12 leads ECG

Dr Syed Muneer Ahmed

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 Challenge

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 A picture is worth a thousand
words

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 What is the ECG?
The electrocardiogram (ECG or EKG) is a diagnostic tool
that measures and records the electrical activity of the heart

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 Leads position

aVR aVL

aVF

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 What happen during ECG
recordings?

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 Cont

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 Measurements

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 How to read ECG ?

Rhythm
Rate (PP&RR intervals)
Axis (-30 to 90)
P wave (0.12 x 2.5mm)
PR interval (0.12-0.2 s)
QRS ( 0.1 s)
ST segment
T wave (0.04-0.08)
QT interval ( 0.40 @ 70b/m)
QTc ( 0.44 s)
 Rhythm

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1. Pattern of QRS complexes
Regular or irregular?
If irregular is it regularly irregular or irregularly irregular?

2. QRS morphology
Narrow complex sinus, atrial or junctional origin.
Wide complex ventricular origin, or supraventricular with aberrant
conduction.
3. P waves
Absent sinus arrest, atrial fibrillation
Present morphology and PR interval may suggest sinus,
atrial, junctional or even retrograde from the ventricles.

4. Relationship between P waves and QRS complexes

AV association
AV dissociation
atrial and ventricular activity is always independent.
 What is the heart rate?

(300 / 6) = 50 bpm

What if the rhythm is irregular ?

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 Axis

Predominantly Predominantly Equiphasic

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 The Quadrant Method

The most efficient way to estimate axis is to look at leads I + aVF.

LEAD
LEAD I QUADRANT AXIS
AVF

Positive Positive Left lower quadrant Normal (0 to +90 degrees)

Positive Negative Left upper quadrant Possible LAD (0 to -90 degrees)

Negative Positive Right lower quadrant RAD (+90 to 180 degrees)

Negative Negative Right upper quadrant Extreme Axis Deviation (-90 to 180 degrees)
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 Test 1

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 Test 2

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 Re ax
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 What types of pathology can we identify and
study from EKGs?

Arrhythmias
Conduction defects - Pacemaker
Myocardial ischemia and infarction
Pericarditis
Chamber hypertrophy
Electrolyte disturbances (i.e.
hyperkalemia, hypokalemia)
Drug toxicity (i.e. digoxin and drugs
which prolong the QT interval)
 Arrhythmia
Dysrhythmia

Tachy Brady Tachy- Brady Extrasystol

Regular Irrigular
PACS PVCS
Atrial Atrial
Sinus Atrial fibrelation

SVT

Atrial Flutter
Ventricular

Ventricular fiberaltion
Ventricular

V tachy
 Extra systol

Atrial Ventricular
 Tachycardia

Atrial Ventricular
 Bradycardia

Node defect Conduction defect

SA node
1st degree heart block
2nd degree heart block
3rd degree heart block

AV node
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 Conduction defects
1st degree heart block 2nd degree heart block type II

2nd degree heart block (type I)

Complete Heart Block

Increment in conduction delay for each subsequent impulse
gets smaller until conduction failure finally occurs.
Cont. conduction defects
 P wave
(0.12 x 2.5mm)

Present or Absent Morphology How many

Bifid (P mitral) Peaked (P pulmonal)

 P R interval abnormalities

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 Measuring ST Segments

ST measurement = vertical difference between the

isoelectric line + end of QRS complex, the J point
 Q& ST abnormalities
Definition of a pathologic Q wave
More than 40ms (1mm wide)
More than 2mm deep
More than 25% of depth of QRS
If seen in leads V1-V3
ST elevation

Measure: 2 mm beyond QRS

Significant: 1 mm limb lead
2 mm chest lead
Con. Q& ST abnormalities
 Con. Q& ST abnormalities

Significant: 1 mm limb leads

2 mm chest leads
 T wave Abnormality

Inverted

Hyper
acute
Test 3
 Cardiac arrest

Asystol

Pulseless
V tachycardia

V fibrillation V F
Thank You
 1 st degree Heart Bock

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 2 nd degree heart block (type I)

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 2 nd degree heart block type II

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 Complete Heart Block

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