Basics of ECG II

Dr. Loay Abudalu. MD. MSc (UK)

ECG Lead

Limb Leads

Chest Leads

Calculations

Timing

ECG leads

ECG leads Lead systems allow you to look at the heart from different angles. Each different angle is called a lead. Each lead has a positive and negative pole attached to the surface of the skin, which can then be used to measure the spread of electrical activity within the heart.

ECG leads Upward deflection on the ECG- is produced when electrical impulses travel towards a positive electrode. Downward deflection on the ECG- is produced when electrical impulses travel towards a negative electrode. Flat line (isoelectric line)- is produced when there is no electrical spread through the heart, or if the electrical forces are equal.

Limb leads

Limb leads

Electrical current moving from negative electrode to positive electrode

Lead 1 Negative right shoulder Positive left shoulder Lead 2 Negative right shoulder Positive left lower chest Lead 3 Negative left shoulder Positive left lower chest

Einthovens Triangle

They are called the augmented limb leads because they are augmented (or amplified) through a modification of Wilsons Central Terminal (WCT). The modification was necessary because otherwise the complexes would have been too small aVR positive electrode right shoulder aVL positive electrode left shoulder aVF positive electrode left lower chest (foot)

Chest Leads

Chest Leads

Unlike limb leads that measure electrical activity in the vertical plane, the precordial leads measure activity in the horizontal plane. Each of the 6 electrodes are set as positive

V1 = right ventricle and far left ventricle V2 = right ventricle and AV node V3 = anterior left ventricle V4 = anterior left ventricle V5 = lateral left ventricle V6 = lateral left ventricle

Gives a 2 dimensional picture of what is going on electrically in the heart

12 Lead ECG Placement

Rhythm strip

Calculations of Axis

Normal Cardiac Axis

In healthy individuals you would expect the normal 11 oclock to 5 oclock spread Therefore the spread of depolarisation would be heading towards leads I,II & III As a result you would see a positive deflection in all of these leads With lead II been the most positive (its at 5 oclock) You would expect to see the most negative deflection in aVR This is due to aVR looking at the heart in the opposite direction to lead II

Right axis deviation

Right axis deviation (RAD) is usually caused by right ventricular hypertrophy. In right axis deviation the direction of depolarisation is distorted to the right (1-7 oclock) Extra heart muscle causes a stronger signal to be generated by the right side of the heart This causes deflection in lead I to become negative & deflection in lead II & III to be more +ve RAD is associated with pulmonary conditions as they put strain on the right side of the heart

Left axis deviation

In left axis deviation (LAD) the general direction of depolarisation becomes distorted to the left This causes the deflection in lead III to become negative It is only considered significant if the deflection of Lead II also becomes negative LAD is usually caused by conduction defects & not by increased mass of the left ventricle

Axis trick
Positive in I and II = normal Positive in I Negative in II = LAD Negative in I Positive in II = RAD

Timing

Timing

Timing

Rate R-R interval Is it regular?

What is the heart rate?

300, 150, 100, 75, 60, 50 300 / (# of large boxes) 1500 / (# of small boxes)

Timing

Are there P waves.? Normally =0.08 s = 2 sm sq Pointy = P pulmonale (RA hypertrophy) Bifid = P mitrale (LA hypertrophy)

PR interval

Start of P wave to start of QRS

Normal = 0.12-0.2s

Too short can mean WPW

Too long means AV block (heart block) - 1st/2nd/3rd degree

QRS complex

Should be <0.12s duration

>0.12s = BBB (either LBBB or RBBB)

QRS amplitude
R in V5 or V6 < 2.6 mV
Increased amplitude indicates cardiac hypertrophy

Timing
ST segment connects the QRS complex and the T wave and has a duration of 0.08 to 0.12 secR-R interval ST depression Downsloping or horizontal = abnormal Ischaemia (coronary stenosis) ST elevation Infarction (coronary occlusion) Pericarditis (widespread)

Timing
T wave 160ms

Peaked (hyperkalaemia or normal young man)

Inverted/biphasic (ischaemia, previous infarct)

Small (hypokalaemia)