Reading ECGs

Dr Sherwan R Shal
2007
Exclusive

03/24/09 1
 YOU should have the following
information:
• Patients IDs e.g. name,
• Date (in years, months, days,
hours and minutes).
• Place where ECG was taken.
• ALL written or printed on the
ECG paper
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 You should be able to..
Differentiate normal from abnormal ECG.
And at this level:
3. Heart rate.
4. Rhythm.
5. Time duration.
6. Voltage amplitude.
7. Heart axis, deviations to right or left.
8. Overall wave forms and configuration.
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• ECG is recorded on a paper which is
divided by horizontal and vertical
lines forming squares.
• A large square is divide into 25 small
squares.
• One large square is (5 X 5) square
mm; i.e. 5mm length and 5mm
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• Each large 1
square is divide mm
into 25 small
squares. 5 raws
and 5 columns. 5
mm
• Each small
square is 1X1
square mm; i.e.
1mm in length
and 1mm width.
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 • The normal speed of the ECG paper is
25mm/second.
• This is equal to 25 small squares per second.
• This also means 5 large squares perSpeed =
second.
25 25
25 small mm/second
squares

1 2 3 4 5

5 large
One large square squares/second
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• Horizontal line represents time.
• So, one small square equals to 1/25 second or
equals to 0.04 second.
• And, one large square equals to 1/5 second or
0.2 second.

25 small
5 large squares
squares
= one second
= one second
One large one small
square square
= 0.2 second = 0.04 second
5 4 3 2 1

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• Vertical line represents voltage.
• Traditionally, every 1o small squares (or 2 large
squares) up or down is 1mV.
• So, one small square is 1/10 or 0.1 mV.
• And, one large square is ½ mV or )0.5 mV.
One large
square
0.5 mV

One small square

2 0.1 mV
Two large
Squares 1
1 mV

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03/24/09 9
 Measurements
1. Measurements
Heart Rate: 60 - 100 bpm  
PR Interval: 0.12 - 0.20 sec (= 3 to 5
small sq.)
QRS Duration: 0.06 - 0.10 sec (= 1.5
to 2.5 small sq.)
QT Interval (QTc <0.40 sec)  (= ≤ 10
Corrected QT interval = QT interval /√
(RR) interval
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03/24/09 11
 Measurements
2. Rhythm: Normal sinus rhythm:
The P waves in leads I and II must be
upright (positive) if the rhythm is
coming from the sinus node.
3. Conduction:
Normal Sino-atrial (SA), Atrio-ventricular (AV),
and Intraventricular (IV) conduction
Both the PR interval and QRS duration should be
within the limits specified above.
P Wave  P duration < 0.12 sec  P amplitude <
0.25 mV
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 Normal Voltages in the
Electrocardiogram
Ø The voltage of the QRS complex
usually is 1.0 to 1.5 millivolt from the
top of the R wave to the bottom of
the S wave;
Ø The voltage of the P wave is between
0.1 and 0.3 millivolt;
Ø The voltage of T wave is between 0.2
and 0.3 millivolt.
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 P-Q or P-R Interval
The time between the beginning of the P
wave and the beginning of the QRS complex
is the interval between the beginning of
electrical excitation of the atria and the
beginning of excitation of the ventricles.
This period is called the P-Q interval.
The normal P-Q interval is about 0.16
second. (Often this interval is called the P-R
interval because the Q wave is likely to be
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 Heart Rate
• Heart rate is measured in
beats/minute.
• ECG paper speed is in mm/second, so
we should change it to mm/minutes.
• 25 mm/second equals to 60X25
mm/second
• = 1500 mm/min. (1500 small
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 Heart Rate
• One heart beat is one cardiac cycle.
• One cardiac cycle starts from one
wave e.g. R wave , to the next R
wave (or from p to next p)
• Count the number of small sq.
between two successive R waves,
• OR the number of large sq. between
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 Heart Rate

= 1500 / No. of small sq. bet. 2

RR waves

= 300/ No. of large sq. bet. 2

RR waves .
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03/24/09 18
 Applications

RR interval
V P QR
o S T
l Q

t
a Time (seconds)
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 Applications
Heart
rate
P
duration
P Voltage P QR
QRS S T
duration
QT Q
duration

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 Regular Rhythm
Regular
if the
distance
between
two
successi
ve R
waves R
regular
and all
other
wave
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are
 Irregular Rhythm
Irregular
if the
distance
between
two
successi
ve R
waves R
is

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 Heart Axis
• The hexagonal reference
system…
• Remember..
• I is 0 angle (or 180 degree).
• II is 60 degree
• aVf is 90 degree.
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 Heart Axis

aV
III f II
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 Heart Axis
L
EFT
I

aV
III f II
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 Heart Axis
RIGH
T
I

III aV
f II
03/24/09 26
Physiological Causes of axis
deviation
• When the diaphragm ascends up
with expiration, the heart
becomes more horizontal (i.e.
deviates to the left)
• Inspiration, on the other hand,
makes the diaphragm to
descends down, and the heart
03/24/09 27
Physiological Causes of axis
deviation
• Diaphragm moves down with
inspiration, standing (because
abdominal contents descends)
this happen also with tall
persons.
• Diaphragm moves up with
expiration, lying down, or in
fatty person and any cause of
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 AXIS DEVIATION
H Vertical
eart Heart

RAD

Norm
Horizon
Heart
LAD

tal

al
Diaphra
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 The axis of the heart
Normal cardiac axis is
about 58o
It is close to L
lead II eft
It might shift to R
the left or to igh
the right t
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 Left Axis
Axis is to the
left of
hexagonal
reference
system.
Angle is near
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 Left Axis
Axis is to the
left of
hexagonal
reference
system.
Angle is near
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 Right Axis
Axis is to the
right of
hexagonal
reference
system.
Angle is near 90
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 Right Axis
Axis is to the
right of
hexagonal
reference
system.
Angle is near 90
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 Left and Right axis
I
I
I
II II
LA RA I
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 Left axis Right axis
deviation deviation
I I

I I
I I
II II
I I

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 Normal

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 Test Your Knowledge

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 Test Your Knowledge

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 Test Your Knowledge

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