ECG
Leads
Limbs lead Chest lead
High lateral
Lead I , lead aVL
Inferior
Lead II, lead III, lead aVF
Anterior
Lead V3, lead V4
Septal
Lead V1, lead V2
Lateral
Lead V5, lead V6
Nawraa ateeq 1
ECG
Notes:
The standard paper speed is 25mm/sec:
small square = 0.04 sec
large square = 0.2 sec
Paper speed is 50mm/sec:
Small square = 0.02 sec
Large square = 0.1 sec
P wave 0.12s
Atrial depolarization 2.5 x 2.5 squares
PR interval 0.12-0.2s
QRS complex 0.08-0.10s
Ventricular contraction
ST segment 0.08s
T wave
Ventricular repolarization
QT interval 0.4-0.43s
Nawraa ateeq 2
ECG
+ ve
- ve
V1,V2
S wave big
R wave small
V5,V6
S wave small
R wave big
V3,V4
S+R wave equal
Nawraa ateeq 3
ECG
THE ORDER OF ECG INTERPRETATION
1. Regularity of heart beats (regular, irregular)
2. Rhythm (sinus, atrial, nodal, ventricular)
3. Heart rate (using formulas for regular and irregular rhythm)
4. Cardiac axis
5. A description of the P wave (left and/or right atrium overload)
6. Conduction interval (AV-block)
7. A description of the QRS complex (look for hypertrophy‒amplitude; for impaired
conductivity ‒ bundle brunch block; assess the progression of R waves in V1-V3;
pathological Q- wave)
8. A description of the ST segment and T wave (elevation, depression of the segment;
positive, isoelectric or inverted / negative T)
9. A description of the corrected QT (QTc) interval based on calculation (download
Calculate by QxMD application for free)
10. ECG final report
Nawraa ateeq 4
ECG
Rate REGULAR
= 300 / number of LARGE squares between consecutive R waves
IRREGULAR
SLOW = Number of R waves X 6
FAST = 1500 / number of SMALL squares between consecutive R waves
Interpretation (adults)
- Normal: 60‒100 beats/min
- Tachycardia: >100 beats/min
- Bradycardia: <60 beats/min
Normal Heart Rates in Children
- Newborn: 110 ‒ 150 bpm
- 2 years: 85 ‒ 125 bpm
- 4 years: 75 ‒ 115 bpm
- 6 years+: 60 ‒ 100 bpm
Axis Normal axis:
Lead I +ve, Lead II +ve, lead III +ve
aVF +ve
0 to +90
Right axis devision:
Lead I -ve, Lead II +ve, Lead III +ve
aVF +ve
+90 to +180
left axis devision:
Lead I +ve, Lead II -ve, lead III -ve
aVF -ve
-90 to 0
Rhythm P wave present:
- If +ve in lead II: sinus rhythm
- If -ve before QRS complex: low atrial
- If -ve after QRS complex: nodule rhythm
P wave absent:
A. Regular rhythm
- Narrow QRS
1. Nodal rhythm
2. Atrial flutter with regular conduction
- Wide QRS
1. Ventricle rhythm
2. Supra-ventricle tachycardia + bundle branch block
B. Irregular rhythm
- Atrial fibrillation
- Atrial flutter with irregular conduction
Nawraa ateeq 5
ECG II
Cardiac conduction system:
is a specialized group in the walls of the heart that send signals
to the heart muscle causing it to contract.
- SA node starts the sequence by causing the atrial muscles to
contract.
- Signal travels to the AV node.
- Then through the bundle of His, down the bundle branches,
and through the Purkinje fibers, causing the ventricles to
contract.
Conduction defects:
1st degree heart block Prolonged fixed PR interval
2nd degree heart block P wave presence
Type1 QRS complex absence
2nd degree heart block 2:1
Type2 2P-wave:1QRS complex
3rd degree heart block Complete heart block
Right bundle branch block RSR pattern V1 or V2+V3
Left bundle branch block RSR-M shaped V6 or V5+V4
Nawraa ateeq 1
ECG II
Anterior fascicular block Left axis devision
Lead I +ve
Lead II, Lead III -ve
Posterior fascicular block Right axis devision
Lead I -ve
Lead II, Lead III +ve
Bifascicular block RSR pattern (V2,V3)
Right bundle branch block + left axis devision:
anterior fascicular block Lead I +ve
Lead II, Lead III -ve
Arrhythmia
is a group of conditions in which the heartbeat is irregular, too fast, or too slow
Atrial escape rhythm P-wave: -ve
Nodal escape rhythm P-wave: absent
Ventricular escape rhythm P wave: regular
QRS complex: wide
Complete heart block
Accelerated idioventricular QRS complex: wide
rhythm Tachycardia
Ventricular extrasystole QRS complex: one wide
Nodal extrasystole P-wave: one absent
QRS complex: regular
Supra-ventricular tachycardia P-wave: absent
Nawraa ateeq 2
ECG II
Atrial flutter P-wave: regular
4:1
2:1
Tachycardia
Atrial fibrillation QRS complex: irregular and
tight
P-wave: not defined
Paroxysmal Ventricular Monomorphic Monomorphic
tachycardia QRS complex: wide and regular
Polymorphic Polymorphic
QRS complex: wide and
irregular
Ventricular fibrillation Complex: not defined
Emergency status
Wolf Parkinson syndrome Delta wave
PR interval short less than 120
ms
Prolonged QR interval > 120 ms
Nawraa ateeq 3
ECG III
P-wave - Right atrial hypertrophy
Normal: 2.5 x 2.5 small squares If P-wave tall than normal (P-pulmonale)
- Left atrial hypertrophy
Wide notched P-wave
QRS complex - Right ventricular hypertrophy
If R tall in V1, V2
And T-wave inversion in (V1, V2, V3)
And S-wave deep in (V6, or V5)
And right axis division
- Pulmonary embolism
If sinus tachycardia
or right axis devision, R tall in V1, T-wave
inversion in (V1, V2, V3), and P-pulmonale
or S-wave deep in lead I, Q-wave deep in lead
III, T-wave inversion in lead III + right bundle
branch block (RSR pattern) in (lead I, II, III),
deep S-wave in V6
- Left ventricular hypertrophy
If the sum of tall R in V6 and tall S in V1 is
more than 7 large squares, T-wave inversion in
lead I, aVL, V5, V6
Q-wave maybe old or recent, it s old if there s only Q-wave
Normal: W1 x H2 small squares without ST-elevation, also if there s no problem in
the patient and heart
-Inferior MI
If Q-wave (>normal) in lead II, III, aVF
- Anteroseptal MI
If Q-wave (>normal) in V1, V2, V3
Nawraa ateeq 1
ECG III
ST-segment - Acute inferior STEMI
Normally Isoelectric If it s higher than isoelectric line on (Lead II, III,
aVF)
- Acute antero-lateral STEMI
If it s higher than isoelectric line on (V2, V3, V4,
Myocardial infarction If it s higher than V5)
isoelectric line on 2 leads at least
- Acute antero-septal STEMI
If it s higher than isoelectric line on (V1, V2, V3)
- Posterior wall MI
If it s higher than isoelectric line on (Lead II, III,
aVF) + and we can see it below the the
isoelectric in (V1, V2, V3) + also Tall R in (V1,
V2)
If we find these we put 3 leads on the back
under scapula
- Right ventricle MI
If it s higher than isoelectric line on (Lead II, III,
aVF, V1) but ST segment should be in lead III
higher than in lead II + also ST depression in
lead I, aVL
Move chest lead (V3 ,V4 , V5, V6) from left
side to right side then it s well showed ST
segment higher than isoelectric line on
(V3 ,V4 , V5, V6)
Nawraa ateeq 2
ECG III
T wave Left ventricular hypertrophy
T wave inverted in lead I, aVL (V5,V6)
Right ventricular hypertrophy
T wave inverted in (V1, V2, V3)
Inferior and lateral ischemia
T wave inverted in lead (I, II, III, avF, V5, V6)
Effects of elements
Digitalis effect T-wave inversion
ST depression
U wave
Hypokalemia (decrease in potassium) T-wave flatten or inverted with U wave
Hyperkalemia (increase in potassium) Hyper acute T-wave (Big T)
ST segment maybe disappear
QRS complex wide
Hypocalcemia (decrease in calcium) Prolonged QT interval in (V4, V5, V6)
Hypercalcemia (increase in calcium) QT interval less than normal
Pericarditis If ST segment higher than isoelectric line on
(V2, V3, V4, V5, V6, lead I, II) and its look like
concave shape
Nawraa ateeq 3
