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Interpreting ECG

Rucira Ooi

What is an ECG?

12 leads V1 6, I, II, III, aVR, aVL, aVF

Where to place an ECG?

Where to place an ECG?
Where to place an ECG?

ECG wave form

ECG wave form

P wave First bump Atrial depolarization Small, rounded wave

P wave • First bump • Atrial depolarization • Small, rounded wave

Q wave Follows after a P wave Downward dip May or may not be present

Q wave • Follows after a P wave • Downward dip • May or may not

R wave First upward peak after the P wave

R wave • First upward peak after the P wave

S wave Any dip below the baseline following an R wave

S wave • Any dip below the baseline following an R wave

T wave Upward deflection following QRS Complex Large, rounded wave

T wave • Upward deflection following QRS Complex • Large, rounded wave

PR Interval

PR Interval • Measured from the beginning of the P wave to the beginning of the

Measured from the beginning of the P wave to the beginning of the QRS complex

Normal value: 0.12 0.2 secs (3 5 small squares)

QRS duration

QRS duration • Measured from initial deflection of the QRS from the isoelectric line to the

Measured from initial deflection of the QRS from the isoelectric line to the end of the QRS complex

Normal value: < 0.12 secs (less than 3 small squares)

Systematic way of interpreting ECG

In the following order:

  • 1. Heart rate

  • 2. Heart rhythm

  • 3. Cardiac axis

  • 4. P waves

  • 5. QRS complexes

  • 6. ST segment

  • 7. Q-T interval

Heart rate

Usually runs on a standard rate

25mm/s

Remember to check the paper speed!

Each small square represents 0.04 secs

One large square = 5 small squares -> 0.2 seconds

Heart rate • Usually runs on a standard rate 25mm/s • Remember to check the paper

Measuring the R-R interval

Ventricular rate is calculated by looking at the distance between consecutive QRS complexes

Usually the distance between R waves is analysed

Measuring the R-R interval • Ventricular rate is calculated by looking at the distance between consecutive

When there are a number of large square between each R wave, the ventricular rate is most easily calculated by counting the number of large squares between each R wave and dividing this number into 300

Formula: 300 / Number of large squares (eg. 300 / 5 = 60bpm)

When the ventricular rhythm is more rapid use number of small squares

Formula: 1500 / Number of small squares

Bradycardia = Heart rate of < 60 bpm Tachycardia = Heart rate of > 100bpm

If heart rhythm is irregular, calculate the rate using the number of squares between several R waves. Divide the answer to obtain an

average R-R interval.

Eg. If there are 40 large squares between the first and the eleventh R wave, the average R-R interval is 4 large squares => 300 / 4 = 75bpm

Heart rhythm

Look for P waves and their relationship to QRS complex Normally one P wave should be followed by one QRS complex Good leads to assess P wave are leads II, V1 and V2

Sinus rhythm

Normal heart rhythm P wave followed by QRS complex

Sinus rhythm • Normal heart rhythm • P wave followed by QRS complex

In sinus arrhythmia, the heart rate Increases on Inspiration

To diagnose sinus rhythm, all of the following criteria should be met:

  • 1. P wave preceding every QRS complex

  • 2. P-R interval is normal

  • 3. P-R interval is constant

Atrial fibrillation

No P waves ECG baseline shows irregularity QRS complexes are irregular

Atrial flutter

Flutter waves Baseline adopts a ‘saw-toothed’

Atrial flutter may occur with a fixed degree of atrio-ventricular block (eg. 3-to-1 block)

This means that, for every three flutter waves, there would be one QRS complex

1 st degree heart block

P wave precedes each QRS complex, but the P-R interval is prolonged (> 5 small squares )

P-R interval remains constant from beat to beat

1 degree heart block • P wave precedes each QRS complex, but the P-R interval is

2 nd degree heart block

Conduction problem more severe than 1 st degree, but less severe than 3 rd degree heart block

Has 3 main types

1. Mobitz Type 1 (Wenckebach phenomenon)

Rhythm runs in cycles First P-R interval is often normal With each successive heart beat, the P-R interval lengthens Eventually, there will be a P wave with no following QRS complex

1. Mobitz Type 1 (Wenckebach phenomenon) • Rhythm runs in cycles • First P-R interval is

2. Mobitz Type 2

P-R interval is constant Duration may be normal or prolonged

Periodically there will be no conduction between the atria and ventricles, and there will be a P wave with no associated QRS complex

2. Mobitz Type 2 • P-R interval is constant • Duration may be normal or prolonged

3. Fixed degrees of AV block

Two-to-one, three-to-one, four-to-one block

3. Fixed degrees of AV block • Two-to-one, three-to-one, four-to-one block

3 rd degree heart block

No functioning conduction between atria and ventricles No constant relationship between P and QRS waves

3 degree heart block • No functioning conduction between atria and ventricles • No constant relationship

Cardiac axis

Axis

Lead I

Lead II

Lead III

Normal

Upgoing

Upgoing

Upgoing (or downgoing)

Right axis

Downgoing

Upgoing

Upgoing

deviation

Left axis

Upgoing

Downgoing

Downgoing

deviation

Cardiac axis Axis Lead I Lead II Lead III Normal Upgoing Upgoing Upgoing (or downgoing) Right

P waves

Tall, peaked P waves => P pulmonale

Sign of right atrium enlargement

Wide P waves, often bifid => P mitrale

Sign of left atrium enlargement

QRS duration

A normal QRS complex should be less than 3 small squares wide

Problems in the conducting tissue result in widening of QRS complexes Right BBB and Left BBB Important to identify LBBB, because its able to develop into MI

QRS duration • A normal QRS complex should be less than 3 small squares wide •

Do not attempt to comment on the ST segment when LBBB is present

ST segment

Normally, isoelectric

Lies between QRS complex and T wave

ST elevation = MI (specific to location of damaged parts) and pericarditis (in all

leads) STEMI -> Convex upwards Pericarditis -> Saddle- shaped

ST segment • Normally, isoelectric • Lies between QRS complex and T wave • ST elevation

ST elevation that persists over weeks and months after a MI commonly signifies the presence of a ventricular aneurysm Horizontal ST depression can represent cardiac ischaemia, and may be seen during episodes of angina pectoris ST depression may also indicate a NSTEMI which can be distinguished from ischaemia only by measuring TnI ST depression in lateral chest leads => LVH (strain on the left ventricle) Down-sloping ST depression (reverse-tick) ST depression Patients on digoxin

• ST elevation that persists over weeks and months after a MI commonly signifies the presence

Q-T interval

Start of QRS complex to the end of the T wave Long Q-T intervals = cardiac dysrhythmias

Q-T interval varies with heart rate, but should in general not be more than 2 large squares in duration

QT interval increases with bradycardia

T wave

Final stage in ECG interpretation Can be upright or inverted Generally less than two-thirds of the height of their neighbouring R wave, and should not be more than 2 large squares tall Inverted T waves are normally seen in leads aVR and III May also be seen in lead V1 and V2 but not V2 alone T wave inversion = Often a sign of Cardiac ischaemia or NSTEMI

Hyperkalaemia

Hypokalaemia

Tall, tented T waves

Flat, broad T waves

Loss of P waves QRS complex broadening Sine-wave shaped ECG

ST depression Long Q-T interval Ventricular dysrhythmia

Cardiac arrest rhythms

Cardiac arrest rhythms - Shockable

Priority in treatment is to deliver electricity to the heart using a defibrillator

Ventricular fibrillation

Erratic nature of electrical activity Random and unpredictable

Classified as being fine or coarse depending on whether the electrical activity is of small (fine) or large (coarse) amplitude

Cardiac arrest rhythms - Shockable • Priority in treatment is to deliver electricity to the heart

Ventricular tachycardia

Broad QRS complex tachycardia Distinctive appearance on ECG monitor

Not always associated with cardiac arrest, but is always a significant arrhythmia

Tombstone sign

• Ventricular tachycardia • Broad QRS complex tachycardia • Distinctive appearance on ECG monitor • Not

Non-shockable rhythms

Defibrillation will not be helpful to patients with one of these rhythms CPR should be administered and attempts made to reverse the cause of the cardiac arrest PEA (Pulseless electrical activity)

Heart rhythm is indistinguishable from a heart rhythm normally compatible with life

Non-shockable rhythms • Defibrillation will not be helpful to patients with one of these rhythms •

Asystole

No identifiable cardiac electrical activity

Important to adjust the gain on the ECG monitor to ensure that ‘fine’ ventricular fibrillation is not missed

• Asystole • No identifiable cardiac electrical activity • Important to adjust the gain on the

P wave asystole

Rhythm where only P waves are seen No ventricular activity Rhythm may respond to cardiac pacing

• P wave asystole • Rhythm where only P waves are seen • No ventricular activity

Example 1

Example 1

Example 2

Example 2