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SCOPE OF ECG

1. ECG LEADS
2. NORMAL ECG
3. TACHY ARRYTHMIAS
4. BRADY ARRYTHMIAS
5. ISCHAEMIC HEART DISEASE
6. BUNDLE BRANCH BLOCK
7. ECTOPICS
8. CHAMBER ENLARGEMENT
9. POTASSIUM DISTURBANCES
10.MISCELLANIOUS
ORIENTATION OF THE 12 LEAD ECG
AXIS OF ECG
COMPONENTS OF NORMAL ECG COMPLEX
NORMAL ECG VALUES
P waves : P amplitude < 2.5 mm and width < 2.5 mm. May see notched. Best seen in lead II
PR Interval: 0.12 - 0.20 sec i.e. max one big square
q-waves :are narrow (<0.04s duration) and small (<25% the amplitude of the R wave). They are
often seen in leads I and aVL when the QRS axis is to the left of +60, and in leads II, III, aVF when
the QRS axis is to the right of +60.
Septal q waves should not be confused with the pathologic Q waves of myocardial infarction.
QRS Duration: 0.06 - 0.10 sec i.e. around max three small squares
QT Interval (QT
c
0.40 sec)
Bazett's Formula: QT
c
= (QT)/Sq Root RR (in seconds)
ST segment: is a misnomer, because a discrete ST segment distinct from the T wave is usually
absent. More often the ST-T wave is a smooth, continuous waveform beginning with the J-point
(end of QRS), slowly rising to the peak of the T and followed by a rapid descent to the isoelectric
baseline or the onset of the U wave. This gives rise to an asymmetrical T wave. In some normal
individuals, particularly women, the T wave is symmetrical and a distinct, horizontal ST segment
is present.
Normal ST segment elevation: this occurs in leads with large S waves (e.g., V1-3), with concavity
upwards; this is often called early repolarization
T wave :The normal T wave is usually in the same direction as the QRS except in the right
precordial leads. In the normal ECG the T wave is always upright in leads I, II, V3-6, and always
inverted in lead aVR.

QRS axis : The normal QRS axis range (+90 to -30 ); this implies that the QRS be mostly
positive (upright) in leads II and I
Precordial leads:
Small r-waves begin in V1 or V2 and progress in size to V5.
In reverse, the s-waves begin in V6 or V5 and progress in size to V2.
Small "septal" q-waves may be seen in leads V5 and V6.
U Wave : amplitude is usually < 1/3 T wave amplitude in same lead. Direction is the same as T
wave direction in that lead
Rate : 60 100 per min i.e. 3 -5 big squares
Correlate with old ECGs
Amplitude of complexes will be affected by thickness of chest wall

NORMAL
Sinus rhythm
PR interval max 0ne square
R-R interval between 3-5 squares
QRS max 3 small squares

ST segment normal
t waves upright except aVR
Normal axis


SINUS TACHYCARDIA
Sinus rhythm
R-R interval < 3 squares
SVT
Regular Narrow QRS complex Tachycardia
No definite P waves
ATRIAL FIBRILLATION
Irregular Narrow QRS complex Tachycardia
Irregular R-R interval

Baseline wavy
No definite P waves
ATRIAL FLUTTER
Narrow QRS complex Tachycardia
Irregular or regular R-R interval

Baseline saw toothed
No definite P waves
MULTIFOCAL ATRIAL TACHYCARDIA (MAT)
Narrow QRS complex Tachycardia
Irregular or regular R-R interval
multifocal P' waves at least 3 different P wave
morphologies in a given lead
Varying PR interval
Commonly seen in COPD

VENTRICULAR TACHYCARDIA
Regular broad QRS complex Tachycardia
No P & QRS relation

Capture & fusion beats may be seen

VENTRICULAR FIBRILLATION
Irregular broad QRS complex Tachycardia
Chaotic rhythm

No definite P or QRS
TACHYCARDIA
NARROW/NORMAL QRS BROAD QRS
NARROW/NORMAL QRS TACHYCARDIA


DEFINITE P WAVES

REGULAR



PRESENT

ABSENT

SINUS
TACHYCARDIA

SVT

MAT/PAT



DEFINITE P WAVES




IRREGULAR



PRESENT

ABSENT

BASELINE

IRREGULAR

SAW TOOTHED


ATRIAL FLUTTER


ATRIAL FIBRILLATION


BROAD QRS TACHYCARDIA
EACH QRS PRECEEDED BY P WAVE


NO P &QRS RELATION

SINUS RHYTHM WITH BROAD QRS
ALMOST
REGULAR R-R
INTERVAL

IRREGULAR R-R
INTERVAL / CHAOTIC
RYTHM

VENTRICULAR
TACHYCARDIA
VENTRICULAR
FIBRILLATION
SINUS BRADYCARDIA
Sinus rhythm
R-R distance > 5 squares
FIRST DEGREE HEART BLOCK
Sinus rhythm
P-R interval > one square
2 nd DEGREE A-V BLOCK
Sinus rhythm
Some P waves not followed by QRS complex
COMPLETE HEART BLOCK
bradycardia
No association between p and qrs i.e. pr interval
is varying
Constant pp and rr interval
NODAL RHYTHM
Bradycardia
No P waves
Regular narrow QRS
SICK SINUS SYNDROME
Sinus pauses i.e. Missed p waves
Seen in elderly
BRADYCARDIA
P WAVES ABSENT P WAVES SEEN
P WAVES SEEN

MISSED QRS

PRESENT

ABSENT

P & QRS RELATION
ABSENT CONSTANT
COMPLETE HEART BLOCK

SINUS BRADYCARDIA

A V BLOCK

ABSENT P WAVES

SICK SINUS SYNDROME

NO SINUS PAUSES

INTERMITTENT SINUS PAUSE

NODAL RYTHM

ANTERIOR WALL MI
ST elevation in V1 - V6 Reciprocal ST depression in inferior leads
EVOVLED ANTERIOR WALL MI
T waves inverted

Q waves developed
INFERIOR & LATERAL WALL MI
ST elevation in II, III and Avf, V5 V6 Reciprocal ST depression in anterior leads
POSTERIOR WALL MI
ST depression in V1 V2

May have ST elevations in V5 V6 i.e. lateral
leads
UNSTABLE ANGINA
Horizontal ST Depression
Anginal symptoms
RIGHT BUNDLE BRANCH BLOCK
Broad QRS
M pattern in right sided leads i.e. V1 V2
Reciprocal T inversion usually present in left
sided leads

LEFT BUNDLE BRANCH BLOCK
Broad QRS
M pattern in left sided leads i.e. V5 V6
Reciprocal T inversion usually present in left
sided leads
ECTOPICS
VPC APC
VPC
Early onset broad QRS
No preceding P wave
Usually associated with T inversion
Complete compensatory pause
APC
Early onset narrow QRS
Deformed P wave
Incomplete compensatory pause
No reciprocal T wave inversion
VENTRICULAR BIGEMINY
Alternating normal QRS and ventricular ectopic
LEFT VENTRICULAR HYPERTROPHY WITH STRAIN
LVH S wave in V1 + R wave in V5 or 6 > 35 mm i.e. 7 squares
R + S in any leads > 45 mm
Downsloping ST depression in lateral leads V5,V6,I,AvL
ATRIAL ENLARGEMENT
P wave height > 2.5 small square P wave width >2.5 small square
P PULMONALE
RIGHT VENTRICULAR HYPERTROPHY
R/S ratio < 1
May be associated with p pulmonale, RBBB
Right axis deviation i.e. deep s in lead I
HYPOKALAEMIA
usual triad of: ST depression, low T waves or
inversion, and large U waves
HYPERKALAEMIA
Tall peaked broad based t waves
Suspect in kidney failure patients
WRONG LEAD PLACEMENT
Positive QRS in aVR
Deep S wave and small R in lead I
EARLY REPOLARISATION
COMMON NONSIGNIFICANT ABNORMALITIES
1. T inversion in V1-3 in females
2. Isolated T inversion or q wave in lead III
3. Minor conduction defects in limb leads