ECG
GAJE SINGH
The Heart
What is an ECG ?
Electro Cardio
Gram
Graphic recording of electric potentials
generated by the heart.
Clinical Scenario 1
Your mother’s paternal uncle’s brother’s cousin meets you at a random get
together. You’re the star attraction - future doctor n all. He flips open his
phone, opens the gallery and shows a picture of his ECG and asks you If
this is normal ?
Wave Forms
By Duration
By Amplitude
By Morphology
P - Wave
Duration : less than 3 small squares (<120ms)
Amplitude : 1.5 -2.5 small squares
QRS Complex
Positive/ Upward – R wave
Preceding Negative – Q wave
Following Negative – S wave
T - Wave
3, 3, 3 and 5
• P duration = 3 small sqs = 0.12 sec.
• P height = 3 small sqs = 0.12 sec.
• QRS duration = 3 small sq = 0.12 sec
• P-R interval = 5 small sqs = 0.2 sec.
ECG LEADS
• 12 ECG leads record the difference in potential
between electrodes placed on the surface of the body.
• 6 extremity ( limb ) leads & 6 chest ( precordial )
leads.
LIMB LEADS
• 3 bipolar leads- I,II & III
• 3 unipolar leads- aVR, aVL & aVF
Eithoven’s Triangle
- I +
- 60˚
-
II III
+ +
Einthoven’s Law : I + III = II
Einthoven’s Triangle
Augmented Limb Leads
aVR aVL
30˚
----------------------------------------------
Sum total = 0
aVF
Augmented Limb Leads
Cardiac Axis
• General direction of wave of depolarization
through the ventricle.
• Top right hand corner to bottom left hand
corner.
BASIC LAWS OF ECG
Positive deflection appears in any lead if the wave of depolarization
spreads toward the positive pole of that lead
Negative deflection appears in any lead if the wave of depolarization
spreads away from the positive pole of that lead
Biphasic deflection appears if the mean depolarization path is directed at
right angles to any lead
aVL
aVR
III
aVF II
Chest Leads
In Precordial Leads positive electrode is placed on the chest(V1-V6). The Leads record
Electrical changes of the Heart in Cross sectional plane
HEART RATE
Regular Vs. Irregular
• Normal Heart Rate range : 50 to 100 bpm
• Maximum limit for sinus rate : 220 – Age of patient
1500 ÷ No. of Small squares
Regular Heart Rate or
300 ÷ No. of Large squares
Arrythmias
• Tachycardia -HR>150/min
• Bradycardia -HR<50/min
• Unusual Complexes
Sinus Tachycardia
Atrial Fibrillation
Atrial Flutter
Tachycardias
Multifocal Atrial Tachycardia
SVT
VT
5 simple Questions
• What is the Rate and Regularity?
• What is the atrial rhythm? (P waves)
• What is ventricular rhythm? (QRS complexes)
• Is there a “P” wave before “QRS” and a ‘QRS” after
every “P” WAVE?
• What is the PR interval?
Tachycardia ( >150bpm )
Narrow ( <0.12 sec) Wide ( >0.12 sec)
Regular Irregular Regular Irregular
• Sinus Tachy • Atrial • Monomorphic VT • Polymorphic VT
• SVT Fibrillation • SVT with Aberrancy
• Atrial Flutter
Bradycardias
5 simple Questions
• What is the Rate and Regularity?
• What is the atrial rhythm? (P waves)
• What is ventricular rhythm? (QRS complexes)
• Is there a “P” wave before “QRS” and a ‘QRS” after
every “P” WAVE?
• What is the PR interval?
Boss Raj
Wednesday
Monday
Tuesday
First Degree Block
Thursday
Wednesday
Monday
Tuesday
Wednesday
Monday
Tuesday
iiems
62
Eletrolyte imbalances
ECG changes of
Hyperkalemia
•Early Changes
̣Increased T wave amplitude
̣Peaked T waves
• Late Changes
̣Prolonged PR interval
̣Prolonged QRS duration
̣AV conduction delay
̣Absent P waves
̣Sine wave pattern ( > 8 mEq/L)
̣VF or asystole
ECG changes in
Hypokalemia
• ST depression
• Flattened or inverted T wave
• Prominent U wave
• Prolonged PR interval
• S-A block (Rare)
Assess the Rhythm
A Systematic Assess the QRS – Axis and Morphology
Approach
Assess the ST Segment and T waves
One Last Slide
Never Trust the computer
Always use the systematic approach
Gather all your findings into one clinical impression
Compare any old ecgs
Remember when the ECG is actually useful
Thank You!
