Electrocardiograms

Cindy Chan, MD

 Electrocardiograms (EKGs or ECGs) display the electrical activity of the heart

 One electrode is placed on each arm One electrode is placed on a leg (sometimes, one on each leg) Six electrodes are placed across the chest wall (from right sternal border to left midaxillary line)

 Each lead has its own an axis (or direction) Each lead then reads the electrical current relative to its axis
Imagine that youre standing at the receiving end of the axis, watching the current If the current is coming toward you, the EKG deflection is upward (ie. positive) If the current is going away from you, the EKG deflection is downward (ie. negative)

 So, if there is no deflection on the EKG, there are two explanations:

No current The current is perpendicular to the lead axis

Precordium

Up
Right arm

Left arm

Down

avR

avL

avF

avR

avL

avF

Inferior leads

avR

avL

1
Lateral leads

avF

Rate
0.04 sec (or 40 msec) = small box 0.2 sec = (small box) X 5 = large box 0.2 sec = 1/300th of minute
So, if QRSs are 1 large box apart, rate is 300 If QRSs are 2 large boxes apart, rate is 150 (300/2) If QRSs are 3 large boxes apart, rate is 100 (300/3), etc.

MEMORIZE: 300, 150, 100, 75, 60, 50 Bradycardia: (cycles/10 sec strip) X 6

Rhythm

P before QRS

Rhythm
1. Sinus arrhythmia - varies with respiration 2. Wandering pacemaker - varying P waves 3. Multifocal atrial tachycardia - varying P waves + rate > 100 4. Atrial fibrillation - no P waves + irregular ventricular rhythm 5. Escape beats - from automaticity focus after pause (atrial, junctional, ventricular, all can lead to escape rhythm) 6. Premature beats - from irritable automaticity focus (atrial, junctional, ventricular)

Rhythm
Tachyarrhythmias: 1. Sinus Tach 2. Supraventricular tachycardia (SVT) (paroxysmal atrial, junctional, or ventricular tachycardia; with or without block) - rate 150-250 3. Atrial flutter - "saw-tooth", from single atrial focus, rate 250-350 4. Ventricular flutter - "sine waves", rate 250-350 5. Atrial fibrillation with rapid ventricular rate (RVR) - from multiple atrial foci, no P waves + irregular ventricular rhythm, rate 350-450 6. Ventricular Fibrillation - from multiple ventricular foci, erratic rhythm, rate 350-450

Rhythm
Bradyarrhythmias: 1. Sick sinus syndrome - with pauses 2. 1 AVB - prolonged PR interval 3. 2 AVB - ie. Wenckeback, Mobitz Type I, gradual lengthening of PR until dropped QRS 4. 2 AVB - ie. Mobitz Type II, sporadic dropped QRS 5. 3 AVB - ie. Complete HB, complete disassociation of P and QRS

Rhythm
Bundle branch blocks: RBBB: Prolonged QRS upright in V1 LBBB: Prolonged QRS downwards in V1 L anterior hemiblock: LAD, R1S3 (large R wave in lead I, large S wave in lead III) L posterior hemiblock: RAD, S1R3 (large S wave in lead I, large R wave in lead III)

Axis
Normal axis is -30 to +105 degrees Normal axis if upright in leads I and aVF I downwards, aVF upright: RAD I downwards, aVF downwards: extreme RAD I upright, aVF downards: LAD

LAD: left axis deviation RAD: right axis deviation

avR
Extreme RAD
LAD

avL

1 0
RAD
Normal axis

avF
90

Intervals
Lead II tends to be the easiest/clearest to read..

QRS
ST T

P
P wave

Normal

QRS
ST T

P
PR interval

Normal

QRS
ST T

P
QRS complex

Normal

QRS
ST T

P
QT interval

Normal

Intervals
P wave: <0.10 sec PR interval: 0.12-0.2 sec QRS: 0.05-0.10 sec QT interval: depends on the rate, but generally <0.5 sec

Intervals quick method

P wave: less than 2.5 small boxes PR interval: 3-5 small boxes QRS: 1-2.5 small boxes QT interval: <1/2 RR interval
Corrected QT: QT/RR

Hypertrophy
1. R atrial hypertrophy: P height > 2.5 mm (right high) 2. L atrial hypertrophy: P length >0.12 sec (left long) 3. R Ventricular Hypertrophy (RVH) criteria:
RAD with widened QRS Persistent S wave in V5, V6 R > S in V1, but progressively smaller from V1-V6

4. L Ventricular Hypertrophy (LVH) criteria:

LAD with widened QRS S in V1 + R in V5 = >35 mm R in aVL > 11 mm

Infarction
Q waves: 1 mm wide, 1/3 amplitude of QRS Inverted T waves: ischemia ST segment elevation: infarct
Anterior leads: V1, V2, V3, V4, V5 Lateral: 1, aVL, V6 Inferior: II, III, aVF

QRS
ST T

P
ST segment

Normal

Anterior

Right

Left

Posterior

RV

LV

Anterior Anterioseptum

RV
Inferioseptum

Lateral

LV

Inferio-Posterior

Anterioseptum

Anterior

RV
Inferoseptum
Inferioseptum

Lateral

LV

Inferio-Posterior

LAD

RCA

LCx

LATERAL WALL

Circumflex
ANTERIOR WALL

LAD
POSTERIOR WALL

RCA

Frontal plane
avR avL

LATERAL 1 WALL

Circumflex
2 avF

ANTERIOR 3 WALL

inferior Dead tissue

Leads 2, 3 and avF ST POSTERIOR WALL and then Q waves

RCA

LAD

Inferior MI

Significant Q waves Occlusion of RCA in 2,3 and avF

INFERIOR = RCA

Anterioseptum

Anterior

RV
Inferioseptum

Lateral

LV

Inferio-Posterior

LAD EKG: V1-V5

RCA 2,3,avF

LCx 1,avL,V6

Lets look at a few EKGs..