BASIC

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic

recording of the electrical potentials produced by
the cardiac tissue.

Electrical impulse formation occurs within the

conduction system of the heart.
Excitation of the muscle fibers throughout the
myocardium results in cardiac contraction.

The ECG is recorded by applying electrodes to

various locations on the body surface and
connecting them to a recording apparatus.

ELECTROCARDIOGRAM

Clinical Value of the ECG

Atrial enlargement and ventricular hypertrophy

Myocardial ischemia and infarction
Pericarditis
Systemic diseases that affect the heart
Determination of the effect of cardiac drugs
Disturbances in electrolyte balance
Evaluation of function of cardiac pacemakers

ELECTROCARDIOGRAM

Considerable diagnostic value

Conduction delay of atrial and ventricular

electrical impulses
Determination of the origin and behavior of
dysrhythmias

12 LEAD ECG

Limb Leads
RA Red Right arm
LA Yellow Left arm
LL Green Left leg
RL Black Right leg

Chest Leads
V1
V2
V3
V4
V5
V6

Red 4th ICS RPSB

Yellow 4th ICS LPSB
Green Midway between V2 and V4
Brown 5th ICS LMCL
Black LAAL Lateral & horizontal to V4
Violet LMAL Lateral & horizontal to V4

ELECTROPHYSIOLOGY OF THE
HEART

Four Electrophysiologic Events Involved in

the Genesis of the ECG

Impulse formation
Transmission of the impulse
Depolarization
Repolarization

CONDUCTION SYSTEM OF THE

HEART
SA Node
Atrial Muscle
AV Node
Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle

ECG PAPER

THE NORMAL
ELECTROCARDIOGRAM

P wave

PR segment

Represents the duration of atrioventricular (AV)

conduction

QRS complex

Generated by activation of the atria

Produced by activation of both ventricles

ST-T wave

Reflects ventricular recovery

STANDARD 12 LEAD ECG

The P wave

Atrial activation
Height < 0.2 mV (2 mm)
Duration < 0.12 sec

STANDARD 12 LEAD ECG

P-R Interval

Intraatrial, internodal, His purkinje conduction

Duration 0.12 to 0.20 or 0.22 sec

STANDARD 12 LEAD ECG

The QRS Complex

Ventricular activation
Duration of 100 msec

STANDARD 12 LEAD ECG

The ST-segment

Phase 2 of transmembrane potential

Isoelectric in normal subjects

STANDARD 12 LEAD ECG

The T wave

Upright after the age of 16

Juvenile T wave

STANDARD 12 LEAD ECG

The U wave

Surface reflection of negative after potential

Repolarization of Purkinje fibers
Ventricular relaxation

STANDARD 12 LEAD ECG

The QT Interval

From beginning of QRS to end of T wave

Reflects the duration of depolarization and
repolarization
Bezett: Q-Tc Interval = Q-T/ R-R

ANALYZING A RHYTHM STRIP

Rate
Rhythm
Axis
P wave
PR Interval
QRS Complex
T wave
Q-T Interval

ANALYZING A RHYTHM STRIP

What is the rate?

To determine the ventricular rate,measure the

distance between 2 consecutive R-waves (RR interval)
To determine the atrial rate, measure the
distance between 2 consecutive P-waves (PP interval)

What Is The Rate?

Ventricular Rate

Small squares (R-R Interval) / 1500

Big squares (R-R Interval) / 300

What Is The Rate?

Sinus rhythm

Atrial Fibrillation

QRS complexes in 6-sec strip X 10

ANALYZING A RHYTHM STRIP

What Is The Axis?

Normal

Left axis

0 (-90)

Right axis

AVL

0 (+90)

(+90) (+180)

Extreme axis

AVR

(-90) (-180)

AVF

What Is The Axis?

10

AVL

Lead I

AVR

10

AVF

AVF

ANALYZING A RHYTHM STRIP

Is the rhythm regular or irregular?

To determine if the ventricular rhythm is regular or

irregular, measure the distance between 2
consecutive R-R intervals and compare that distance
with the other R-R intervals.
For atrial rhythm, measure the distance between 2
consecutive P-P intervals.
Generally, a variation of up to 0.12 seconds (3 small
boxes) is acceptable. The slower the heart rate, the
more acceptable the variation.

ANALYZING A RHYTHM STRIP

Is there 1 P wave before each QRS?

Are P waves present and uniform in

appearance?
Is there a P wave before each QRS or are
there P waves that are not followed by
QRS complexes?
Is the atrial activity occurring so rapidly that
there are more atrial beats than QRS
complexes?

ANALYZING A RHYTHM STRIP

Is the PR interval within normal limits?

If the PR interval is less than 0.12 or more

than 0.20 second, conduction followed an
abnormal pathway or the impulse was
delayed in the area of the AV node.
Is the PR interval of conducted beats
constant or does it vary?

ANALYZING A RHYTHM STRIP

Is the QRS narrow or wide?

What is the duration of the QRS complex?

If it is 0.10 second or less (narrow), it is
presumed to be supraventricular in
origin.
If it is greater than 0.12 second (wide), it
is probably ventricular in origin.
Do the QRSs occur uniformly throughout
the strip?

ANALYZING A RHYTHM STRIP

Interpret the rhythm

Specifying the site where the dysrhythmia

originated (sinus), the mechanism
(bradycardia), and the vetnricular rate.
For example, sinus bradycardia with a
ventricular response (rate) of 38/min.

Segmental Localization by ECG

Localization
I, AVL

High lateral

II, III, AVF

AVL

Inferior

AVR

AVF

Segmental Localization by ECG

Localization
V1,V2

V3,V4

Apicolateral

V1-V3 or V4

Anterior

V5,V6

Septal

Anteroseptal

V3 or V4-V6

Anterolateral

V1-V6 Extensive anterior

I,AVL,V5,V6 - Lateral

NORMAL SINUS RHYTHM

Rate
Rhythm

P waves

PR interval
QRS

60-100 beats per minute

Atrial regular
Ventricular regular
Uniform in appearance, upright, normal
shape, one preceding each QRS complex
0.12-0.20 second
0.10 second or less. If greater than 0.10
second in duration, the QRS is termed
wide since the existence of a bundle
branch block or other intraventricular
conduction defect cannot be accurately
detected in a single-lead.

Sinus Rhythms
Normal Sinus Rhythm
Rate
Rhythm
P waves
PR interval
QRS

60-100 beats per minute

Atrial regular
Ventricular regular
Uniform in appearance, upright, normal shape, one
preceding each QRS complex
0.12-0.20 second
0.10 second or less. If greater than 0.10 second in
duration, the QRS is termed wide since the
existence of a bundle branch block or other
intraventricular conduction defect cannot be
accurately detected in a single-lead.

Sinus Rhythms
Sinus Bradycardia
Rate
Rhythm
P waves
PR interval
QRS

Less than 60 beats per minute

Atrial regular
Ventricular regular
Uniform in appearance, upright, normal
shape, one preceding each QRS
complex
0.12-0.20 second
Usually 0.10 second or less

Sinus Rhythms
Sinus Tachycardia
Rate
Rhythm
P waves
PR interval
QRS

Usually 100-160 beats per minute

Atrial regular
Ventricular regular
Uniform in appearance, upright, normal
shape, one preceding each QRS
complex
0.12-0.20 second
Usually 0.10 second or less

Sinus Rhythms
Normal Heart Rates in Children
Age
Neonate
Infant (6 mos)
Toddler
Preschooler
School-aged
Adolescent

Awake Heart
Rate
(per minute)
100-180
100-160
80-110
70-110
65-110
60-90

Sleeping Heart
Rate
(per minute)
80-160
75-160
60-90
60-90
60-90
50-90

Sinus Rhythms
Sinus Dysrhythmia (Arrhythmia)
Rate
Rhythm
P waves
PR interval
QRS

Usually 100-160 beats per minute but may

be faster or slower
Irregular (R-R intervals shorten during
inspiration and lengthen during
expiration)
Uniform in appearance, upright, normal
shape, one preceding each QRS
complex
0.12-0.20 second
Usually 0.10 second or less

Sinus Rhythms
Sinoatrial (SA) Block
Rate
Rhythm
P waves
PR interval
QRS

Usually normal but varies because of

pause
Irregular the pause is the same as (or an
exact multiple of) the distance between
two other P-P intervals
Uniform in appearance, upright, normal
shape, one preceding each QRS
complex
0.12-0.20 second
Usually 0.10 second or less

Sinus Rhythms
Sinus Arrest
Rate
Rhythm

P waves
PR interval
QRS

Usually normal but varies because of the

pause
Irregular the pause is of undetermined
length (more than one PQRST complex
is omitted) and is not the same distance
as other P-P intervals.
Uniform in appearance, upright, normal
shape, one preceding each QRS
complex
0.12-0.20 second
Usually 0.10 second or less

Atrial Rhythms
Premature Atrial Complexes
Early (premature) P waves
Upright P waves that differ in shape from normal
sinus P waves in Lead II

1.
2.

3.

P waves may be biphasic (partly positive, partly

negative), flattened, notched or pointed

The early P wave may or may not be followed by a

QRS complex

Atrial Rhythms
Premature Atrial Complexes (PACs)
Rate
Rhythm
P waves
PR interval
QRS

Usually normal but depends on underlying rhythm

Essentially regular with premature beats
Premature
Differ from sinus P waves may be flattened, notched,
pointed, biphasic, or lost in the preceding T wave
Varies from 0.12-0.20 second when the pacemaker site
is near the SA node; 0.12 second when the
pacemaker site is nearer the AV junction
Usually less than 0.10 second but may be prolonged.
The QRS of the PAC is similar to those of the
underlying rhythm unless the PAC is abnormally
conducted.

Atrial Rhythms
Supraventricular Tachycardia
Rate
Rhythm
P waves

PR interval

QRS

150-250 beats per minute

Regular
Atrial P waves may be seen which differ from sinus P
waves (may be flattened, notched, pointed, or
biphasic). P waves are usually identifiable at the
lower end of the rate range but are seldom
identifiable at rates above 200. May be lost in the
preceding T wave.
Usually not measurable because the P wave is difficult
to distinguish from the preceding T wave. If P waves
are seen, the RR interval will usually measure 0.120.20 second.
Less than 0.10 second unless an intraventricular
conduction defect exists.

Atrial Rhythms
The Unstable Patient
Signs and Symptoms

Shock

Chest pain

Hypotension

Shortness of breath

Pulmonary congestion

Congestive heart failure

Acute myocardial infarction

Decreased level of consciousness

Atrial Rhythms
ELECTRICAL THERAPY Synchronized Countershock
Description and Purpose
Synchronized countershock reduces the potential for delivery of energy
during the vulnerable period of the T wave (relative refractory period).
A synchronizing circuit allows the delivery of a countershock to be
programmed. The machine searches for the peak of the QRS
complex (R wave deflection) and delivers the shock a few
milliseconds after the highest part of the R wave.
Indications:

Supraventricular tachycardia

Atrial fibrillation

Atrial flutter

Unstable ventricular tachycardia with pause

Atrial Rhythms
Wandering Atrial Pacemaker (Multiformed Atrial
Rhythm)
Rate
Rhythm
P waves

PR interval
QRS

60-100. If the rate is greater than 100 beats

per minute, the rhythm is termed multifocal
(or chaotic) atrial tachycardia.
Atrial irregular
Ventricular - irregular
Size, shape, and direction may change from
beat to beat. At least three different P waves
are required for a diagnosis of wandering
atrial pacemaker
Variable
Usually less than 0.10 second unless an
intraventricular conduction defect exists

Atrial Rhythms
Atrial Flutter
Rate

Rhythm
P waves
PR interval
QRS

Atrial rate 250-350 beats per minute; ventricular rate

variable determined by AV blockade. The ventricular
rate will usually not exceed 180 beats per minute due
to the intrinsic conduction rate of the AV junction.
Atrial regular
Ventricular may be regular or irregular
Not identifiable P waves; saw-toothed flutter waves
Not measurable
Usually less than 0.10 second but may be widened if
flutter waves are buried in the QRS complex or if an
intraventricular conduction defect exists.

Atrial Rhythms
Atrial Fribrillation
Rate
Atrial rate usually greater than 350-400 beats
per minute; ventricular rate variable
Rhythm
Ventricular rhythms usually very irregular; a
regular ventricular rhythm may occur
because of digitalis toxicity.
P waves
No identifiable P waves; fibrillatory waves
present. Erratic wavy baseline.
PR interval
Not measurable
QRS
Usually less than 0.10 second but may be
widened if an intraventricular conduction
defect exists.

Junctional Rhythms
Premature Junctional Complexes
Rate
Usually normal, but depends on the underlying
rhythm
Rhythm
Essentially regular with premature beats
P waves
May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III,
AVF
PR interval
If the P wave occurs before the QRS, the PR
interval will be usually less than or equal to
0.12 second. If no P wave occurs before the
QRS, there will be no PR interval.
QRS
Usually 0.10 second or less unless an
intraventricular conduction defect exists.

Junctional Rhythms
Junctional Escape Rhythm
Rate
40 to 60 beats per minute
Rhythm
Atrial and ventricular rhythm very regular
P waves
May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III,
AVF
PR interval
If the P wave occurs before the QRS, the PR
interval will be usually less than or equal to
0.12 second. If no P wave occurs before the
QRS, there will be no PR interval.
QRS
Usually 0.10 second or less unless an
intraventricular conduction defect exists.

Junctional Rhythms
Accelerated
Rate
Rhythm
P waves
PR interval

QRS

Junctional Rhythm
60 to 100 beats per minute
Atrial and ventricular rhythm very regular
May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III,
AVF
If the P wave occurs before the QRS, the PR
interval will be usually less than or equal to
0.12 second. If no P wave occurs before the
QRS, there will be no PR interval.
Usually 0.10 second or less unless an
intraventricular conduction defect exists.

Junctional Rhythms
Junctional Tachycardia
Rate
100 to 180 beats per minute
Rhythm
Atrial and ventricular rhythm very regular
P waves
May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III,
AVF
PR interval
If the P wave occurs before the QRS, the PR
interval will be usually less than or equal to
0.12 second. If no P wave occurs before the
QRS, there will be no PR interval.
QRS
Usually 0.10 second or less unless an
intraventricular conduction defect exists.

Ventricular Rhythms
Premature Ventricular Complexes
Rate
Usually normal but depends on the underlying
rhythm
Rhythm
Essentially regular with premature beats. If the
PVC is an interpolated PVC, the rhythm will
be regular.
P waves
There is no P wave associated with the PVC
PR interval
None with the PVCs because the ectopic beat
originates in the ventricle
QRS
Greater than 0.12 second.
Wide and bizarre.
T wave frequently in opposite direction of the
QRS complex.

Ventricular Rhythms
Patterns of PVCs
1.
2.
3.
4.
5.

Pairs (couplets) two sequential PVCs

Runs or bursts three or more sequential PVCs are
called vntricular tachycardia (VT)
Bigeminal PVCs (ventricular bigeminy) every other
beat is a PVC
Trigeminal PVCs (ventricular trigeminy) every third
beat is a PVC
Quadrigeminal PVCs (ventricular quadrigeminy)
every fourth beat is a PVC

Ventricular Rhythms
Common Causes of PVCs

Normal variant
Anxiety
Exercise
Hypoxia
Digitalis toxicity
Acid-base imbalance
Myocardial ischemia
Electrolyte imbalance (hypokalemia, hypocalcemia, hypercalcemia,
hypomagnesemia)
Congestive heart failure
Increased sympathetic tone
Acute myocardial infarction
Stimulants (alcohol, caffeine, tobacco)
Drugs (sympathomimetics, cyclic antidepressants, phenothiazines)

Ventricular Rhythms
Warning Dysrhythmias

Six or more PVCs per minute

PVCs that occurred in pairs (couplets) or in
runs or three or more (ventricular tachycardia)
PVCs that fell on the T wave of the preceding
beat (R-on T phenomenon)
PVCs that differed in shape (multiformed
PVCs)

Ventricular Rhythms
Idioventricular (Ventricular Escape) Rhythm
Rate
Rhythm
P waves
PR interval
QRS

Atrial not discernible, ventricular 20-40

beats per minute
Atrial not discernible
Ventricular essentially regular
Absent
None
Greater than 0.12 second.
T wave deflection is in the opposite
direction of the QRS.

Ventricular Rhythms
Accelerated Idioventricular Rhythm
Rate
Rhythm
P waves
PR interval
QRS

Atrial not discernible, ventricular 40-100

beats per minute
Atrial not discernible
Ventricular essentially regular
Absent
None
Greater than 0.12 second.
T wave deflection is in the opposite
direction of the QRS.

Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate
Atrial rate not discernible, ventricular rate 100250 beats per minute
Rhythm
Atrial rhythm not discernible
Ventricular rhythm is essentially regular
P waves
May be present or absent; if present they have
no set relationship to the QRS complexes
appearing between the QRSs at a rate
different from that of the VT.
PR interval
None
QRS
Greater than 0.12 second.
Often difficult to differentiate between the QRS
and the T wave.

Ventricular Rhythms
VENTRICULAR TACHYCARDIA - CAUSES

Hypoxia

Exercise

R-on T PVCs

Catecholamines

Digitalis toxicity

Myocardial ischemia

Acid-base imbalance

Electrolyte imbalance

Ventricular aneurysm

Coronary artery disease

Rheumatic heart disease

Acute myocardial infarction

CNS stimulants (cocaine, amphetamines)

Ventricular Rhythms
Torsades de Pointes (TdP)
Rate
Rhythm
P waves
PR interval
QRS

Atrial rate not discernible, ventricular rate

150-250 beats per minute
Atrial not discernible
Ventricular may be regular or irregular
None
None
Greater than 0.12 second.
Gradual alteration in the amplitude and
direction of the QRS

Ventricular Rhythms
Ventricular Fibrillation
Rate
Rhythm
P waves
PR interval
QRS

Cannot be determined since there are no

discernible waves or complexes to
measure
Rapid and chaotic with no pattern or
regularity
Not discernible
Not discernible
Not discernible

Ventricular Rhythms
Defibrillation (Unsynchronized Countershock)
Description and Purpose:
The purpose of defibrillation is to produce momentary
asystole. The shock attempts to completely depolarize the
myocardium and provide an opportunity for the natural
pacemaker centers of the heart to resume normal activity.
Defibrillation is a random delivery of energy there is no
relation of the discharge of energy to the cardiac cycle.
Indications:
Unstable ventricular tachycardia with a pulse
Pulseless ventricular tachycardia
Ventricular fibrillation
Sustained Torsades de Pointes

Ventricular Rhythms
Asystole
Rate
Rhythm
P waves
PR interval
QRS

Ventricular usually indiscernible but may

see some atrial activity.
Atrial may be discernible.
Ventricular indiscernible.
Usually not discernible
Not measurable
Absent

Ventricular Rhythms
Causes of Pulseless Electrical Activity
(MATCHx4ED)
Myocardial infarction (massive acute)
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypovolemia (most common cause)
Hypoxia
Hyperkalemia
Hypothermia
Embolus (massive pulmonary)
Drug overdoses (cyclic antidepressants, calcium channel
blockers, beta-blockers, digitalis)

Atrioventricular Blocks
First Degree AV Block
Rate
Rhythm
P waves
PR interval
QRS

Atrial and ventricular rates the same;

dependent upon underlying rhythm.
Atrial and ventricular regular
Normal in size and shape
Only one P wave before each QRS
Prolonged (greater than 0.20 second) but
constant
Usually 0.10 second or less unless an
intraventricular conduction exists

Atrioventricular Blocks
Second-Degree AV Block, Type I (Wenckebach)
Rate
Rhythm
P waves
PR interval

QRS

Atrial rate is greater than the ventricular rate.

Both are often within normal limits.
Atrial regular (Ps plot through)
Ventricular irregular.
Normal in size and shape. Some P waves are
not followed by a QRS complex (more Ps
than QRSs).
Lengthens with each cycle (although
lengthening may be very slight), until a P
wave appears without a QRS complex. The
PRI after the nonconducted beat.
Usually 0.10 second or less but is periodically
dropped.

Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate
Rhythm
P waves
PR interval

QRS

Atrial rate is greater than the ventricular rate.

Ventricular rate is often slow.
Atrial regular (Ps plot through)
Ventricular irregular.
Normal in size and shape. Some P waves are
not followed by a QRS complex (more Ps
than QRSs).
Within normal limits or prolonged but always
constant for the conducted beats. There may
be some shortening of the PRI that follows a
nonconducted P wave.
Usually 0.10 second or greater, periodically
absent after P waves.

Atrioventricular Blocks
Second-Degree AV Block, 2:1 Conduction
Rate
Rhythm
P waves
PR interval
QRS

Atrial rate is greater than the ventricular rate.

Atrial regular (Ps plot through)
Ventricular regular.
Normal in size and shape; every other P wave
is followed by a QRS complex (more Ps
than QRSs)
Constant
Within normal limits if the block occurs above
the bundle of His (probably type I); wide if
the block occurs at or below the bundle of
His (probably type II); absent after every
other P wave.

Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate
Atrial rate is greater than the ventricular rate.
The ventricular rate is determined by the
origin of the escape rhythm.
Rhythm
Atrial regular (Ps plot through). Ventricular
regular. There is no relationship between the
atrial and ventricular rhythm.
P waves
Normal in size and shape.
PR interval
None the atria and ventricles beat
independently of each other, thus there is no
true PR interval.
QRS
Narrow or broad depending on the location of
the escape pacemaker and the condition of
the intraventricular conduction system.
Narrow = junctional pacemaker; wide =
ventricular pacemaker.

Atrioventricular Blocks
Classification of AV Blocks
Ventricular
Rhythm
PR Interval
QRS Width

Ventricular
Rhythm
PR Interval

QRS Width

Second-Degree AV Block
Type I

Second-Degree AV Block
Type II

Irregular
Lengthening
Usually narrow

Irregular
Constant
Usually wide

Second-Degree AV Block, 2:1

Conduction

Complete (Third-Degree)
AV Block

Regular
Constant

Regular
None no relationship
between P waves and
QRS complexes
May be narrow or wide

May be narrow or wide

Chamber Enlargement

Right Atrial Enlargement

Tall peaked P wave >2.5 mm and normal width in lead II,
III, or AVF
Increased in the initial positive P wave in V1

Left Atrial Enlargement

Features:

Width of the P wave >

0.12 sec in lead II

Notched P wave

P terminal force is > 0.04

sec & >1mm tall

Lead V1 shows large

biphasic P wave with
wide terminal component

Leftward shift of P axis to

+45 and -30

Right Ventricular Hypertrophy

Sokolow-Lyon
R in V1 + S in V5-V6 >11 mm
R in V1 > 7mm
R:S ratio in V1 >1
RAD >+90 degrees

RVH

Left Ventricular Hypertrophy

Sokolow-Lyon
RV5 or RV6 + SV1 = 35 mm or greater
(Sokolow index) most widely used
R in aVL > 12 mm
R in aVF > 20 mm
R in I + S in III > 25 mm
S in V1 > 24 mm

Left Ventricular Hypertrophy

Ischemia/Infarction

Myocardial Infarction

ECG patterns in
Infarction

Ischemic zone

Injury zone

ST segment
depression
ST segment
elevation

Infarction zone

Large Q wave

Anatomical and ECG locations of

MI

Occlusion of the Left Anterior Descending Artery

(LAD)

ECG: AMI with prominent Q waves in V1-V4

Anatomical and ECG

locations of MI

Occlusion of the Left Circumflex Artery (LCx)

ECG: AMI with prominent Q waves in I, aVL, V5, V6

Anatomical and ECG

locations of MI

Occlusion of the Right Coronary Artery (RCA)

ECG: AMI with prominent Q waves in II, III, and aVF

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