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

V6

Lateral surface
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
Axis

Right Axis
deviation

Left Axis
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 (WolffParkinson-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

0.35 0.45 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 (0.2second) 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
Bradyarrhythmias

VF, Pulseless VT

Non Shockable
Asystole, PEA

Drugs to control
rate
Drugs to revert the
rhythms

The drugs to be given

at this stage are
vasopressors

Note that by
this 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
DRUGSHOCK CPR. At any time, if
rhythm becomes non-shockable, follow

For cardiac arrest, the first thing to know is

whether the rhythm is shockable or not
shockable. In periarrest rhythms
(bradyarrhythmias and tachyarrhythmias,

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
temporizin
g measure
only.
Needs
transcutane
ous/transve
nous 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.
Dont 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