ELECTROCARDIOGRAMM

ECG
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ECG
ECG

The first step in interpreting an ECG is the
explanation of a normal ECG.

To explain a normal ECG, we have to

know the electrical vectors and the leads
(electrods) toward which they are
directed.
 ECG


|nowing the fact that the heart beats as a single
cell, we can group many different vectors as one.
First, we need to know that the depolarization
vector has its head positive and its ³tail´ (end)
negative (for the cell from -80mV shifts to +30mV
during this process), recording thus, a positive
deflection when it goes toward a lead that is in
front of it. The repolarization vector has its head
negative and its tail positive (for the cell from +30mV shifts to -80mV),
recording thus a negative deflection.
So, all we need to know is the lead position and what does the vector
show to the lead (its head or its tail).
 ECG 


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ECG 

 
The impulse starts at the sino-atrial node
(SAN). From there it goes to both atria
[depolarization ± P wave],
meanwhile the same impulse starts
ventricular septum depolarization
[Q wave], main ventricular mass [R wave],
and the ventricle base [S wave]
depolarization.
T repolarization vector shows the
ventricle repolarization.
ECG P
Using D2 lead
I will explain how ECG waves
are formed

The electrical impulse starts at SAN and

spreads to both atria. The resultant vector
shows to D2 lead the positive head ±
thus, a positive deflection is recorded.
But, every atrium has its own vector that
shows to D2 lead the positive head. We
use this fact to explain the atrial
hypertrophy, both right and left. If P wave
is higher than 2.5 mm, we have atrial
hypertrophy.
Meanwhile the time of impulse
progression from SAN to AVN [PR
interval], shows the conduction time from
the atria to the ventricles ± if this is
greater than 0.2 seconds, then we have
conduction disorders.
ECG Q
-It represents ventricular
septum depolarization
-Since His bunch begins the
depolarization from the
bottom of the septum, it
spreads upwards. The vector
is directed upward, showing
to D2 lead the negative tail ±
thus, a negative deflection is
recorded, Q wave.
ECG R
- It represents the depolarization
of the main mass of the
ventricles
-The impulse that initially has
involved the septum, goes on
spreading in the main mass of
the ventricles. R vector is a
depolarization vector, thus it
spreads from the endocardium
to the epicardium. It shows to
D2 lead the positive head ± thus
a positive deflection is recorded,
R wave.
ECG S
-It represents the
depolarization of the ventricles
base.
-After the depolarization of the
main mass of the ventricles,
comes the base
depolarization. The S vector is
directed upwards, due to the
ventricle anatomy, showing to
the D2 the negative tail ± thus,
a negative deflection is
recorded, S wave.
 ˜

 
  

EKG QRS 



 
 
 
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EKG T
-It represents the ventricles
repolarization.
-The ventricles
repolarization occurs µen
block¶ from the epicardium
to the endocardium. The
repolarization vector has its
tail positive and its head
negative, thus a positive
deflection is redorded on D2.
-T wave has always the
same direction with P wave.
If not (T wave upside down
or inverted), then it is
myocardial ischemia.
ECG  



Now, this is how
an ECG looks like
on the vertical leads.
The vectors are the
same, with the same
directions ± the
only thing that is
different are the
leads position.
EKG  

 

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THE
I˜TERPRETATIO˜
TECG



THEI˜TERPRETATIO˜
When you hold an ECG letter in your hands, don¶t rush in making a
diagnosis. As for every examination, even here there is a order to
follow:
‡   

‡     
 ± Leads D1 and aVF
‡    

 
‡  
  
 
 
(T wave inversion, ST segment elevation, pathologic
Q waves)
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The quickest way to measure
the cardiac frequency is by
counting the big boxes that are
between two consecutive QRS
complexes; then we divide 300
by that number.
Example: the adjacent ECG has
4 big boxes between the two
consecutive QRS complexes.
So, 300:4=75 beats/min.
Frequency > 100 beats/minute
is called 


.
Frequency < 60 beats/minute is
called 


.
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The rhythm can be regular or irregular. The regularity is assessed by

looking at 3-4 consecutive beats and see if they are equivalent.

 

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 : every QRS complex is preceeded by a P
wave and the PR interval does not change from beat to beat.
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: there is not a P wave before each
QRS and the QRS complexes are narrow and regular (<0.12 sec)
  

Not every QRS is preceeded by a P wave. There are also different
PR interval lengths.

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R wave is
positive in
D1 and
negative
in aVF

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 S vector shows completely to V1
and V2 its negative tail.
R vector shows completely to V5
and V6 its positive head.




 This is why we have deep S
waves in V1 and V2, also high R
waves in V5 and V6.

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- Deep S wave in V1, V2
- High R wave in V5, V6
- R in aVL>12mm
- Sokolow-Lyon Criteria:



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S vector shows completely to V5
and V6 its negative tail.
R vector shows completely to V1
and V2 its positive head.




 This is why we have wide S
waves in V5 and V6, also wide R
waves in V1 and V2.

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Displacement of the atrial vectors
toward the left or the right side,
makes those vectors show completely
to D2 or V1 their heads or tails. So we
get a different P wave.

à  P>2.5 mm high in D2
(P pulmonale)  P in V1 begins with
a positive deflection and ends with a
negative one.
 à  P>3 mm wide in D2 and notched (P mitrale)  P wave in V1
has a more negative terminal deflection.
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Both left and right branch block can be ³normally´ found in the population.
Finding of a new left branch block should raise concerns and, if it is related
to an acute episode of chest pain, then it possibly indicates a myocardial
infarction. Both left and right branch block, maybe indicate an increased risk
for cardiovascular disease; however, they do not indicate for pacemaker
placement.
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ATRIALIRILLATIO˜

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The atrial fibrillation, can be:
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 ± up to 7 days
 ð   ± more than 7 days
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 ± failed or unatempted cardioversion
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ATRIALLUTTER


  
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VE˜TRICULARTACHYCARDIA
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 T wave represents the ventricle
depolarization. During ischemia, there
is a disruption of it, because the

I   muscle remains depolarized for a long

time. So, the repolarization vector
shows to the lead (electrode) a
negative tail, as if it was a
depolarization vector.


 
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ST segment represents the time

between systole (depolarization) and
diastole (repolarization) of the
ventricles. During ischemia there is a
disruption of this and the muscule
remains depolarized. So, the ST
segment shows elevation (+ electrical
charge). ST elevation denotes a
transmural ischemia (all muscle
thickness is involved), caused by a
thrombus. That is why we give
thrombolytics when there is a ST
elevation.
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It appears in the leads placed
on the infarction area, due to
the fact that the necrotic
muscle does not generate
impulses. In the figure, in aVL a
Q wave is recorded, because
the lateral infarction here, has
left without electricity the other
part of the ventricle (R vector is
lost).
Q wave occurs only in the
transmural infarction and not in
the subendorcardial blockages.
Often, Q wave is associated
with T wave inversions.
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INFARCTION LOCALIZATION ST SEGMENT ELEVATION

Anterior ² Septal V1,V2,V3, V4
Posterior V1 ,V2
Inferior II, III, aVF
Lateral I , aVL
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 NOTE

EXAMPLES
-The Pardee wave
- Pathologic Q wave
- T wave inversion

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EXAMPLES
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NOTE
-The lateral ischemia
in D1, V4-V6

T WAVE INVERSION
Ischemia
EXAMPLES NOTE
-The acute infarction
(ST segment elevation)
EXAMPLES
NOTE
-The infarction and
the ischemia with
a branch block
LET·SDOATEST«
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(Positive R in D1 and negative in aVF)

A˜OTHERTEST?

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(R in aVL >12 mm)
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(Wide QRS,³W´ form QRS [V1] and ³M´ form QRS [V6])

THELASTTEST
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(ST elevation [V1-V4], T wave inversion [V5, V6])
 I invite you also«.
È to search and click on scribd.com some of the
materials I have used for this lecture on ECG
interpretation. You will find them by the name
ECG INTERPRETATION MATERIALS.
You will find very easy to understand other topics
of ECG interpretation, such as dysrhythmias and
some of their treatments, fascicular blocks, etc.
    
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ECG 


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