bundle branch blocks present
- Wide QRS
o Most likely a bundle branch block
o Ventricular rhythm (i.e., tachycardia)
Step 5: Check the intervals
- PR interval (normal 0.12 - 0.20 sec (3 – 5 small boxes)
o Prolonged in AV block, drugs
- QT interval (normal: 0.38-0.48s, < 1/2 R-R interval)
o Prolonged with ↓ Ca, ↓ Mg, ↓ K
o Shortened with ↑ Ca, digoxin toxicity
o Prolonged by antiarrhythmic drugs, other drugs
(Quinidine, Macrolide)
o Prolonged QT Can lead to torsades de pointes
Step 6: ST segments
- Normal is Isoelectric (less than 1mm)
- ST elevation (< 1 mm)
o Transmural ischemia
o STEMI
o Acute pericarditis (diffuse elevation)
- ST depression
o Subendocardial ischemia
o Common in UA/NSTEMI
- T wave abnormalities
o Inverted: ischemia
o Peaked: Early ischemia, hyperkalemia (↑K)
o Flat/U waves: hypokalemia (↓K)
THE END