# ECG Fundamentals - Tutorial

* components of 12-lead ECG

* ensure correct paper speed = 25 mm/s
* calibration: 10mm = 1 mV
* sq = 0.04s
* SQ = 0.2s
* waves
* p = atrial contraction
* PR = time from SA node/atrial ectopic to AV node
* QRS = ventricular depol
* Q down
* R up
* S down
* T wave = Ventricular repol
* ST = end of QRS to beginning of T
* early part of Ventricular repol
* J point = point where QRS ends & ST segment begins
* QT = from beginning QRS to end of T wave
* start ventricle depol to end ventricle repol
* 0.36-0.45
* varies by HR, gender, age, rate
* should be less than 1/2 R-R interval between two complexes
* U wave
* unknown
* abnormal if prominent or inverted

Rhythm Strip

* long strip of any lead

* used to work out HR, rhythm
* and diagnose sinus/AV blocks

12-lead ECG

* determine cardiac axis, hypertrophies, blocks, ischemia/MI, complex arrhy,

toxic/inf changes

## Systematic Evaluation

* Details
* Name
* DOB
* UR number
* date
* HOPC/indication for ECG
* compare with previous ECGs (look for subtle changes)
* Check for mistakes
* aVR has -ve complexes
* since aVR is situated at R shoulder (opposite to current direction)
* current should not be going to here, unless pathology or leads stuck on wrong
* paper speed + calibration

### Steps - do in this order

1. Rhythm Strip Eval (Trace)

1. rate
1. use lead II preferably
 2. P-waves:
1. < 0.1s, 0.5-2.5 mV in lead II, small, smooth, rounded
2. 1P:1QRS (each P-wave is followed by a QRS)
3. PP-interval regular?
4. smaller P-waves and shorter PR interval = atrial ectopic (e.g. SA node
is fucked)
5. Failure backups: SA ---> atrial ectopic --> AV node
3. PR-interval
1. x< 0.2s
2. PR interval 0.2s --> excessive AV nodal laggy
3. Dx: blocks, atrial tachycardia
4. QRS
1. x < 0.12s (under 3 sq)
2. wide QRS = not normal (e.g. BBB --> lose heart twist during contraction
--> _ SV _ CO)
5. QT interval
1. 0.36-0.44
2. check RR interval, make sure end of T-wave before 1/2 way (QT < 1/2 RR
interval)
3. prolonged QT interval = ^ repol time --> ^ chance of premature APs &
Arrhythmias
4. e.g. genetic long QT (young people, dehydrated), Terfenidine poisoning
6. Determining Rate
1. 300/n(SQ between QRS complexes)
2. n(QRS in 10s strip) x6
7. Rates
1. x > 100 = tachy
2. x < 60 = brady
2. rhythm
1. sinus (SR) = each P wave followed by QRS (1:1)
3. regularity

1. e.g. 1
1. HR = 136
2. peaked P-waves with inconsistent/craggly shape = sinus tachycardia w/
ventricular response rate 120 (check if atrial tachycardia)
2. e.g. 2 = AFib w/ ventricular response rate 70-140 bpm (AF 70-140 bpm)
1. defined as irregularly irregular (wth no P-waves)
2. not sinus
3. no P-waves seen, fibrillating
4. QRS ok
5. long QT irregular
6. lose atrial kick
7. treat it, or get thrombus or _CO and pass out while say you're driving.
fuck
3. e.g. 3 Atrial Flutter 3:1 block, w/ ventricular response rate of 100
1. ventricular HR = 100
2. re-entrant pathway in atria with focus doing 300 BPM
3. F-waves = sawtooth P-waves (@ 300 bpm)
1. 3:1 block = every third F wave conducted thru the AV node (this is a
safety check)
2. have F-R interval, not a PR interval; FR intervals should all be the
same
3. can get 3rd degree AV block with flutter --> get ventricular escape
rhythm
4. QRS narrow
5. QT hard to tell
6. T-waves = have F-wave superimposed, so morphology looks funny
 7. will _ CO cos _ SV
4. e.g. 4 = Sinus rhythm with 1st degree AV-block (1HB) @ ventricular response
rate 62 bpm
1. HR = 60-65 bpm
2. sinus regular
3. P waves regular, look ok
4. long PR interval
5. QRS ok, QT ok
6. 1st degree AV blocks (1HBs)
1. excessive lag specifically at AV node (fibrosis, ischemic, swollen,
drugs)
2. PR > 5sq
5. e.g. 5) Sinus with Third Degree Heart Block (3HB) woth V response rate 52
1. P waves: 57
1. sinus rhythm PP interval regular
2. sometimes get obscured
2. AV node is totally fucked and not passing current
3. Ventricular: 52 bradycardia
4. QRS
1. wide as fuck
2. totally dissociated from P (no P:QRS ratio)
3. get ventricular escape rhythm (final backup), very slow
5. T waves
1. sometimes have a P-wave inside --> altered morphologu
6. e.g. 6) Ventricular Tachycardia
1. wide complex tachycardia --> looks like VT anyway
2. P
1. regular
2. can't see P waves
3. PR
4. AV
5. QRS
1. wide as fuck QRS

2. Axis

1. measure voltage from 2 perpendicular leads

2. ==read from lead 1 and aVF==
1. easiest way
2. these leads are perpendicular
3. Lead II = 45% between lead 1 and aVF; don't use lead 2 (not perpendicular
with lead)
3. or use I, II and III - must look at all 3 or get bad interpretation
4. can also plot
5. normal = between +90 degrees and 30 deg
1. ^I ^aVF
6. Left AD: ^I _aVF (diamond): Ladies Adore Diamonds
7. Right AD: _I ^aVF (dog bone): Rover adores bones
8. no man's land = _I _aVF : wtf is going on (indeterminate)
9. e.g. 1) normal
10. e.g. 2) LAD
11. e.g. 3) RAD

3. Hypertrophy - can alter morphology of ST and T-waves (may misdiagnose for

ischemia)

1. Atrial
2. Ventricular
1. QRS are narrow
 2. LVH
1. LAD - hypertrophy or BBB
2. high complexes V1, V2, V5 or V6 > 30 mm
1. can be so high that they smear over onto other strips
2. QRS taller on the left side of chest leads
3. biggest complex of V1 or V2 added to biggest complex of V5 or V6 35mm
1. thick LV walls --> ^ amplitudes
4. lateral ST T-wave strain pattern in I, aVL + V5, V6
1. T-wave inversion or ST elevation
2. aberrant pathway of repol d/t excessive muscle tissue
5. ddx infarct
3. RVH
1. RAD
2. dominant R wave in V1 > 7mm or R/S ratio > 1
1. QRS larger on the right side of the chest leads
3. Dominant S wave in V5/6 > 7mm deep or R/S ratio < 1
4. RA enlargement
5. ST depression T wave inversion strain pattern in V1-V2 and inferior
leads

4. Blocks

1. hemi-blocks
2. AV Blocks
1. 1HB
2. 2HB
1. a Wenkebach
2. b 2:1 block
3. 3HB
3. BBBs
1. always have
1. wide QRS with normal sinus rhythm
2. St/T=wave changes on opposite axis of terminal QRS
3. increase ventricualr activation time (first upward deflection of QRS is
longer)
2. RBBB - one bundle on right
1. usually no axis deviation
2. V1-V3 ST-Twave strain pattern
3. d/t current having to go from L bundle across to right (coz Rbundle is
fucked)
1. secondary R wave in V1-3 (RSR pattern)
2. wide slurred S waves in lateral leads
4. 'Marrow' M in V1, W in V6
5. e.g. RBBB
1. Marrow
2. wide QRS
6. RBBB can be normal
1. check if changed from previous ECG
3. LBBB - 2 bundles on left
1. ventricles activated sequentially (R than left) rather than
simultaneously)
2. Deep S waves in V1 to V3, with rabbit-ear notch in middle
3. LAD often
4. Tall R waves in laterla leads I, V5,-6
5. 'William' W in V1, M in V6
6. e.g. 1) LBBB
1. wide P-wave - LA enlagement
2. AV block (long PR)
3. LAD (diamond)
 4. William + ST-T-wave changes
5. ddx MI
6. is this a new change? in context of chest pain --> an MI, send to
cath lab
7. LBBB always linked to pathology

5. Ischemia/Infarction

1. Lead Grouping - where do the leads look?

1. Inferior = II, III aVF (right coronary)
2. Lateral = I, aVL, V5, V6 (LCX, diagonal)
3. Septal (V1, V2) --> LAD
4. Anterior V1-V4 (LAD)
2. ST changes
1. normal = flat/isoelectric
2. Elevation = infarct
3. depression = ischemia/reciprocal
4. x > 2mm high/low in chest leads in 2 leads at same location (e.g. two
anterior leads)
5. x > 1mm high/low in limb leads in 2 leads
3. T-wave changes
1. normal shape
1. slightly rounded
2. slightly asymmetrical
3. < 5mm limb leads, < 10mm precordial leads
2. changes
1. inverted?
2. peaked?
3. flattened?
3. global T-wave changes - hyperkalemia, pericarditis
4. Q-waves
1. small septal Q waves in LV leads d/t depol of septum from L to R
2. pathologicla Q-waves
1. d/t irreversible myocardial necrosis
2. x > 0.04 s wide
3. needs to be in 2 leads in same area
4. 25% heart of R wave
5. e.g. old infarcts

### **<u>Main Examples</u>**

**Question 1 - normal sinus rhythm**

* HR 85, sinus
* normal axis
* P wave: normal length, normal morphology
* QRS length ok, height ok
* no hypertrophy
* no blocks
* no ischemia

**Question 2 LVH**

* HR 60, sinus
* P waves ok
* PR higher end of normal
* QRS wide (3+ to 4 sq)
* LAD
* hypertrophy
 * very long S-waves ( = 65mV)
* ST changes
* ST depression I, aVL, V5/6 (lateral side)
* ST T-wave (inversion) strain V1-4

**Question 3 STE Anterolateral with 1HB**

* HR 75, sinus
* P waves: exist
* PR elongated as fuck - 1HB (1st degree AV block)
* QRS too low
* QT ok
* LAD
* no hypertrophy
* ST changes
* STE anterolateral: I, V1-V4
* tombstoning

**Question 4 LBBB with 1HB**

1. aVR has -ve complexes = ok

2. rate 100 bpm, sinus rhythm
3. long P wave >0.1 - LV enlargement
4. PR extended > 0.2 1st degree AV block
5. wide QRS >3 sq - unlikely is hypertrophy
6. LAD (I and aVF)
7. William V1 V6/I/aVL
8. ST-Twave strain
9. T wave inversion V5/6
10. QT ok

**Question 5 - Sinus/Atrial rhythm 3HB**

* HR
* atrial = 60
* ventricular = 36
* P waves slightly flattened - non-sinus (ectopic focus)
* QRS being dropped, dissociated from P waves
* wide as fuck