ECG BASIC

dr. fikri Taufiq, M.Si.Med

Physiology Department
Hp: 08122519992
email: fikri_taufiq@yahoo.com

Cardiac Conduction Pathway

SA Node
Intra-atrial conduction

Internodal tract: SA Node AV Node

Bachman bundle: Right Atrium Left Atrium

AV Node
Bundle of His
Bundle branch

Left Bundle Branch

Left anterior fasicular branch

Left ponterior fasicular branch

Right Bundle Branch

Purkinje Fibers

Impulse Conduction & the ECG

Sinoatrial node
AV node
Bundle of His
Bundle Branches

Purkinje fibers

Electrical Measurement
-Single Cell Model

In the resting state the surface of the cell is

positive charged relative to the inside because
the surface is homogeneously charged the
voltmeter electrodes outside the cell do not record
any electrical potential different

If depolarization current is directed toward the (+)

electrode of the voltmeter an upward
deflection is recorded

If depolarization current is directed away from the

(+) electrode of the voltmeter a downward
deflection is recorded

Electrocardiographic Lead

Bipolar limb lead

Lead I
Lead II
Lead III

Unipolar limb lead

aVR
aVL
aVF

Precordial lead

V1
V2
V3
V4
V5
V6

Position of ECG Limb Leads

Lead

(+) Electrode

(-) Electrode

LA

RA

II

LL

RA

III

LL

LA

Bipolar Lead

Unipolar lead
aVR

RA

aVL

LA

aVF

LL

Position of ECG Chest Electrodes

V1

4th ICS, 2 cm to the right of sternum

V2

4th ICS, 2 cm to the left of sternum

V3

Midway between V2 and V4

V4

5th ICS, left midclavicular line

V5

5th ICS, left anterior axillary line

V6

5th ICS, left midaxillary line

The axial reference system

Hexadensial System

The ECG Paper

The ECG Paper

Horizontally

One small box - 0.04 s

One large box - 0.20 s

Vertically

One large box - 0.5 mV

3 sec

Every

3 sec

3 seconds (15 large boxes) is

marked by a vertical line.
This helps when calculating the heart rate.
NOTE: the following strips are not marked
but all are 6 seconds long.

Sequence of Normal Cardiac

Activation

The PQRST
P

wave - Atrial depolarization

QRS Ventricular depolarization

T wave Ventricular repolarization

The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)

(delay allows time for the

atria to contract before
the ventricles contract)

Interpretation of The
Electrocardiogram

Calibration
Heart Rhytm
Regularity
Heart Rate
P wave
PR interval
QRS wave

QRS interval
Axis
Transition zone
Atrium Abnormality
Ventricular hipertrophy
Pathologic Q wave

ST Segment
T wave

Calibration

Check 1.0 mV vertical box inscription (normal

standard = 10 mm)
25 mm/second speed

Heart Rhytm

Sinus rhytm is present if

Each P wave is followed by a QRS complex
Each QRS is preceded by P wave
P wave is upright in lead I, II, and III
PR interval is >0.12 sec (3 small boxes)

Atrial rhytm
Junctional rhytm
Ventricular rhytm

 Regularity

Regular
Regular-Irregular
Irregular-Irregular

Heart

Rate

Use one of three methode:

1500/(number

of mm between beat)
Count-off methode: 300-150-100-75-60-50
Number of beat in 6 sec x 10

If regular
If irregular

Example to count Heart Rate

R wave

Find a R wave that lands on a bold line.

Count total of large boxes to the next R wave. If
the second R wave is
1 large box away the rate is 300,
2 boxes - 150,
3 boxes - 100,
4 boxes - 75, etc.

Example to count Heart Rate

3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

Memorize

the sequence:

300 - 150 - 100 - 75 - 60 - 50

Interpretation?

Approx. 1 box less than 100 = 95 bpm

Example to count Heart Rate

3 sec

Count

3 sec

total of R waves in a 6 second

rhythm strip, then multiply by 10.

Interpretation?

9 x 10 = 90 bpm

wave
Inspect P in lead II and V1 for:
Right

atrial enlargment (P pulmonal)?

Left atrial enlargment (Pmitral)?

 PR

interval

Normal PR interval = 0.12-0.20 sec (3-5 small

boxes)

QRS Wave
QRS interval?

Axis look at lead I and aVF

Normal QRS interval 0.10 sec (2.5 small boxes)

NAD?
LAD?
RAD?

Transition zone?

Normal in V3 and V4
V1 and V2 counter clockwise
V5 and V6 clockwise

Inspect for left and right ventricular hypertrophy

Inspect for pathologic Q wave: what anatomic distribution?

QRS Axis

 ST

segment or T wave abnormalities

Inspect for ST elevation
Myocard

Infartion STEMI
what anatomic distribution?

Inspect for ST depressions or T wave

inversion:
Myocardial

ischemia or Non-ST elevation MI

what anatomic distribution?

Abnormalities of the P Wave

P

wave Represent depolarization of the

right atrium followed quickly by the
depolarization of the left atrium
The two components are nearly
superimposed on one another
Right atrial enlargment best observed
in lead II
Left atrial enlargment best observed in
lead V1.

Right atrial abnormality

wave amplitude
> 2.5 mm in leads II

Left atrial abnormality

Negative

P in V1

> 1 mm wide
> 1 mm deep

Abnormalities of the QRS Complex

For
1.
2.

this Modul, we will discuse:

Ventricular hypertrophy
Pathologic Q wave

Right ventricular hypertrophy

V1 & V2 record greater

than normal upward
deflections

The R wave becomes

taller than the S wave
in V1 & V2

The increased right

ventricular mass shifts
the mean axis of the
heart RAD (mean
axis > +900)

Left ventricular hypertrophy

V5 & V6 show taller

than normal R waves

V1 & V2 demonstrate
the opposite
deeper than normal
S waves

Pathologic Q Wave

In Myocardial Infarction
Irreversible necrosis of the heart muscle
Width 1 small box and depth > 25% of total
height of QRS
Necrotic muscle does not generate electrical
force.
The ECG electrode over that region detects
electrical currents from the healthy tissue on
opposite regions of the ventricle inscribing the
downward deflection
Do not differentiated between acute event and
an MI that ocured week or years earlier

ST Segment and T Wave

Abnormalities

Acute ST Segment Elevation MI

The initial abnormality is elevation of the ST segment,

often with a peaked appearance of the T wave.
Abnormality of injured myocardial cell

The diastolic current theory

Capable of depolarization but abnormally leaky

Allowing ionic flow that prevents the cells from fully
repolarization

The systolic current theory

Acute Non-ST Segment Elevation MI

Result from an acute partially occlusive coronary

thrombus
ST segmen depression and T wave inversion

The diastolic current theory

MI Locations
First, take a look
again at this
picture of the
heart.

Anterior portion
of the heart

Inferior portion
of the heart

Lateral portion
of the heart

MI location

Resource

Pathophysiology of Heart Disease, Leonard S. Lilly

Lange Instant Access EKGs and CARDIAC STUDIES, Anil M. Patel
Kursus Elektrokardiografi, Perki