ECG Interpretation

Normal ECG
The P wave represents the spread of electrical activation (depolarisation) through the atrial myocardium. Normally, it is a smooth,
rounded deflection preceding the QRS complex.

The QRS complex represents the spread of electrical activation through the ventricular myocardium. It is usually (not always) the
largest deflection on the ECG and is "spiky" in shape.

Deflections resulting from electrical activation of the ventricles are called QRS complexes, irrespective of whether they start with a
positive (above the baseline) or a negative (below the baseline) deflection and whether they have one or more recognisable deflections
within them.
Normal ECG
The various components of the QRS complex however, are named on the basis of the following convention :

a) The first positive wave (above the baseline) is called r or R

b) Any second positive wave is called r' or R'
c) A negative wave that follows an r or R wave is called an s or S wave
d) A negative wave that precede an r or R wave is called a q or Q wave
e) An entirely negative wave is called a qs or QS wave
f) LARGE DEFLECTIONS are named with an appropriate CAPITAL letter and small waves with an appropriate small (lower case)
letter.

The T wave represents electrical recovery (repolarisation) of the ventricular myocardium. It is a broad, rounded wave following the
QRS complex.

The U wave may be due to slow repolarization of the papillary muscles. Some causes include: Bradycardia, hypokalaemia and digoxin.
The 12 lead system
leads I, II, III are standard limb leads/bipolar leads

Bipolar meaning a lead is pair of electrodes joined together to record the potential difference between the electrodes

With the bipolar system, one limb is connected to the positive terminal of the recording galvanometer and another limb to its negative
terminal. Three limbs (right arm-RA, left arm-LA and left leg/foot-LL) are used. The right leg was used as "earth", to minimise
interference.

Bipolar leads:
Lead I: RA (-) to LA (+)
Lead II: RA (-) to LL (+)
Lead III: LA (-) to LL (+)
Augmented/unipolar limb leads (frontal plane)
Initially, unipolar limb leads were used, in which recordings were made from the RA (lead R), LA (lead L) and LL (lead F for "foot").

Any voltage measurement requires two electrodes: a "reference electrode", whose potential does not change during the cardiac cycle,
and an "exploring electrode" attached to the limb in question. A voltage or "V" lead was used as an indifferent electrode by joining R, L
and F together.

Nowadays, the limb connections are slightly modified, to "augment" the size of the deflections obtained from leads L, R and F. These
are named as follows:

aVR: RA (+) to [LA & LL] (-)

aVL: LA (+) to [RA & LL] (-)
aVF: LL (+) to [RA & LA] (-)
The precordial/chest leads (horizontal plane)
The precordial/chest leads (horizontal plane)

With each precordial lead, the positive (recording) terminal of the galvanometer is connected to an electrode at an agreed site on the
chest wall, and the negative terminal is connected to an indifferent electrode, the"V" electrode (see above).

Hence, the chest leads are designated as V1, V2, V3, V4, V5 and V6.

The sites of the above electrodes are as follows:

V1: Right sternal margin at 4th intercostal space (ICS)

V2: Left sternal margin at 4th ICS
V4: Intersection of 5th ICS and left mid-clavicular line
V3: midway between V2 and V4
V5: Intersection of left anterior axillary line with a horizontal line through V4
V6: Intersection of left mid-axillary line with a horizontal line through V4 and V5
Einthoven's triangle hypothesis

Published in 1913, this hypothesis attempts to explain the principles of electrocardiography on a scientific basis. It is based on four
assumptions which are not completely true, but do provide some basis. The four assumptions are as follows:

1. The trunk is a homogeneous volume conductor.

2. The mean of all the electrical forces generated during the cardiac cycle can be considered as originating from a dipole situated at the
heart’s centre.
3. The limb leads pick up voltage changes in the frontal plane only.
4. The attachments of the three extremities used in making the limb leads (R, L and F) form the apices of an equilateral triangle with the
dipole at its centre
ECG Definitions
Wave +/- deflection from baseline indicate specific electrical events PQRSTU

Interval is time bw 2 specific ECG events PR, QRS,QT,RR Interval

Segment is the length between 2 specific points on ecg ,suppose to be at baseline

Complex coordination of multiple waves group together, the only main complex QRS

Point -only one pt on ECG that is the Jpoint where QRS ends and ST segment begins
ECG paper
10 second strip

Bottom one or two lines has the full rhythm strip of a specific lead spanning the
entire 10 seconds other leads span about 2.5sec

Divided large and small boxes

1 large box is 5mm, 0.2sec equal 5 small boxes 1 small box 0.04sec and 1mm in
length
Electrophysiology of heart
The sino-atrial or SA node is situated in the right atrium at its junction with the superior vena cava. Normally, the SA node initiates
activation of the atria, which causes a wave of contraction to pass across the atria. Following atrial contraction, the impulse is delayed at
the atrioventricular (AV) node, located in the septal wall of the right atrium.

Spread of electrical activation

1) Activation of the atrial myocardium begins in the SA node. The radial spread of depolarisation then converges on the AV node,
where there is a delay for about 0.1 seconds (AV nodal delay).
2) From here, His-Purkinje fibres allow rapid conduction of the electrical impulse via right and left branches, causing almost
simultaneous depolarisation of both ventricles, approximately 0.2 s after the initial impulse has arisen in the SA node.
3) In humans, the ventricular depolarisation starts at the left side of the interventricular septum and moves first to the right across the
mid-portion of the septum.
4) It then spreads down the septum to the apex of the heart.
5) It then returns along the ventricular walls to the AV groove, proceeding from the endocardial to the epicardial surface.
6) The last parts of the heart to be depolarised are the posterobasal portion of the left ventricle, the pulmonary conus and the uppermost
portion of the interventricular septum.
The predominant direction of spread of atrial activation is to the left and somewhat downwards.

The predominant direction of spread of ventricular activation is downwards and somewhat to the left
Demographics the name of the patient and the date and time it was recorded.

Calibration signal: The amplifier gain is normally adjusted so that a 1 millivolt signal through the ECG amplifier results in a vertical
deflection of 10 mm (two large ECG squares). All voltage measurements on the ECG depend entirely on the accuracy of this calibration
signal. (The paper speed is 25 mm/s, which amounts to 0.04 s per small box on the horizontal axis).

Recording quality: Look for any baseline drift (which makes ST segment analysis impossible), skeletal muscle interference (seen as
sharp, irregular, spiky waves throughout the recording - e.g. during shivering) or mains frequency interference (seen as regular sine
wave oscillation with a frequency of 50 Hz).
Rate
1 small square 0.04ms,1 Large square 0.2ms

Regular R -R interval equal rate= 300/number of squares between RR

Irregular RR interval not equal to determine rate 300 x 3 /number of big squares in 3 RR distances.
Rhythm
The heart is said to be in sinus rhythm based on the following criteria:

P waves must be present and be regular.

P wave frequency should be within the range of 60-100 per min.
There must be one P wave for each QRS complex.
The P wave must precede each QRS complex.
The PR interval must be normal and constant.
The morphology of the P waves and QRS complexes must be the usual form for that patient.
ECG Axis
Causes of LAD Causes of RAD Indeterminate

Normal variant Normal variant

LVH rarely normal RVH

LBBB RBBB, Left

posterior fascicular
block

Inferior MI Lateral wall MI

WPW syndrome dextrocardia

with pseudoinfarct
pattern

Ventricular Ventricular
rhythms(accelerated rhythms(accelerated
idioventricular or idioventricular or
ventricular ventricular
tachycardia tachycardia

Ostium primum Acute heart

ASD strain/pressure
overload McGinn -
White Sign in
ACLS rhythm recognition
PVC
PAC