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Heart rate
Rhythm
The QRS axis
Intervals: PR, QRS, and QT
The P wave amplitude and duration
The QRS amplitude
ST-segment and T-wave abnormalities
Abnormal findings: hypertrophy, abnormal rate, conduction
abnormalities, metabolic disturbances
INTERVALS AND COMPLEXES
PR interval
Measured in lead II
QRS complex
<0.10 sec
Measured in V5
Low voltage is 5mm or less in limb leads and 8mm or less in chest
leads
P wave
QRS complex
R waves: taller in the right precordial leads (i.e., V4R, V1, V2)
S waves: deeper in the left precordial leads (i.e., V5, V6) in infants
and small children
ST segment
Isoelectric
It is bullet shape.
If the cardiac rhythm originates from the sinus node, the expected
vector of depolarization will be from right to left and superior to inferior.
Thus, the P wave deflection should be positive (upward) in leads I, II,
and aVF.
P-R interval
Time interval for impulse to go from the SA to the
AV node
From the beginning of the P wave to the beginning
of the QRS complex
Normal 0.12-0.20 secs
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-ParkinsonParkinson
P-WAVES MORPHOLOGY
Q wave
Pathologic Q wave
Pathologic Q waves occur when the electrical signal passes
through stunned or scarred myocardium; as such, they are usually
markers of previous myocardial infarcations, with subsequent fibrosis.
A pathologic Q wave is defined as having a deflection amplitude
of 25% or more of the subsequent R wave, or being > 0.04 s (40 ms) in
width and > 2 mm in amplitude. However, diagnosis requires the presence
of this pattern in more than one corresponding lead.
Pathological Q waves may be seen with ventricular hypertrophy
(right or left), left bundle branch block, or after myocardial infarction
Except in the newborn, the q wave is absent in V4R and V1.
The amplitude should be less than 6 mm in leads aVF and V5,
less than 5 mm in lead V6, and not more than 25% of the amplitude of the
associated R wave in any lead.
The duration does not normally exceed 0.03 s.
Pathological Q waves may be seen with ventricular hypertrophy
(right or left), left bundle branch block, or after myocardial infarction.
In congenitally corrected transposition of the great arteries, the
septum is depolarised from right to left, resulting in q waves in the right
precordial leads and their absence from the left precordial leads (Fig. 10).
In conditions with a single functional ventricle (e.g. Hypoplastic
left heart syndrome) there may be no q waves in the precordial leads.
QT Intervals
Measured in Lead II
Normal: <0.44s
R-wave height greater than the 98th percentile for age on lead V1
S wave depth greater than the 98th percentile for age in lead V6
Neonates
1.
2.
3.
4.
5.
6.
4.
a.
b.
Criteria
1. RAD, at least for the terminal portion of the QRS complex
2. QRS duration longer than the upper limit for age: greater
than 0.10 sec in children ages 4 to 16 years, and greater
than 0.90 sec in children less than 4 years of age
3. Terminal slurring of the QRS complex directed to the right
and usually, but not always, anteriorly:
- Wide and slurred S waves in leads I, V5, and V6
Interpretation
T-wave changes
Myocardial Infarction
Limb Leads
Lateral
I, aVL
Anterior
V5, V6
V1, V2, V3
Anterolateral
I, aVL
Diaphragmati
c
Posterior
Precordial Leads
V2V6
HYPERKALEMIA
At K levels of 8 meq/L the P waves are not usually seen but QRS
complex are seen
V1V3
ELECTROLYTE DISTURBANCES
Common ELECTROLYTE disturbances which interferes with ECG changes
are
1. Hypokalemia
2. Hyeprkalemia
3. Hypocalcemia
4. Hypercalcemia
5. Hypomagnesemia
6. Hypermagnesemia
Potassium
Levels of Hypokalemia
HYPOCALCEMIA
HYPERMAGNESEMIA
Similar to hyperkalemia
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