ElectroCardioGraphy

ECG made extra easy

 Overview
Objectives for this tutorial
What is an ECG?
Overview of performing
electrocardiography on a patient
Simple physiology
Interpreting the ECG
 Objectives
State a definition of electrocardiogram
Perform an ECG on a patient, including explaining to the patient
what is involved
Draw a diagram of the conduction pathway of the heart
Draw a simple labelled diagram of an ECG tracing
List the steps involved in interpreting an ECG tracing in an orderly
way
Recite the normal limits of the parameters of various parts of the
ECG
Interpret ECGs showing the following pathology:
MI, AF, 1st 2nd and 3rd degree heart block, p pulmonale, p mitrale, Wolff-
Parkinson-White syndrome, LBBB, RBBB, Left and Right axis deviation,
LVH, pericarditis, Hyper- and hypokalaemia, prolonged QT.
 What is an ECG?

ECG = Electrocardiogram
Tracing of heart’s electrical activity
Recording an ECG
 Overview of procedure
GRIP Turn on machine
Greet, rapport, introduce, Calibrate to 10mm/mV
identify, privacy, explain Rate at 25mm/s
procedure, permission
Record and print
Lay patient down
the tracing
Expose chest, wrists, Name, DoB, hospital
ankles number, date and
Clean electrode sites time, reason for
May need to shave recording
Apply electrodes Disconnect if
adequate and remove
Attach wires electrodes
 Electrode placement
10 electrodes in total are placed on the
patient

Firstly self-adhesive ‘dots’ are attached to

the patient. These have single electrical
contacts on them

The 10 leads on the ECG machine are

then clipped onto the contacts of the ‘dots’
 Electrode placement in 12 lead
ECG
6 are chest electrodes
Called V1-6 or C1-6

4 are limb electrodes

Right arm

Remember
The right leg electrode
is a neutral or “dummy”!
 Electrode placement

V1 4th intercostal space right sternal edge

V2 4th intercostal space left sternal edge
(to find the 4th space, palpate the manubriosternal angle (of
Louis)
Directly adjacent is the 2nd rib, with the 2nd intercostal space
directly below. Palpate inferiorly to find the 3rd and then 4th
space

V4 over the apex (5th ICS mid-clavicular

line)
V3 halfway between V2 and V4
V5 at the same level as V4 but on the
anterior axillary line
V6 at the same level as V4 and V5 but on
the mid-axillary line
 Recording the trace
Different ECG machines have different buttons
that you have to press.

Ask one of the staff on the ward if it is a machine

that you are unfamiliar with.

Ask the patient to relax completely. Any skeletal

muscle activity will be picked up as interference.

If the trace obtained is no good, check that all

the dots are stuck down properly – they have a
tendency to fall off.
Electrophysiology
 Electrophysiology
Pacemaker = sinoatrial node

Impulse travels across atria

Reaches AV node

Transmitted along interventricular septum in Bundle of

His

Bundle splits in two (right and left branches)

Purkinje fibres
Overall
direction
of
cardiac
impulse
 How does the ECG work?

If the electrical impulse travels the positive

electrode this results in a deflection

If the impulse travels from the positive electrode

this results in a deflection
Away from Towards
the the
electrode electrode
= negative = positive
deflection deflection

Direction of impulse (axis)

 Types of Leads
Coronal plane (Limb Leads)
1. Bipolar leads — l,ll,lll
2. Unipolar leads — aVL , aVR , aVF

Transverse plane
V1 — V6 (Chest Leads)
Electrodes around the heart
 Leads

Lead I is formed using the

right arm electrode (red)
as the negative electrode
and the left arm (yellow)
electrode as the positive
Leads
 Leads
Lead II is formed
using the right arm
electrode (red) as the
negative electrode Lead II
and the left leg
electrode as the
positive
Lead II
 Leads
Lead III is formed using the left arm
electrode as the negative electrode and
the left leg electrode as the positive

aVL, aVF, and aVR are ,

computed using the information from the
other leads
Leads and what they tell you

aVL, I and II = lateral

II, III and aVF = inferior
aVR = right side of the heart
Leads look at the heart from
different directions

axis
 Leads and what they tell you
Each lead can be thought of as ‘looking at’ an area
of myocardium

’
V1 and V2 look at the anterior of the heart and R
ventricle
V3 and V4 = anterior and septal
V5 and V6 = lateral and left ventricle
Elements of the trace
 What do the components
represent?

P wave = atrial depolarisation

QRS = ventricular depolarisation

T= repolarisation of the
ventricles
Interpreting the ECG
 Interpreting the ECG
Check
Name
DoB
Time and date
Indication e.g. “chest pain” or “routine pre-op”
Any previous or subsequent ECGs
Is it part of a serial ECG sequence? In which case it may be
numbered
Calibration
Rate
Rhythm
Axis
Elements of the tracing in each lead
 Calibration

10mm = 1mV
Look for a reference pulse which should be the
rectangular looking wave somewhere near the
left of the paper. It should be 10mm (10 small
squares) tall

25mm/s
25 mm (25 small squares / 5 large squares)
equals one second
 Rate
If the heart rate is regular
Count the number of large squares between
R waves
i.e. the RR interval in large squares

Rate = 300
RR

e.g. RR = 4 large squares

300/4 = 75 beats per minute
 Rate
If the rhythm is irregular (see next slide on rhythm
to check whether your rhythm is regular or not) it
may be better to estimate the rate using the
rhythm strip at the bottom of the ECG (usually
lead II)

The rhythm strip is usually 25cm long (250mm i.e.

10 seconds)
If you count the number of R waves on that strip
and multiple by 6 you will get the rate
 Rhythm

The easiest way to tell is to take a sheet of paper and line up one
edge with the tips of the R waves on the rhythm strip.

Mark off on the paper the positions of 3 or 4 R wave tips

Move the paper along the rhythm strip so that your first mark lines
up with another R wave tip

See if the subsequent R wave tips line up with the subsequent

marks on your paper

If they do line up, the rhythm is regular. If not, the rhythm is irregular
 Rhythm

Definition Cardiac impulse originates from the

sinus node. Every QRS must be
preceded by a P wave.

(This does not mean that every P wave must be

followed by a QRS – such as in 2nd degree heart
block where some P waves are not followed by a
QRS, however every QRS is preceded by a P wave
and the rhythm originates in the sinus node, hence it
is a sinus rhythm. It could be said that it is not a
sinus rhythm)
 Rhythm

There is a change in heart rate depending on the phase of

respiration

Q. If a person with sinus arrhythmia inspires, what happens to their

heart rate?

A. The heart rate speeds up. This is because on inspiration there is

a decrease in intrathoracic pressure, this leads to an increased
venous return to the right atrium. Increased stretching of the right
atrium sets off a brainstem reflex (Bainbridge’s reflex) that leads to
sympathetic activation of the heart, hence it speeds up)

This physiological phenomenon is more apparent in children and

young adults
 Rhythm

Rhythm originates in the sinus node

Rate of less than 60 beats per minute

Rhythm originates in the sinus node

Rate of greater than 100 beats per minute
 Axis
The axis can be though of as the overall
direction of the cardiac impulse or wave of
depolarisation of the heart

An abnormal axis (axis deviation) can give

a clue to possible pathology
 Axis An axis falling
outside the normal
range can be
or

A
can lie
anywhere
between -30
and +90
degrees
or +120
degrees
according to
some
 Axis deviation - Causes
Wolff-Parkinson-White
syndrome can cause both Left
and Right axis deviation

A useful mnemonic:

“RAD RALPH the LAD from

VILLA”
eft

Ventricular tachycardia
Right ventricular hypertrophy Inferior MI
Anterolateral MI Left ventricular hypertrophy
Left Posterior Hemiblock Left Anterior hemiblock
 The P wave
The P wave represents atrial
depolarisation

It can be thought of as being

made up of two separate
waves due to right atrial
depolarisation and left atrial Sum of
depolarisation. right and
left waves

Which occurs first? right atrial depolarisation

Right atrial depolarisation left atrial depolarisation
 The P wave

No hard and fast rules

Height
a P wave over 2.5mm should arouse suspicion

Length
a P wave longer than 0.08s (2 small squares) should
arouse suspicion
 The P wave

A tall P wave (over

2.5mm) can be called

Occurs due to R atrial

hypertrophy

Causes include: >2.5mm

pulmonary hypertension,
pulmonary stenosis
tricuspid stenosis
 The P wave

A P wave with a length

>0.08 seconds (2 small
squares) and a bifid
shape is called

It is caused by left atrial

hypertrophy and delayed
left atrial depolarisation

Causes include:
Mitral valve disease
LVH
 The PR interval
The PR interval is measured between the
start of the P wave to the start of the QRS
complex

(therefore if there is a Q wave before the R

wave the PR interval is measured from the
start of the P wave to the start of the
wave, not the start of the R wave)
 The PR interval
The PR interval corresponds to the time
period between depolarisation of the atria
and ventricular depolarisation.

A normal PR interval is between 0.12 and

0.2 seconds ( 3-5 small squares)
 The PR interval
If the PR interval is short (less than 3 small
squares) it may signify that there is an accessory
electrical pathway between the atria and the
ventricles, hence the ventricles depolarise early
giving a short PR interval.

One example of this is Wolff-Parkinson-White

syndrome where the accessory pathway is
called the bundle of Kent. See next slide for an
animation to explain this
Depolarisation begins at
the SA node
The wave of
depolarisation spreads
across the atria
It reaches the AV node
and the accessory bundle
Conduction is delayed as
usual by the in-built delay
in the AV node
However, the accessory
bundle has no such delay
and depolarisation begins
early in the part of the
ventricle served by the
bundle

As the depolarisation in this part of the ventricle Until rapid depolarisation

does not travel in the high speed conduction resumes via the normal
pathway, the spread of depolarisation across the pathway and a more normal
ventricle is slow, causing a slow rising delta wave complex follows
 The PR interval
If the PR interval is long (>5 small squares
or 0.2s):

If there is a constant long PR interval 1st

degree heart block is present

First degree heart block is a longer than

normal delay in conduction at the AV node
 The PR interval
If the PR interval looks as though it is widening
every beat and then a QRS complex is missing,
there is 2nd degree heart block, Mobitz type I.
The lengthening of the PR interval in
subsequent beats is known as the Wenckebach
phenomenon
(remember (w)one, Wenckebach, widens)

If the PR interval is constant but then there is a

missed QRS complex then there is 2nd degree
heart block, Mobitz type II
 The PR interval
If there is no discernable relationship
between the P waves and the QRS
complexes, then 3rd degree heart block is
present
 Heart block (AV node block)

1st degree
constant PR, >0.2 seconds

2nd degree type 1 (Wenckebach)

PR widens over subsequent beats then a QRS is dropped
2nd degree type 2
PR is constant then a QRS is dropped

3rd degree
No discernable relationship between p waves and QRS
complexes
 The Q wave

A Q wave can be pathological Normal if in

if it is: I,II,III,aVL,V5-6
Deeper than 2 small squares
(0.2mV)
and/or Pathological
Wider than 1 small square anywhere
(0.04s)
and/or
In a lead other than III or one
of the leads that look at the
heart from the left (I, II, aVL,
V5 and V6) where small Qs
(i.e. not meeting the criteria
above) can be normal
 The QRS height
If the complexes in the chest leads look
very tall, consider left ventricular
hypertrophy (LVH)

If the depth of the S wave in V1 added to

the height of the R wave in V6 comes to
more than 35mm, LVH is present
 QRS width
The width of the QRS complex should be less
than 0.12 seconds (3 small squares)

Some texts say less than 0.10 seconds (2.5

small squares)

If the QRS is wider than this, it suggests a

ventricular conduction problem – usually right or
left bundle branch block (RBBB or LBBB)
LBBB
If left bundle branch block
is present, the QRS
complex may look like a
‘W’ in V1 and/or an ‘M’
shape in V6.

New onset LBBB with

chest pain consider
Myocardial infarction

Not possible to interpret

the ST segment.
 RBBB
It is also called RSR
pattern
If right bundle branch
block is present, there
may be an ‘M’ in V1
and/or a ‘W’ in V6.

Can occur in healthy

people with normal QRS
width – partial RBBB
 QRS width
It is useful to look at leads V1 and V6

LBBB and RBBB can be remembered by the

mnemonic:

Bundle branch block is caused either by

infarction or fibrosis (related to the ageing
process)
 The ST segment
The ST segment should sit on the isoelectric line

It is abnormal if there is planar (i.e. flat) elevation

or depression of the ST segment

Planar ST elevation can represent an MI or

Prinzmetal’s (vasospastic) angina

Planar ST depression can represent ischaemia

 Myocardial infarction
Within hours:
T wave may become peaked
ST segment may begin to rise

Within 24 hours:
T wave inverts (may or may not persist)
ST elevation begins to resolve
If a left ventricular aneurysm forms, ST elevation may persist

Within a few days:

pathological Q waves can form and usually persist
 Myocardial infarction
The leads affected determine the site of
the infarct

Inferior II, III, aVF

Anteroseptal V1-V4
Anterolateral V4-V6, I, aVL
Posterior Tall wide R and ST in V1
and V2
Acute Anterior MI

ST elevation
 Inferior MI

ST elevation
 The ST segment
If the ST segment is elevated but slanted,
it may not be significant

If there are raised ST segments in most of

the leads, it may indicate pericarditis –
especially if the ST segments are saddle
shaped. There can also be PR segment
depression
Pericarditis
 The T wave
Are the T waves too tall?
No definite rule for height
T wave generally shouldn’t
be taller than half the size
of the preceding QRS

Causes:
Hyperkalaemia
Acute myocardial
infarction
 The T wave
If the T wave is flat, it may indicate
hypokalaemia

If the T wave is inverted it may indicate

ischaemia
 The QT interval
The QT interval is measured from the of the
QRS complex to the of the T wave.

The QT interval varies with heart rate

As the heart rate gets faster, the QT interval gets
shorter

It is possible to correct the QT interval with

respect to rate by using the following formula:
QTc = QT/ RR (QTc = corrected QT)
 The QT interval
The normal range for QTc is 0.38-0.42

A short QTc may indicate hypercalcaemia

A long QTc has many causes

Long QTc increases the risk of developing

an arrhythmia
 The U wave
U waves occur after the T wave and are
often difficult to see

They are thought to be due to

repolarisation of the atrial septum

Prominent U waves can be a sign of

hypokalaemia, hyperthyroidism
Supraventricular tachycardias
These are tachycardias where the impulse is initiated in
the atria (sinoatrial node, atrial wall or atrioventricular
node)

If there is a normal conduction pathway when the

impulse reaches the ventricles, a narrow QRS complex
is formed, hence they are narrow complex tachycardias

However if there is a conduction problem in the

ventricles such as LBBB, then a broad QRS complex is
formed. This would result in a form of broad complex
tachycardia
 Atrial Fibrillation

There maybe tachycardia

The rhythm is usually irregularly irregular
No P waves are discernible – instead
there is a shaky baseline
This is because there is no order to atrial
depolarisation, different areas of atrium
depolarise at will
Atrial Fibrillation
 Atrial flutter
There is a saw-tooth baseline which rises above and
dips below the isoelectric line.
Atrial rate 250/min
This is created by circular circuits of depolarisation
set up in the atria
Ventricular Tachycardia
 Ventricular Tachycardia
QRS complexes are wide and irregular in shape
Usually secondary to infarction
Circuits of depolarisation are set up in damaged
myocardium
This leads to recurrent early repolarisation of the
ventricle leading to tachycardia
As the rhythm originates in the ventricles, there is a
broad QRS complex
Hence it is one of the causes of a broad complex
tachycardia
Need to differentiate with supraventricular tachycardia
with aberrant conduction
Ventricular Fibrillation
 Ventricular fibrillation
Completely disordered ventricular
depolarisation

Not compatible with a cardiac output

Results in a completely irregular trace

consisting of broad QRS complexes of
varying widths, heights and rates
 Elements of the tracing
P wave ST segment
Magnitude and shape, Should be isoelectric
e.g. P pulmonale, P mitrale

T wave
PR interval (start of P to start of QRS) Magnitude and direction
Normal 3-5 small squares,
0.12-0.2s
QT interval (Start QRS to end of T)
Pathological Q waves? Normally < 2 big squares or
0.4s at 60bpm
Corrected to 60bpm
QRS complex
(QTc) = QT/ RRinterval
Magnitude, duration and
shape
3 small squares or 0.12s
duration
 Further work
Check out the various quizzes / games
available on the Imperial Intranet

Get doctors on the wards to run through a

patient’s ECG with you