ECG INTERPRETATION:

the basics

Damrong Sukitpunyaroj,
Sukitpunyaroj MD
Perfect Heart Institue, Piyavate Hospital
 Overview
• Conduction Pathways
• Systematic Interpretation
• Common abnormalities in Critical Care
– Supraventricular arrhythmias
– Ventricular
Ventric lar arrh
arrhythmias
thmias
Conduction Pathways
Conduction Pathways
P wave = atrial depolarisation.
PR Interval = impulse from atria
to ventricles.
ventricles
QRS complex = ventricular
depolarisation.
ST segment = isoelectric - part
of repolarisation.
T wave = usually same direction
as QRS - ventricular
repolarisation.
QT Interval = This interval
spans the onset of
depolarisation to the
completion of repolarization
of the ventricles.
ventricles
Interpretation
 Interpretation
1. Rate = Number of P’s (atrial) R’s (ventricular) per
minute (6 second [30 squares] X 10 = minute rate).
P rate: 8 x 10 = 80 R rate: 8 x 10 = 80

2. Rhythm = Regular or irregular. Map P-P and R-R

intervals.
intervals
 Interpretation
3 P wave = present,
3. t 1 per QRS,
QRS shape,
h d
duration,
ti voltage.
lt

4. P-R interval = length (0.12 - 0.2 sec = <1 big square), isoelectric.
 Interpretation
5. QRS = duration (0.06 - 0.10 ), voltage, q or Q waves

6. ST Segment = shape, isoelectric with PR segment

 Interpretation
7. T wave = shape, direction

8. QT interval = length (R-R/2 or QTc <0.40 sec)

 Abnormalities:
Supraventricular arrhythmias
• Atrial Fibrillation
• Atrial Flutter
• Supraventricular Tachycardia (SVT)

Abnormalities:
V t i l arrhythmias
Ventricular h th i
• Premature Ventricular Complexes (PVCs)
• Ventricular tachycardia (VT)
Conduction Pathways
Supraventricular
Narrow QRS complex

Ventricular
V ti l
Wide QRS complex
 Abnormalities:
atrial fibrillation
Rhythm: Irregular
Rate: A: 350 – 650; V: varies
P: poorly defined
P-R: N/A
QRS: narrow complex
S-T: normal
T: normal
Q-T: normal
 Abnormalities:
atrial flutter
Rhythm: Regular / Irregular
Rate: A: 220 – 430; V: <300 (2:1, 3:1 or sometimes 4:1)
P: Saw toothed appearance
P-R: N/A
QRS: narrow complex
S-T: normal
T: normal
Q-T: normal
 Abnormalities:
supraventricular tachycardia (SVT)
Rhythm: Regular
Rate: >100
P: not visible
P-R: not defined
QRS: narrow complex
S-T: depression (sometimes)
T: normal
Q-T: prolonged (sometimes)
 Abnormalities:
premature ventricular complexes
Examples
Examples
ECG INTERPRETATION:
12 Lead
 Overview
• Lead Placement
• Axis
• Common abnormalities in Critical Care
– Heart block
– Bundle
B ndle branch blocks
– Life threatening arrhythmias
 Lead Placement
V1 = 4th ICS right
i ht sternum
t
V2 = 4th ICS left sternum
V3 = midway between V2
and V4
V4 = 5th ICS midclavicular
V5 = between V4 and V6
anterior auxiliary line
V6 = midauxillary line
lateral to V4 and V5
 Lead Placement
• Electrical activity towards = ↑
• Electrical activity away = ↓
Lead Placement
 Axis
• The direction of an ECG
waveform in the frontal
plane measured in
degrees
p
• Represents the flow of
the majority of electrical
activity
• Normally
N ll the
h QRS
complex is measured
 Axis
• Each lead has its own axis
 Lead Placement
Standard Leads (bipolar) Chestt L
Ch Leads
d (unipolar)
• I - lateral wall • V1 - septal wall
• II - inferior wall • V2 - septal wall
• III - inferior wall • V3 - anterior wall
• V4 - anterior wall
• V5 - lateral wall
Augmented leads (unipolar)
• V6 - lateral wall
• aVR - no mans land
• aVL - lateral wall
• aVF - inferior wall
 Lead Placement
No-mans land, inferior, lateral, anterior, septal,
 Abnormalities:
bundle branch blocks
• QRS widened, greater than 0.12 secs
• Change in axis
• Difficult to interpret ECG
• Right or Left
• Normal P wave
• Followed by a T wave
 Abnormalities:
right bundle branch blocks
• Indicates conduction
problems in the right side of
the heart
• May be normal in healthy
people
• R wave in V1, ie two R waves
in V1
• Q wave in V6
• Lead V1 cats ears
 Abnormalities:
left bundle branch blocks
• Always indicates heart
disease, usually of the left
side of the heart
• Hard to interpret an ECG with
LBBB
• Lead V1 Q wave and an S
wave
• Lead V6 an R wave followed
byy another R wave
• Lead V6 Rabbit ears
 Abnormalities:
heart block
• SA block (exit block)
• 1st degree AV block
• 2nd degree AV block
– Wenckeback (type I)
– Mobitz
Mobit (type
(t pe II)
• 3rd degree AV block
 Abnormalities:
heart block – SA block
 Abnormalities:
heart block – 1st degree AV
 Abnormalities:
heart block – 2nd degree AV
W k b k
Wenkeback

Mobitz
 Abnormalities:
heart block – 3rd degree AV
 Abnormalities:
life threatening arrhythmias
• Ventricular Tachycardia
• Ventricular Fibrillation
• Asystole
 Abnormalities:
life threatening arrhythmias - VT
 Abnormalities:
life threatening arrhythmias - VF
 Abnormalities:
life threatening arrhythmias – Asystole
Examples
Examples