MBBS Part 2 Cardiorespiratory

Data interpretation A 12 lead ECG Position of Leads

Electrocardiograms (ECGs) It is important to remember that the 12-lead ECG
provides spatial information about the heart's
electrical activity in 3 approximately orthogonal
directions:

• Right to Left
• Superior to Inferior
• Anterior to Posterior

Calculating rates and intervals

Method of ECG interpretation Measurements • Paper moves 25 mm/sec
• Measurements • Heart Rate: 60 - 90 bpm • Each large square = 0.20 sec
• Rhythm Analysis • PR Interval: 0.12 - 0.20 sec • 1 complex per square = 300 bpm
• Conduction Analysis • QRS Duration: 0.06 - 0.10 sec • 2 = 150 bpm
• Waveform Description • QT Interval (QTc < 0.40 sec at HR = • 3 = 100 bpm
• ECG Interpretation 70bpm) • 4 = 75 bpm
• Comparison with Previous ECG (if any) • QRS Axis (frontal plane): +90o to -30o (in • 5 = 60 bpm
the adult) • 6 = 50 bpm

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 Sinus Rhythm 12 lead ECG QRS complexes

Calculating the QRS axis Normal axis

QRS axis determination
• Find isoelectric lead
• (equal force +ve and –ve)
• QRS axis is one of the two perpendiculars to that lead
• Choose the perpendicular that fits in with the size of the
other leads
• Either in the same direction as the largest +ve or in the opposite
direction as the largest –ve
• Sometimes all of the 6 limb leads are small and/or
isoelectric. This is an indeterminate axis and a normal
variant.

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 Premature atrial complexes
Rhythm Analysis Atrial flutter
(PACs)
• State basic rhythm
• Identify additional rhythm events if present
• Consider all rhythm events from atria, AV
junction, and ventricles

Premature Ventricular Conduction Analysis Cardiac conduction system

Complexes (PVC) • Normal" conduction implies normal sino-
atrial (SA), atrio-ventricular (AV), and
intraventricular (IV) conduction.
• The following conduction abnormalities are
to be identified if present:
• SA block
• AV block
• IV blocks
• Exit blocks

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 Possible conduction First degree AV block Second degree AV block
abnormalities
• The following conduction abnormalities are
to be identified if present:
– SA block
– AV block
– IV blocks
– Exit blocks

Complete AV block Ventricular tachycardia Ventricular fibrillation

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 Evolution of an acute MI ECG interpretation
Waveform Description
• This is the conclusion of the above analyses.
• P waves: are they too wide, too tall, look funny • Interpret the ECG as "Normal", or "Abnormal".
(i.e., are they ectopic), etc.? Occasionally the term "borderline" is used if
• QRS complexes: look for pathologic Q waves, unsure about the significance of certain findings.
abnormal voltage, etc. • List all abnormalities.
• ST segments: look for abnormal ST elevation • Examples of "abnormal" statements are:
and/or depression. – Inferior MI, probably acute
• T waves: look for abnormally inverted T waves. – Left ventricular hypertrophy (LVH)
• U waves: look for prominent or inverted U waves.

Comparison with previous ECG

• If there is a previous ECG in the patient's
file, the current ECG should be compared
with it to see if any significant changes
have occurred. These changes may have
important implications for clinical
management decisions.