BASIC ECG

DR UMUL KHAIR MOHAMAD

EMERGENCY PHYSICIAN
HOSPITAL KUALA LUMPUR
 OUTLINE

ECG

Axis

How to interpret
What Is An ECG?

The electrocardiogram (ECG) is a representation

of the electrical events of the cardiac cycle

Think of it as a map that shows the road traveled

by an electrical impulse
Conducting System
Pacemaker of The Heart

SA Node : Dominant pacemaker with an intrinsic

rate of 60-100 beats/min

AV Node : Back-up pacemaker with an intrinsic

rate of 40-60 beats/min

Ventricular cells : Back-up pacemaker with an

intrinsic rate of 20-45 beats/min
Pathology In ECG

Arrhythmias

Acute Coronary Syndrome

Heart Blocks

Pericarditis

Electrolyte Imbalance etc

Position Of The Leads
 ECG Paper

ECG paper speed : 25mm/sec

Voltage calibration 1 mV : 1 cm
ECG paper-standard calibration
Each small square : 1 mm
Each large square : 5 mm
Timing
1 small square : 0.04 sec
1 large square : 0.2 sec
25 small squares : 1 sec
5 large squares : 1 sec
 CARDIAC AXIS
Represents overall direction of the heart activity

Normal cardiac axis (-30 - +90 degrees)

RVH (right ventricle hypertrophy) axis swings

to the right

LVH (left ventricle hypertrophy) axis swings to

the left
The Quadrants Approach

QRS are up in I and AVF = normal

Arrangement of Leads In ECG
Anatomy Groups (Septum)
Anatomy Groups (Anterior)
Anatomy Groups (Lateral)
anatomy Groups (Inferior)
Anatomy Groups (Summary)
Interpretation of An ECG

Step 1 : Heart rate

Step 2 : Rhythm

Step 3 : P wave

Step 4 : PR interval

Step 5 : QRS Complex

Heart Rate

HR 60 - 100 : normal

HR > 100 : Tachycardia

HR < 60 : Bradycardia
Determining of Heart Rate

Rule of 300

10 second rule
Rule of 300

Count the number of big boxes between QRS

complexes, and divided into 300

For regular rhythm

10 Second Rule

Count the number of 30 big boxes

Then count how many R-R in 6 sec

Multiply to 10

For irregular rhythm

What Is The Heart Rate?

(300 / 6) = 50 bpm
What Is The Heart Rate?

(300 / 4) = 75 bpm
What Is The Heart Rate?

(300 / 1.5) = 200 bpm

What Is The Heart Rate?

11 X 10 = 110 bpm
Rhythm

Classified as regular or irregular rhythm

Sinus rhythm ;

originating from SA node

P wave before every QRS

P wave in same direction as QRS

Normal Sinus Rhythm
 Torsades de Pointes

Means twisting of the points.

An unusual variant of polymorphic VT that is associated w
with long QT interval.
P Wave
P-R Interval
 3 questions to ask :

1. Are PR interval < 0.12 sec?

2. Are PR interval > 0.2 sec?

3. Are PR interval constant across ECG strip?

BLOCKS

AV blocks
First degree block
PR interval fixed and > 0.2 sec
Second degree block, Mobitz type 1
PR gradually lengthened, then drop QRS
Second degree block, Mobitz type 2
PR fixed, but drop QRS randomly
Third degree block
PR and QRS dissociated
What Is The Rhythm
What Is The Rhythm

First degree heart block

PR is fixed and longer than 0.2 seconds
What Is The Rhythm
What Is The Rhythm

Type 1 second degree block (Wackenbach)

What Is The Rhythm
What Is The Rhythm

Dropped QRS

Type 2 second degree block

What Is The Rhythm
What Is The Rhythm

3rd Degree Heart (Complete)

 QRS Complex

3 questions to ask :
1. Are QRS duration > 0.12 seconds (wide)? If so,
the complex may be ventricular in origin
2. Are QRS duration < 0.12 seconds (narrow)? If so,
the complex is most likely supraventricular in origin
3. Are QRS complexes similar in appearance across
the ECG strip?
 Lets Practice
The sample EKGs were obtained from the following text:
Normal Sinus Rhythm

Mattu, 2003
First Degree Heart Block

PR interval >200ms
 First Degree Heart Block,
Mobitz Type I (Wenckebach)

PR progressively lengthens until QRS drops

Second Degree Heart Block, Mobitz
Type II

PR interval fixed, QRS dropped intermittently

3 rd Degree Heart Block

67
 Hypokalemia

U waves
Can also see PVCs, ST depression, small T waves
 Hyperkalemia

Tall, narrow and symmetric T waves

 Torsades de Pointes

Notice twisting pattern

Treatment: Magnesium 2 grams IV
Supraventricular Tachycardia

Retrograde P waves

Narrow complex, regular; retrograde P waves, rate <220

Ventricular Tachycardia
Inferior Myocardial Infarction
Anteroseptolateral Myocardial Infraction
 Torsades de Pointes

Notice twisting pattern

Treatment: Magnesium 2 grams IV
Ventricular Fibrillation
Asystole