12 L ECG

MOONLIGHT
MEDICINE
Diana Tamondong-Lachica, MD, FPCP
 ELECTROCARDIOGRAM

• Lead placement

• Normal ECG

• Important morphologies

• Important rhythms
 LEAD
PLACEMENT
LEAD PLACEMENT
NORMAL ECG
 NORMAL MORPHOLOGY

• PR interval: 0.12-0.20
• PR segment: 0.05-0.12
• QRS complex: 0.08-0.12
• QT interval: ≤ 0.45 in males,
≤ 0.47 in females
• Corrected QT
• QT/√(R-R)
NORMAL SINUS RHYTHM
 NORMAL SINUS RHYTHM

• Heart Rate
• 300/number of big
boxes
• 1500/number of small
boxes
• 1 big box = 5 small
boxes
• 1 small box =
• Normal: 60-100 bpm
• 3 to 5 big boxes
• 15 to 25 small boxes
 NORMAL AXIS

• Axis calculation
• 90 x aVF

| I+aVF |
• Sign is determined by aVF
• Normal axis is -30 to +110
• Leaving: LEFT axis deviation
• Returning: RIGHT axis deviation
 ABNORMAL AXIS

• Left axis deviation

• Left ventricular hypertrophy
• Inferior wall myocardial infarction
• Hyperkalemia
 ABNORMAL AXIS

• Right axis deviation

• Right ventricular hypertrophy
• Anterolateral myocardial infarction
• Pulmonary embolism
• Chronic lung disease
• ASD, VSD
• Normal variant (children, thin adults)
PATHOLOGIES IN
MORPHOLOGY
 P WAVE

Left atrial enlargement (Lead II and V1)

Right atrial enlargement (Lead II and V1)
 QRS COMPLEX

• Widened QRS
 QRS COMPLEX

• Pathologic Q waves
• Any Q wave in V2-V3
• Q wave ≥ 0.03 s or > 0.1 mV deep in I, II, aVL, aVF, V4-V6
(contiguous leads)
• Lead III often shows Q waves alone – NORMAL
 ST SEGMENT

• ST segment changes are “normal” or expected in

• Bundle branch blocks
• PVCs, arrhythmias

• ST segment changes are abnormal in

• Intrinsic myocardial disease
• Cardioactive drug use
• Electrolyte abnormalities
• Neurogenic factors (stroke, trauma)
 ST SEGMENT

• Concordant leads
• Anterior wall: V2 to V5
• Anteroseptal wall: V1 to V3
• Anterolateral wall: V4 to V6
• High lateral wall: I and aVL
• Inferior wall: II, III and aVF
• Posterior wall: V1 to V3 depression
• Right ventricle: Right-sided leads
 ST SEGMENT

• Depression = ischemia
• Take the segment 2-3 small boxes away from QRS
• Should be > 0.1 mV V5-V6, or1.5 mm aVF, III
• Reciprocal leads
• Other causes
• RVH/LVH
• Digoxin
• Hypokalemia
• LBBB/RBBB
 ST SEGMENT

• Elevation = infarct
• Take the segment 2-3 small boxes away from QRS
• Should be > 0.1 mV in limb leads, or> 0.2 mV in chest leads
• Reciprocal leads
• Other causes
• Early repolarization
• Pericarditis
• LVH, LBBB
• Hyperkalemia
 T WAVE AND U WAVE

• T wave inversion
• Myocardial infarction
• Subacute pericarditis
• Subarachnoid hemorrhage
PATHOLOGIES
IN RHYTHM
 R-R INTERVAL

Sinus tachycardia (< 3 big boxes)

Sinus bradycardia (>5 big boxes)
Atrial fibrillation
Count number of QRS complexes in 6 big boxes (6 second strip)
Rapid ventricular response: > 100
Slow ventricular response: < 60
 P-R INTERVAL AND AV BLOCKS

First degree AV block

Second degree AV block Mobitz 1
Second degree AV block Mobitz 2
Third degree AV block
 VENTRICULAR RHYTHMS

PAC vs PVC
Supraventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation
Clues Supporting the Diagnosis of VT

AV dissociation
Atrial capture, Fusion beats
Widened QRS at V1
LBBB > 0.16, RBBB > 0.14
Axis -90 to +180

RBBB or LBBB morphology

Concordance in all leads