Basic Abnormal ECG

By Fadhly Shariman Bin Hj Yahaya

INTERVALS/DUR
ATION

P wave
When studying the P
wave, always look at
I, II, avF and V1
Normal:
o How tall? 0.5-2.5 mm
o How wide? 0.10 sec
o P wave is upright in all leads
except
sometimes
it
is
biphasic in V1

P wave

Look at leads I, II,

avF
Are there any P
waves
too
tall
(>2.5 mm)?
o YES: Right Atrial
Enlargement (RAE)

P wave

Look at leads I, II,

avF
Are there any P
waves too wide
(>0.10 sec)? Any
bifid P waves?
o YES: Left Atrial
Enlargement (LAE)

PR interval
Normal:
o 0.12-0.20 secs.

PR interval
Look
at
your
measurements
Is the PR interval
short
(<0.12
sec)?
o YES:
Bypass of
the AV node

PR interval
Look
at
your
measurements
Is the PR interval
long (>0.20 sec)?
o YES:
First
degree AV Block

Q wave
Q wave is present when
the first QRS deflection
is downward
Observed in each lead
Are
there
any
pathological Q waves?
o

If:

> 2 small squares deep

> 25% of the height of the
following R wave
> 1 small square wide

o YES: Infarction

Q wave
If:
o Pathological Q wave
o No ST segment depression
o Normal T wave

o YES: Old Infarction/

Fibrosis/
Previous
documented MI

Where is the location?

Identify the leads.

Leads

Location

I, avL

High Lateral

II, III, avF

Inferior
(right coronary artery)

V1, V2

Septal

V3, V4

Anterior
(left main artery)

V5, V6

Lateral

Q wave
If:
o Pathological Q wave
o ST segment depression
o T wave inversion

o YES: New Infarction

(MED EMERGENCY!)

Where is the location?

Identify the leads.

Leads

Location

I, avL

High Lateral

II, III, avF

Inferior
(right coronary artery)

V1, V2

Septal

V3, V4

Anterior
(left main artery)

V5, V6

Lateral

R and S waves
Are any R or S waves
too big?
o YES:
ventricular
hypertrophy

Left

Check using:
o Sokolow-Lyon index:
SV1 + (RV5 or RV6) >3.5
mV

o Cornell voltage criteria:

SV3 + RavL 2.8 mV
(men)
SV3 + RavL 2.0 mV
(women)

R and S waves
Look at leads V1 to V6
Normal:
o R wave increases in height from V1 to V6
o S wave decreases in depth from V1 to V6

R and S waves
Look at leads V1 to V6
Are the R waves persistent in sizes (<5 mm)?
o YES: Poor R wave progression

R and S waves
Look at leads V1 to V6
Are the S waves persistent in sizes?
o YES: Persistent posterobasal forces

QRS complex
Normally varies in
different ECG leads
Normal:
o < 0.12 sec
o < 3 small squares
o QRS is upright in all leads
except in avR

QRS complex
Is there any bizarre
looking
QRS
with
deep S wave?
Premature,
wide,
aberrant,
notched
QRS, > 0.12s in
duration?
o YES: Premature
ventricular
complex (PVC)

QRS complex
Are
any
QRS
complexes too wide
(> 0.12 secs)?
o YES:
Bundle
Branch Block

QRS complex
Look at V1, V2 and
V5, V6
If:
o Wide QRS complex
o M sign or rSR in V1
YES:
Right
Bundle
Branch Block (RBBB)
o Wide QRS complex
o Deep S in V6
YES: Complete BBB

QRS complex
Look at V1, V2 and
V5, V6
If:
o Wide QRS complex
o srS in V1
o M sign in the peak of R
YES:
Left
Bundle
Branch Block (LBBB)
o Wide QRS complex
o Deep S in V6
YES: Complete BBB

QRS complex
Look at V1, V2 and
V5, V6
If:
o Normal QRS complex
o BBB morphology
YES: Incomplete BBB

ST segment
Isoelectric ( Lies at
the same level as the
baseline)
Normal:
o Deviate between -0.5 and +1
mm from the baseline

ST segment
Are the ST segments
elevated
(raised
above
level
of
baseline)?
o YES: Acute MI to normal
variant

ST segment

ST segment
Are the ST segments
depressed ( > 2 small
squares below level of
baseline)?
o YES: Myocardial ischemia

ST segment

ST segment
Does the J point ensue early at repolarization?
o YES: Early Repolarization Pattern

ST segment
Is there flattening of T waves?
o YES: Non-specific ST wave changes (NSSTWC)

T wave
Normal:
o Not clearly defined
o Guide:
Should not be > size of
the
preceding
QRS
complex
T wave is usually not
above 10 mm in any
precordial leads

T wave
Look at V2, V3, V4
Are the T waves too tall (>10 mm)?
o YES: Peak T waves (Hyperkalemia or AMI)

T wave
Is the T wave inverted
(> 1 mm)?
o YES: Myocardial Ischemia

U wave
Prominent in V3
Normal:
o Not >1 mm amplitude

U wave
Do the U
appear
prominent?

waves
too

o YES: Prominent U waves

(Hypokalemia,
Hypercalcemia,
Hyperthyroidism)

RHYTHM

Sinus Rhythm
Presence of P wave
Followed by QRS complex
Regular rate
Normal:
o 60-100 bpm

Sinus Arrhythmia

Presence of P wave
Followed by QRS complex
Irregular sinus rhythm at rate <100 bpm
Cycle vary by 10% or more

Premature Atrial Complex (PAC)

Premature P wave which results from a
premature ectopic, supraventricular impulse
that originates somewhere in the atria outside
of the SA node

CARDIAC RATE

BRADYCARDIA
RR <60 bpm

Regular

P wave
Sinus
Bradycardia

Irregular
No P-QRS
relation

No P wave
Narrow
QRS
Junctional

Wide QRS
Idioventricular

3rd degree
AV Block

No P wave

Slow AF

P wave but
abn PR
Group
beating
2nd degree
AV Block

BRADYCARDIA
Sinus Bradycardia

BRADYCARDIA
3rd degree AV Block

BRADYCARDIA
2nd degree AV Block

Type 1

Type 2

TACHYCARDIA
RR > 100 bpm

Narrow QRS

Wide QRS

Regular

P wave; 100-140
bpm

Sinus
tachycardia

Irregular

No P wave; 150
bpm

SVT

No P wave

AF

V tach

Flutter waves;
saw tooth; >300
bpm

Atrial flutter

BRADYCARDIA
Sinus Tachycardia

BRADYCARDIA
SVT

BRADYCARDIA
AF

BRADYCARDIA
Atrial flutter

BRADYCARDIA
V-tach

AXIS

Left Anterior Fascicular Block

(LAFB)
Mean QRS axis of -45 to -90 degrees
o > -30 degrees is the hallmark

rS pattern in II, III and avF

qR pattern in I and avL
Normal QRS duration (<0.12 sec)

Left Anterior Fascicular Block

(LAFB)

Left Posterior Fascicular Block

(LPFB)

Mean QRS axis of 120 degrees

rS pattern in I and avL
qR pattern in II, III, avR
Normal QRS duration ( <0.12 sec)

Left Anterior Fascicular Block

(LAFB)

Right Ventricular Hypertropy

(RVH)
Mean QRS axis of >90 degrees
qR in V1 or R wave in V1 7 mm or R/S ratio of
1 or rSR in RBBB

THANK
YOU!