Kalaivani Suppiah

An electrocardiogram (ECG) is a
graphic recording of the electrical
activity of the heart. It is used as a
diagnostic tool to assess cardiac
function.

An ECG can be recorded with 12, 15, and

sometimes even 18 leads. However, the 12 lead
ECG is the most commonly used tool to diagnose
cardiac conduction abnormalities, arrhythmias,
myocardial infarction and ischemia.

Lets look at a normal conduction

pathway:

The SA Node is the primary

pacemaker for the heart at
60-100 beats/minute
The AV Node is the back-up
pacemaker of the heart at
40-60 beats/ minute

The Ventricles (bundle

branches & Purkinje fibers)
are the last resort and maintain
an
intrinsic rate of only
20-40 beats/minute

Now, lets correlate the mechanical

activity with the electrical activity.

Atrial
Systol
e

Ventricular
Systole

Atria
depolari
ze

Figure 5

Ventricles
depolarize

Ventricl
es
repolari
ze

Depolarization occurs when sodium

channels open fast and the inside of the
membrane becomes less negative (electrical
stimulation).
This is manifested as the P wave on an ECG,
which signifies atrial muscle depolarization.

The plateau that immediately follows

the P wave represents atrial
systole, when calcium channels
open slowly and potassium channels
close (at this time mechanical
contraction of the atria takes place).

The PR interval on an ECG reflects

conduction of an electrical impulse from
the SA node through the AV node.
PR = 0.12 0.20 seconds

Figure 6

The QRS complex of an ECG

reflects ventricular muscle
depolarization (the electrical
impulse moves through the Bundle
of His, the left and right bundle
branches and Purkinje fibers).
QRS = 0.08 0.10 seconds

The QT interval measures the

time from the start of
ventricular depolarization to the
end of ventricular repolarization.
QT interval = < 0.43 seconds
or
of the R-to-R interval

The ST segment reflects the

early ventricular
repolarization and lasts from
the end of the QRS complex
to the beginning of the T
wave.

The T-wave on an ECG

reflects ventricular muscle
repolarization (when the
cells regain a negative charge
- the resting state) and
mechanical relaxation, which
is also known as diastole.

Keep in mind how electricity flows

When an electrical current moves toward
a positive electrode, the deflection on
the ECG strip will be positive (up).
When an electrical current moves toward
a negative electrode, the deflection on
the ECG strip will be negative(down).

ST Segment Changes
Any elevation in the ST

segment that is greater than

two small boxes is indicative of
myocardial injury.

Any ST segment depression

greater than two small boxes

indicates myocardial ischemia.

Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV

Every 3 seconds (15 large boxes) is marked by

a vertical line.
This helps when calculating the heart rate.
NOTE: the following strips are not marked but
all are 6 seconds long

Waveforms

ECG Distributions
Anteroseptal: V1, V2, V3, V4
Anterior: V1V4
Anterolateral: V4V6, I, aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF, and V5

and V6

Rhythm
Sinus
Originating from SA node
P wave before every QRS
P wave in same direction as QRS

Rate
Whats the normal heart rate
for an adult human being?

60 100 beats/ minute

Is the rate in your strip too
fast or too slow?

In terms of rate computation, heart

rate generally refers to the number
of ventricular contractions that occur
in 60 seconds or one minute.
When calculating rates, if there is a
P-wave in front of every R-wave, the
atrial and ventricular rates will be the
same.
.

Atrial rate can be calculated by

measuring the interval of time
between P-waves (the P-to-P
intervals).
Ventricular rate can be
calculated by measuring the time
intervals between QRS
complexes (the R-to-R intervals).

There are instances, such as 2nd

and 3rd degree AV block, in
which the atrial rate and
ventricular rates are different.
This is why it is important to
know how to determine both
atrial and ventricular rates.

Rules
1.Count the number of QRSs in a 6 -

second strip, then multiply that

number by 10.
2.Determine the time between R-R

intervals, then divide that number by

60.
For example:
40 (20 small boxes x 0.04
seconds each)
= 50 beats per minute

Rules
Normal Heart rate for an adult = 60
-100 bpm
This means that 3 to 5 large blocks
should exist between R R intervals.
Bradycardia = more than 5 large
blocks
Tachycardia = less than 3 large
blocks

Figure 8

Ischemia
Usually indicated by ST changes
Elevation = Acute infarction
Depression = Ischemia
Can manifest as T wave changes
Remote ischemia shown by q waves

What is the diagnosis?

Acute inferior MI with ST elevation
II, III, aVF

in leads

Inferolateral MI

ST elevation II, III, aVF

ST depression in aVL, V1-V3 are reciprocal changes

Left Bundle Branch Block

Monophasic R wave in I and V6, QRS > 0.12

sec
Loss of R wave in precordial leads
QRS T wave discordance I, V1, V6

Right Bundle Branch

Block

V1: RSR prime pattern with inverted T wave

V6: Wide deep slurred S wave

Hyperkalemia

Tall, narrow and symmetric T waves

Hypokalemia

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

Supraventricular
Tachycardia
Retrograde P waves

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

Atrial Fibrillation

Figure 11

Rhythm: Atrial fibrillation is irregular and chaotic;

Ventricular rhythm is very irregular
Rate: Atrial is > 350 bpm; Ventricular is 120-200
bpm
P-waves: not consistent (they are fine and
fibrillating)
PR Interval: not measurable

Atrial Flutter

Figure 12

Rhythm: Atrial flutter is usually regular

Rate: Atrial is 250-350 bpm
Ventricular rate depends on AV
conduction
P-waves: characterized by saw tooth pattern
PR Interval: can not be determined; more
flutter
waves than QRS complexes

Ventricular Fibrillation

Figure 13

Rhythm: Totally erratic

VF Rate: 350-450 bpm
P-waves: none
QRS: none

Ventricular Tachycardia

Figure 14

aka The Widow-Maker

Rhythm: Typically regular, but can be irregular
Rate: 100 220 bpm
P-waves: can be present but have no correlation
to QRS complex
QRS: > 0.12 seconds with an odd, tomb stone
shape

3rd Degree AV Block = Complete

Heart Block

Figure 15

Rate: 40-60 bpm (narrow QRS and

junctional); 20-40 bpm (wide QRS and
ventricular)
P-waves: normal, but usually more Pwaves than QRSs

Asystole

Figure 16

In Asystole, there is no rate

because the person that
belongs to this rhythm is
DEAD!