Introduction

Technical Aspects
Each small square is 1mm. So each large square is 5mm.
The paper runs at a speed of 5 large square per second (25mm/s), so each small square is 0.04s
and each large square is 0.2s.
On standard calibration, 10 small squares is 1mV.

Intervals
PR: 120-220ms (3-5 small squares)
QRS: 120ms (3 small squares)
ST:
QT: >450ms can lead to v. tach

Cardiac Axis
Determine using I, II, VF. -30 to 90 is normal.

Transition Point
V1-2 looks at right ventricle, V3-4 at septum, V5-6 at left ventricle
Transitional zone at V3/V4.
Conduction
Heart Block
First degree: PR>5 squares, all P waves conducted
Second degree: sometimes P wave fails to conduct
Mobitz type 1: progressive lengthening of PR until failed conduction
Mobitz type 2: constant PR interval with occasional failed conduction
Fixed ratio: 2:1, 3:1, 4:1
Third degree: P wave totally uncoupled.

Bundle Branch Block

QRS is usually prolonged
RBBB: RSR1 best seen in V1
if QRS interval not prolonged its partial RBBB
LBBB: M complex best seen in V6, W pattern in V1 usually not fully developed, associated with T
wave inversion in lateral leads (I, VL, V5, V6)
Distal LBBB block leads to cardiac axis shift:
Left anterior hemiblock: shifts left, QRS may be within normal limits but a bit wide
Left posterior hemiblock (rare): shifts right
Bifasicular block: shifts left
RBBB + both distal LBBB: looks like complete heart block
Rhythm
Bradycardias: Escape
Rhythm: SA 70, junctional 50, ventricular 30
Occurs when SA fails to depolarise or fails to conduct
Atrial escape: abnormal P wave, normal QRS, can occur singly
Junciontal escape: no P wave, normal QRS
Ventricular escape: wide QRS complex and abnormal T wave, can occur singly
Accelerated idioventricular rhythm: ventricular escape rhythm 75/min

Extrasystole
Occur early
Atrial extrasystole: abnormal P wave, normal QRS, resets P wave cycle
Junctional extrasystole: no P wave (or extremely close to QRS) , normal QRS, resets P wave
cycle
Ventricular extrasystole: abnormal QRS and abnormal T wave

Supraventricular Tachycardia
Atrial tachycardia: >150/min
Atrial flutter: >250/min without flat baseline between P waves
Atrial flutter with 2:1 block: remember to look for this, distinguish P waves from T by regularity
Junctional tachycardia: no P wave
Carotid sinus pressure: reduce sympathetic discharge, can slow or abolish supraventricular
tachycardia but not ventricular ones

Ventricular Tachycardia
Wide QRS

Differentiating between supraventricular with bundle block and ventricular tachycardia:

any P waves? -> atrial tachy
is the QRS the same during sinus rhythm? -> not ventricular
QRS wider than 160ms -> probably ventricular
Axis deviation (particularly left) compared to sinus -> ventricular
Very irregular QRS complex -> atrial fibrillation with bundle block

Fibrillation
Atrial fibrillation: no P wave waves, irregular line, occasional flutter waves
Ventricular fibrillation: no QRS, ECG completely disorganised

Wolff Parkinson White

Presence of accessory bundles leads to re-entry circuits and pre-excitation of atrium
PR interval short, QRS complex initially slurred
Waves
Abnormalities of P wave
P wave too tall (peaked P wave) -> right atrial hypertrophy
P wave to broad and bifid -> left atrial hypertrophy

Abnormalities of QRS
Normal QRS should be <120ms, negative in V1, in V5/V6 height of R wave less than 25mm
Abnormal width -> BBB or ventricular ectopics (escape, extrasystole, tachycardia), WPW
Abnormal height
Right ventricular hypertrophy: positive V1 and negative V6, with right axis deviation, peaked P
wave (atrial hypertrophy) and in severe cases T wave inversion in V1/2
Pulmonary embolism
Left ventricular hypertrophy: tall R wave in left leads, deep S wave in right leads. With
significant hypertrophy there may be left axis deviation, and T wave inversion in lateral leads.

Abnormalities of Q wave
Small Q waves (< 1 small square width than 2 small square height) are from septal
depolarisation. These are normal.
Larger Q waves indicate MI.
Anterior infarction: V2-V4
Lateral infarction: V5/V6, I, VL
Inferior infarction: III, VF
Posterior infarction: dominant R wave in V1

Abnormalities of ST Segment
ST elevation -> infarction
ST depression (T wave usually upright) -> ischaemia
Downward sloping -> digoxin

T Wave Inversion
TWI is seen in normality, ischaemia, ven. hypertrophy, BBB, and digoxin
Myocardial infarction: STEMI: ST elevation -> Q -> TWI, NSTEMI: ST depression, TWI, no Q
Ventricular hypertrophy: Left hypertrophy causes TWI in I, II, VL, V5/6, Right hypertrophy causes
TWI in V3 (V1 TWI is normal, V2 may be normal)
BBB: T wave associated with QRS > 160 are insignificant since they might be just BBB

Other Abnormalities of ST Segment and T Wave

Mg/K: hypo causes T wave flattening and U wave, hyper causes peaked T wave and
disappearance of ST
Ca: hypo prolongs QT, hyper shortens
Non specific changes: minor degrees of ST and T abnormalities are usually not importance