ECG at a glance…

ACTION POTENTIAL
 Polarization
 Intracellular is more negative than
extracellular
 Depolarization
 Intracellular becomes more positive
 Influx of Na+
 Repolarization
 Intracellular restores to its resting potential
 Efflux of K+
ACTION POTENTIAL
CARDIAC CELLS
PROPERTIES
 Automaticity
 Excitability

 Conductivity

 Contractility
CONDUCTION SYSTEM
 Sinoatrial Node (SA Node)
 Rhythmic rate : 60 – 100 bpm
 Internodal Pathway
 Anterior, middle, posterior pathways
 Atrioventricular Node (AV Node)
 Regions : atrionodal (AN), nodal (N),
nodal-His (NH)
 Delays the impulse
CONDUCTION SYSTEM
 Bundle of His
 Rate : 40 – 60 bpm
 Bundle Branches
 LBB & RBB
 LBB : anterior, posterior, septal fascicles

 Purkinje Fibers
 Rate : 20 – 40 bpm
CONDUCTION SYSTEM
CONDUCTION SYSTEM
LEADS
 Standard Limb Leads
 Lead I, II, III
 Augmented Limb Leads
 aVL, aVR, aVF
 Precordial Leads
 V1, V2, V3, V4, V5, V6
 V1R, V2R, V3R, V4R, V5R, V6R
LEADS
LEADS
LEADS VIEW OF HEART
I, aVL Lateral
II, III, aVF Inferior
V1, V2 Septal
V3, V4 Anterior
V5, V6 Lateral
ECG WAVEFORMS
ECG WAVEFORMS
 P wave
 No more than 2.5 mm in
height
 No more than 0.11 sec in
duration
 Positive : I,II,aVF,V2-6
 May be positive, negative, or
biphasic : III,aVL,V1
ECG WAVEFORMS
 PR interval
 0.12 – 0.20 sec in adult,
may be shorter in children
and longer in elders
ECG WAVEFORMS
 QRS Complex
 0.06 – 0.10 sec
 Q : 1st negative deflection after P
 R : 1st positive deflection after P
 S : negative deflection after R
ECG WAVEFORMS
 ST Segment
 Isoelectric (flat)
ECG WAVEFORMS
 T wave
 Limb lead : no more than 5 mm (height)
Precordial lead : no more than 10 mm (height)
ECG WAVEFORMS
RATE MEASUREMENT
 Large Boxes  300/R-R interval
 Small Boxes  1500/R-R interval

 Six-Second Method  count the

number of complete QRS complexes
in 6 seconds
AXIS DEVIATION
ABNORMAL WAVEFORMS
 P : tall, notched
 PR interval : prolonged, shortened
 Q : pathologic Q (>0.04 sec, 25% of the R
wave)
 QRS complex : widened (>0.10 sec)
 ST segment : depression (>1 mm), elevation
(>1 mm in limb leads or >2mm in precordial
leads)
 T : peaked/tall, inverted, flattened
 QT interval : prolonged, shortened
ABNORMAL WAVEFORMS
 ST segment : depression (>1 mm),
elevation (>1 mm in limb leads or
>2mm in precordial leads)
ABNORMAL WAVEFORMS
 T wave : peaked/tall, inverted, flattened
R-WAVE PROGRESSION
Poor R-wave progression :
 Infarction (anteroseptal)

 LBBB

 LVH

 Severe COPD (emphysema)

ATRIAL ENLARGEMENT
 Left Atrial Enlargement
Notched P wave
 Right Atrial Enlargement

Peaked P Wave
VENTRICULAR
HYPERTROPHY
 Left Ventricular Hypertrophy
 S wave in V1/V2 + R wave in V5/V6 ≥ 35 mm (mV)
 R wave in aVL ≥ 12 mm (mV)
 Strain pattern in V5 and V6
 May be accompanied by LAD
VENTRICULAR
HYPERTROPHY
 Right Ventricular Hypertrophy
 RAD
 Reversed R-wave progression (taller R waves and smaller S
waves in V1 & V2; deeper S waves & small R waves in V5 & V6
MYOCARDIAL INFARCTION
MYOCARDIAL INFARCTION
Acute inferior myocardial infarction
MYOCARDIAL INFARCTION
Septal wall myocardial infarction
MYOCARDIAL INFARCTION
Extensive (whole) anterior myocardial
infarction
MYOCARDIAL INFARCTION
Inferior wall myocardial infarction with a
possible posterior wall infarction
 MYOCARDIAL
INFARCTION
Evolutionary changes in
anteroseptal myocardial
infarction

A. At admission
B. At 24 hours
C. At 48 hours
MYOCARDIAL
INFARCTION
Evolutionary changes in
inferior and right
ventricular infarction

A. At admission
B. At 12 hours
C. Right chest leads
CAUSES OF
DYSRHYTHMIAS
 Enhanced Automaticity
 Reentry
 Escape Beats
 Conduction Disturbances
SUPRAVENTRICULAR
ARRHYTHMIAS
 Supraventricular Tachycardia
 Rate : 150-250 bpm
 Rhythm : regular
 P waves : frequently buried in preceding T waves
 PR interval : usually not possible to measure
 QRS : normal
SUPRAVENTRICULAR
ARRHYTHMIAS
 Atrial Flutter
 Rate : atrial : 250 – 350 bpm; ventricular : slow/fast
 Rhythm : usually regular
 P waves : “saw teeth appearance”
 PR interval : variable
 QRS : usually normal, may be widened
 Conduction ratio : 2:1, 4:1, 6:1
SUPRAVENTRICULAR
ARRHYTHMIAS
 Atrial Fibrillation (AFib)
 Rate : atrial : > 350 bpm; ventricular : slow/fast
 Rhythm : irregular
 P waves : no true P waves; chaotic atrial activity
 PR interval : none
 QRS : normal
VENTRICULAR
ARRHYTHMIAS
 Ventricular Tachycardia
 Rate : 100 – 250 bpm
 Rhythm : regular
 P waves : none or not associated with QRS
 PR interval : none
 QRS : wide (>0.10 sec), bizarre appearance
VENTRICULAR
ARRHYTHMIAS
 Ventricular Fibrillation
 Rate : indeterminate
 Rhythm : chaotic
 P waves : none
 PR interval : none
 QRS : none
VENTRICULAR
ARRHYTHMIAS
 Torsades de Pointes
 Rate : 200 – 250 bpm
 Rhythm : irregular
 P waves : none
 PR interval : none
 QRS : wide (>0.10 sec), bizarre appearance
EXTRASYSTOLE
 Atrial Extrasystole (AES) / Premature Atrial Contraction
(PAC)
 Rhythm : irregular due to the premature beat
Rate : depends on its basic rhythm
P wave : unusual compare to basic rhythm
PR interval : normal, maybe shorten
QRS : normal
EXTRASYSTOLE
 Ventricular Extrasystole (VES) / Premature Ventricular
Contraction (PVC)
 Rhythm : irregular due to the premature beat
Rate : depends on its basic rhythm
P wave : none
PR interval : none
QRS : > 0.12 sec
 Threatening VES :
‘R on T’ VES
VES > 6 times/min
Bigemini VES
Multifocal VES
Consecutive VES
EXTRASYSTOLE
BLOCKS
 1st Degree AV Block
 Rate : normal
 Rhythm : regular
 P waves : normal
 PR interval : prolonged (>0.20 sec) but constant
 QRS : usually 0.10 sec or less
BLOCKS
 2nd Degree AV Block Type I/Mobitz Type I/Wenckebach
 Rate : atrial > ventricular
 Rhythm : atrial regular; ventricular irregular
 P wave : normal
 PR interval : lengthen with each cycle until P wave appears
without a QRS complex
 QRS : usually 0.10 sec or less
BLOCKS
 2nd Degree AV Block Type II/Mobitz Type II
 Rate : atrial > ventricular
 Rhythm : atrial regular; ventricular irregular
 P wave : normal
 PR interval : normal or slightly prolonged but constant for the
conducted beats; there maybe some shortening of the PR
interval that follows a non-conducted P wave
 QRS : usually 0.10 sec or less
 Conduction ratio 2:1, 3:1, 4:1
BLOCKS
 3rd Degree AV Block/Complete AV Block/Total Heart Block
 Rate : atrial > ventricular.
 Rhythm : atrial regular; ventricular regular (AV dissociation)
 P wave : normal
 PR interval : none; the atria and ventricles beat independently
 QRS : narrow or wide
BLOCKS
 Left Bundle Branch Block (LBBB)
BLOCKS
 Right Bundle Branch Block (RBBB)
BLOCKS
 Fascicular Block/Hemiblock
 Left Anterior Fascicular Block (LAFB) : LAD
 Left Posterior Fascicular Block (LPFB) : RAD
PULSELESS ELECTRICAL
ACTIVITY (PEA)
Electrical activity is seen in ECG but no
pulse is detected when palpating the
artery
Danke !