BASIC PRINCIPLES OF ECG

THE CONDUCTION SYSTEM

 Sinoatrial nodep
 Atrioventricular
junction
 Bundle of His
 Right and left bundle branches
 Purkinje fibers

 Atrioventricular junction
o Area of specialized conduction

 tissue
o Provides electrical links between the atrium and the ventricle

o Intrinsic rate: 40 to 60 beats/min

 Purkinje fibers
o Receive impulses from the bundle
branches
o Relay them to the ventricular
myocardium
o Intrinsic rate: 20 to 40 beats/min

Electrocardiographic Leads

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Three Bipolar Limb Leads

Figure shows electrical connections between the patient’s

limbs and the electrocardiograph for recording
electrocardiograms from the so-called standard bipolar limb
leads. The term “bipolar” means that the electrocardiogram is
recorded from two electrodes located on different sides of the
heart—in this case, on the limbs. Thus, a “lead” is not a single
wire connecting from the body but a combination of two wires
and their electrodes to make a complete circuit between the
body and the electrocardiograph.
The electrocardiograph in each instance is represented by an
electrical meter in the diagram, although the actual
electrocardiograph is a high-speed recording meter with a
moving paper.

Lead I. In recording limb lead I, the negative terminal of the

electrocardiograph is connected to the right arm and the positive
terminal to the left arm. Therefore, when the point where the right arm
connects to the chest is electronegative with respect to the point where
the left arm connects, the electrocardiograph records positively, that is,
above the zero voltage line in the electrocardiogram. When the
opposite is true, the electrocardiograph records below the line.

Lead II. To record limb lead II, the negative terminal of the
electrocardiograph is connected to the right arm and the positive terminal
to the left leg. Therefore, when the right arm is negative with respect to
the left leg, the electrocardiograph
records positively.

Lead III. To record limb lead III, the negative

terminalof the electrocardiograph is connected to the left arm andthe
positive terminal to the left leg. This means that the electrocardiograph
records positively when the left arm is negative with respect to the left
leg.

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LEAD POSITIVE ELECTRODE NEGATIVE HEART SURFACE
ELECTRODE VIEWED
I LEFT ARM RIGHT ARM LATERAL
II LEFT LEG RIGHT ARM INFERIOR
III LEFT LEG LEFT LEG INFERIOR
Augmented Unipolar Limb Leads

Another system of leads in wide use is the augmented unipolar limb lead. In this type of
recording, two of the limbs are connected through electrical resistances to the negative
terminal of the electrocardiograph, and the third limb is connected to the positive terminal.
When the positive terminal is on the right arm, the lead is known as the aVR lead; when on
the left arm, the aVL lead; and when on the left leg, the aVF lead

LEAD POSITIVE ELECTRODE HEART SURFACE

VIEWED
AVR RIGHT ARM NO MAN’S CHEST
AVL LEFT ARM LATERAL
AVF LEFT LEG INFERIOR

Chest Leads (Precordial Leads)

Often electrocardiograms are recorded with one electrode placed

on the anterior surface of the chest directly over the heart at one
of the points shown in Figure. This electrode is connected to the
positive terminal of the electrocardiograph, and the negative
electrode, called the indifferent electrode, is connected through
equal electrical resistances to the right arm, left arm, and left leg
all
at the same time, as also shown in the figure. Usually six
standard chest leads are recorded, one at a time, from the
anterior chest wall, the chest electrode being placed sequentially
at the six points shown in the diagram. The different recordings
are known as leads V1, V2, V3, V4, V5, and V6.

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The figure illustrates the electrocardiograms of the healthy heart as recorded from these six
standard chest leads.

Because the heart surfaces are close to the chestwall, each chest lead records mainly the
electrical potential of the cardiac musculature immediately beneath the electrode. Therefore,
relatively minute abnormalities in the ventricles, particularly in the anterior ventricular wall, can
cause marked changes in the electrocardiograms recorded from individual chest leads. In
leads V1 and V2, the QRS recordings of the normal heart are mainly negative because, as
shown in Figure, the chest electrode in these leads is nearer to the base of the heart than to
the apex, and the base of the heart is the direction of electronegativity during most of the
ventricular depolarization process. Conversely, the QRS complexes in leads V4, V5, and V6
are mainly positive because the chest electrode in these leads is nearer the heart apex, which
is the direction of electropositivity during most of depolarization.

LEAD POSITIVE ELECTRODE HEART SURFACE

VIEWED
V1 Right side of sternum, fourth intercostal Septum
space
V2 Left side of sternum, fourth intercostal space Septum
V3 Midway between V2 & V4 Anterior
V4 Left midclavicular line, fifth intercostal space Anterior
V5 Left anterior axillary line; same level as V4 Lateral
V6 Left midaxillary line; same level as V4 Lateral

The Normal ECG

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When
the cardiac

impulse passes through the heart,electrical current also spreads from the heart into the
adjacent tissues surrounding the heart. A small portion of the current spreads all the way to
the surface of the body. If electrodes are placed on the skin on opposite sides of the heart,
electrical potentials generated by the current can be recorded; the recording is known as an
electrocardiogram. A normal electrocardiogram for two beats of the heart is shown in Figure
1.

Figure 1

The normal electrocardiogram (see Figure 1) is composed of a P wave, a QRS complex, and
a T wave. The QRS complex is often, but not always, three separate waves: the Q wave, the
R wave, and the S wave. The P wave is caused by electrical potentials generated when the
atria depolarize before atrial contraction begins. The QRS complex is caused by potentials
generated when the ventricles depolarize before contraction, that is, as the depolarization
wave spreads through the ventricles. Therefore, both the P wave and the components of the
QRS complex are depolarization waves.

The T wave is caused by potentials generated as the

ventricles recover from the state of depolarization. This process normally occurs in ventricular
muscle 0.25 to 0.35 second after depolarization, and the T wave is known as a repolarization
wave.Thus, the electrocardiogram is composed of both depolarization and repolarization
waves. The distinction between depolarization waves and repolarization waves is so
important in electrocardiography that further clarification is necessary.

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Voltage and Time Calibration of the Electrocardiogram

All recordings of electrocardiograms are made with appropriate calibration lines on the
recording paper. Either these calibration lines are already ruled on the paper, as is the case
when a pen recorder is used, or they are recorded on the paper at the same time that the
electrocardiogram is recorded, which is the case with the photographic types of
electrocardiographs.
As shown in Figure 2, the horizontal calibration lines are arranged so that 10 of the small line
divisions upward or downward in the standard electrocardiogram represent 1 millivolt, with
positivity in the upward direction and negativity in the downward direction.

Figure 2.

The vertical lines on the electrocardiogram are time calibration lines. A typical electrocardiogram is run at a
paper speed of 25 millimeters per second, although faster speeds are sometimes used. Therefore, each 25
millimeters in the horizontal direction is 1 second, and each 5-millimeter segment, indicated by the dark vertical
lines, represents 0.20 second. The 0.20-second intervals are then broken into five smaller intervals by thin lines,
each of which represents 0.04 second.

Normal Voltages in the Electrocardiogram.

The recorded voltages of the waves in the normal electrocardiogram depend on the manner in
which the electrodes are applied to the surface of the body and how close the electrodes are
to the heart. When one electrodeis placed directly over the ventricles and a second electrode
is placed elsewhere on the body remote from the heart, the voltage of the QRS complex may
be as great as 3 to 4 millivolts. Even this voltage is small in comparison with the monophasic
action potential of 110 millivolts recorded directly at the heart muscle membrane. When
electrocardiograms are recorded from electrodes on the two arms or on one arm and one leg,
the voltage of the QRS complex usually is 1.0 to 1.5 millivolts from the top of the R wave to
the bottom of the S wave; the voltage of the P wave is between 0.1 and 0.3 millivolts; and that
of the T wave is between 0.2 and 0.3 millivolts.

P-Q or P-R Interval. The time between the beginning of the P wave and the beginning of the
QRS complex is the interval between the beginning of electrical excitation of the atria and the
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beginning of excitation of the ventricles. This period is called the P-Q interval. The normal P-Q
interval is about 0.16 second. (Often this interval is called the P-R interval because the Q
wave is likely to be absent.).(See figure 3.)

Q-T Interval. Contraction of the ventricle lasts almost from the beginning of the Q wave (or R
wave, if the Q wave is absent) to the end of the T wave. This interval is called the Q-T interval
and ordinarily is about 0.35 second. (See figure 3.)

Figure 3.

STEPS IN ANALYZING THE RHYTHM

Step 1. Assess the rhythm
Regular Rhythm – constant R-R interval
Irregular Rhythm – irregular R-R interval
Step 2. Determine the rate
a. 6 second strip method
- For Regular and Irregular Rhythms
- Count the number of R within the 30 large boxes then multiply the R waves by 10
b. 1500 method
- For Regular Rhythms only
- Count the small boxes within R-R interval then use 1500 as the numerator and the
small boxes as the denominator
c. Box method
- For Regular Rhythms only
- Count the small boxes within R-R interval then use 1500 as the numerator and the
small boxes as the denominator
Step 3. Assess the P wave
- Reflects the atrial activity.
- Duration: 0.06-0.10 secs
- Amplitude: 2-2.5 mm

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- Location: Proceeds the QRS
- Configuration: Usually upright & rounded.
- Must be uniform with other cycles
Step 4. Assess the PR Interval
- Duration: 0.12-0.20 secs
- Must be constant with other cycles
Step 5. Assess the QRS Complex
- Duration: 0.12 seconds or less
- Assess the Height of R waves if it is uniform
Step 6. Assess T wave
Step 7. Assess the QT Interval
Step 8. Identify the Origin of Impulse
a. Sinus Mechanism
- present and normal P-QRS-T
b. Atrial Mechanism
- Present P waves but with abnormalities/not uniform with other P waves
c. Junctional Mechanism
- Absent or inverted P waves or Retrograded in QRS & normal QRS complex
d. Ventricular Mechanism
- Absent of P wave & Wide QRS
e. AV/Heart Blocks
- Prolonged duration of PR Interval
- Constant or irregular duration of PR interval
- Presence of drop beat of QRS

Step 9. Name the ECG tracing

 Origin + Rate
 Origin + Characteristic of Tracing

Step 10. Assess for ST Segment Elevations

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RHYTHM RECOGNITION

SINUS MECHANISM

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

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Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:

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T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

JUNCTIONAL MECHANISM

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

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 BASIC PRINCIPLES OF ECG
Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

VENTRICULAR MECHANISM

Rhythm:
Rate:
P wave:

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PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:

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T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:

QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:

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P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

ATRIAL MECHANISM

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:

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QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Atrioventricular/Heart Blocks

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 BASIC PRINCIPLES OF ECG
Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation

Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation

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 BASIC PRINCIPLES OF ECG
Rhythm:
Rate:
P wave:
PR Interval:
QRS complex:
T wave:
QT Interval:
Interpretation:

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