How to Identify a

Normal ECG

HOW TO
IDENTIFY A
NORMAL ECG
A Stepwise Approach

Liam Mellor
Paramedic
Paramedic Mentor
 Disclaimer
This Ebook is designed as a study guide and is not authoritative. Information in this Ebook should not inform clinical practice nor
replace clinical judgment. The clinical practice guidelines particular to your local ambulance service or health authority should be
followed.

Published by Liam Mellor

© 2020 London

All rights reserved. No part of this book may be reproduced or modified in any form, including photocopying,
recording, or by any information storage and retrieval system, without permission in writing from the publisher.
 Introduction
How on earth do you read an ECG?

This is a question I receive on a daily basis from student

Paramedics.

In 2014, it was also the same question I asked my

mentor on more than 120 million occasions (okay, I
admit that may be a slight exaggeration, but only by a
couple of hundred).

If you're reading this, I imagine this isn't your first

attempt at taming the squiggly line. ECGs are hard, I
won't lie to you, it isn't an easy subject.

But like me, a man with exactly zero GCSEs, you can
understand this fascinating beast. It just takes hard
work and direction.

So I'll make a deal with you.

You supply the hard work, and I'll supply the direction.

Lesson 1

Meet the waves

 Meet the Waves
An ECG tracing is made up of 5 waves (there is a 6th, but it's pretty
irrelevant for now); There's a P wave, a Q, R and S wave and a T wave.
These waves represent electrical impulses that pass through the atria and
the ventricles, causing the the heart to contract.

P-Wave

The P wave represents atrial depolarisation. You can remember that word
for your exams later, for now when you see a P wave, I just want you to
associate it with the atria contracting. So when you see a P wave, think atria,
got it? good.
 QRS complex

The QR and S waves make up what's known as the QRS complex, which is
formed when the impulses pass through the ventricles. To keep things simple,
when you see the QRS complex, think of the ventricles contracting.

PR-interval

The PR interval is the distance from the start of the P wave, to the start of the
QRS complex. It represents the time it takes for the impulses to travel from the
atria to the ventricles.
 QT interval

The QT interval is the measurement of time between the start of the Q

wave and the end of the T wave. The QT interval is said to be prolonged if
it's more than 440ms in men or 460ms in women.

T wave

The T wave represents repolarisation of the ventricles (in other words, when
the ventricles relax). once the T wave has returned to the isoelectric line (see
below), the cardiac impulses have caused the heart to contract and relax. Then,
after a short waveless period, the cycle will repeat itself from the start.
Here's an example of an ECG rhythm strip, with all the waves behaving as they
should.

You'll notice that lead II has been used in the example above, that's because
it's the best lead to assess the rhythm. But wait, how do you assess the
rhythm? well, I'm glad you asked....

In the example below, we've identified the R waves and compared their
distances apart. Because the R waves are an equal distance away from
each other, we can identify the rhythm as regular.

Now compare this to the example below. Once again, we've identified the R
waves and compared their distances apart. Only this time, the R waves are an
unequal distance away from each other, which tells us the rhythm is irregular.
 Once we've established the rhythm, we need to calculate the heart rate:

If the heart rate is regular

Count the number of large squares present within one R-R interval.

Then, divide 300 by this number. In this example, the sum would be 300/4, because
there are 4 large squares between the R waves. 300/4 = 75bpm.

If the heart rate is irregular

Count the number of R waves on a 10-second rhythm strip (1 second=5 big

squares).

Now multiply the number of R waves by 6 (giving you the average number of
complexes in 1 minute).

In the example above, we'd multiply 13 by 6, because there are 13 R waves on a

10-second rhythm strip. 13x6 = 78bpm
 The 12 Lead ECG

A standard 12 lead ECG has 10 physical leads that show us 12 views of the
heart (just read that one more time). Six of the leads are known as the limb
leads (I, II, III, aVL, aVR, and aVF), and in the paramedic world, they're usually
located on the left-hand side of the paper (see below).

There are 4 physical leads we need to place on our patient to be able to see
the limb leads on the ECG tracing. They can be placed either on the chest wall
as seen below or on the patient's arms and legs (the limbs). The leads are
colour coded to help us identify which lead goes where. I use the rhyme Ride
Your Green Bike to remember the order of placement, with the initial letter,
reminded me of the correct colour.
 The other six leads are called chest leads (or the precordial leads if you want to
use their fancy name) because they're placed on the patient's chest, around the
area of the heart (see below).

On the ECG tracing, these leads can be seen on the right-hand side of the paper,
like in the example below.
 A normal 12 lead ECG

Now we've covered some basics, next time your mentor hands you a 12 lead
ECG to assess, here's what I want you to do...

Step 1: Assess the rhythm

Grab the ECG and look at lead II (if you can print off a longish rhythm strip then
even better). Use the R-R method to assess the rhythm.

See how the R waves are an equal distance apart? That means the rhythm is
regular.

Step 1 complete: The rhythm is regular

Step 2: Assess the rate

Now we know the rhythm is regular, we can use the '300 divided by' method to
calculate the heart rate.
Because there are 3.75 large boxes between the R waves, we divide 300 by 3.75
(don't worry, you can get the calculator on your phone out, I always do).

300/3.75 = 80

Step 2 complete: The rate is 80bpm

Step 3: Make sure all waves are upright in lead I and II and negative in aVR

Identify the P, QRS, and T waves in these leads, and makes sure they're facing in
the right direction.

Sometimes the QRS complex may be both negative and positive. As long as it's
pointing predominantly in the right direction it's all good.

Step 3 complete: Waves pointing in the right direction in leads I,II and aVR
 Step 4: Make sure the PR interval is between 3-5 small squares

The normal timeframe for the PR interval is between 0.12-0.20 seconds. 3 small
squares equate to 0.12 seconds and 5 small squares equate to 0.20 seconds. I've
always found the square counting method to be the most practical way to
assess. Lead II is a good lead to assess the PR interval.

By counting the small squares from the start of the P wave to the start of the
QRS complex, we've discovered that the PR interval is 4 and a smidge in length.
Because 4 and a smidge is greater than 3 and less than 5, we know the PR
interval is normal.

Step 4 complete: The PR interval is normal

Step 5: Check to make sure there are no pathological Q waves

Pathological Q waves usually indicate a current or previous heart attack. They

are considered pathological if they are;

- Wider than 1mm

- Deeper than 2mm
- 25% of the depth of QRS complex
- Seen in leads V1-3
 In the example above, prominent Q waves can be seen in lead I and aVL.
Fortunately, they are not deeper than 2mm (1 small box equates to 1mm), and
not wider than 1mm.

Step 5 complete: There are no pathological Q waves

Step 6: Make sure the width of the QRS complex is less than 3 small squares

We take this measurement from the start of the Q wave to the end of the S
wave. If it's wider than 3 small squares, it can indicate abnormalities like bundle
branch blocks.

If there's no Q wave to measure from, like in this example, the measurement

starts at the first wave that forms at the start of the 'QRS' complex. The 'QRS'
complex on this ECG is 2.5 small squares in width.

Step 6 complete: The QRS complex is less than 3 small squares

 Step 7: Assess the R and S waves in the chest leads

In a normal ECG, the R wave should get taller from V1-V4 and the S wave should
get deeper from V1-V3 and disappear in V6.

In the example above, the R wave has got taller from V1 to V3, which is a good
start, but in V4, the R wave is smaller than it is in V3.

The S wave also fails to get deeper from V1-V3 and doesn't disappear in V6. So
we've spotted an abnormality in this ECG.

Sidenote: This is likely due to an incomplete right bundle branch block in this
instance. But I don't want you to worry about that for now.

Step 6 complete: Poor R and S wave progression noted.

Step 8: Check to see if the ST segment starts at the isoelectric line

The ST segment gets a lot of attention when assessing ECGs because

abnormalities here could indicate a heart attack. The ST segment is normal if it
starts at the isoelectric line. Remember, from earlier?
 In the above example, the start of the ST segment is in line with the isoelectric
line, so it's normal. The only exception to this rule is in lead V1 and V2, where a
small amount of ST elevation (no more than 2mm) can be normal.

Step 8 complete: No ST segment abnormalities

Step 9: Look out for any abnormal T wave inversions

After you've assessed the ST segment, bring your focus to the T wave. T waves
should be upright in lead I, II, and V3-V6 and inverted in lead aVR. Lead III, aVF,
aVL, V1 & V2, may have variable T waves, with isolated T wave inversions in
these leads potentially being a normal variant.

Normal upright T
wave (I,II)
Normal upright T
Normal T wave wave (V4-V6)
inversion

T waves variable (III,

aVF, aVL, V1, V2)
 In the ECG above the only T waves that are inverted are in leads aVR and V1.
Meaning there are no abnormal T wave inversions seen on this ECG.

Step 9 complete: No abnormal T wave inversion

Step 10: Make sure the QT interval is normal

The QT interval is a cheeky chap. We can't rely on the box-counting method in

this instance because it becomes inaccurate when the heart rate is abnormal.
Luckily, we aren't the first people to encounter this problem.

Most, if not all ECG machines calculate a QTc reading and print it on the ECG
strip.

This QTc reading gives us an accurate QT interval no matter what the heart rate.
A normal QTc interval is between 0.350s and 0.460s (0.440 in men).

As you can see, the QTc reading is 0.436s. This is normal because it's greater
than 0.350s and less than 0.460s

Step 10 complete: Normal QT interval

 There you have it. How to identify a normal ECG, done
and dusted.

Next time you're on placement, use these steps to

interpret every ECG you can get your hands on. The more
you see the more you learn.

Grab a pen and markdown every abnormality you come

across. Don't worry about knowing exactly what the
abnormality is just yet, that's the next step.

After all, how can you spot an abnormal ECG if you don't
know what a 'normal' one looks like?

Now test your skills with a practice run on the next page.
 Practice

Here's a real life 12 lead ECG.

Use these 10 steps and interpret your findings.

Is the rhythm regular or irregular?

What is the heart rate?

Are all the waves upright in lead I and II and negative in aVR?

Is the PR interval between 3-5 small squares?

Are there any pathological Q waves?

Is the QRS complex wider than 3 small squares?

Does the R wave get taller from V1-V4?

Does the S wave get deeper from V1-V3?
Is there a S wave in V6?

Does the ST segment start at the isoelectric line?

(V1 and V2 exempt)

Are there any abnormal T wave inversions?

Is the QTc reading between 0.350s and 0.460s?