ECG at a glance

ACTION POTENTIAL

Polarization

Depolarization

Intracellular is more negative than

extracellular
Intracellular becomes more positive
Influx of Na+

Repolarization

Intracellular restores to its resting

potential
Efflux of K+

ACTION POTENTIAL

CARDIAC CELLS
PROPERTIES
Automaticity
Excitability
Conductivity
Contractility

CONDUCTION SYSTEM

Sinoatrial Node (SA Node)

Internodal Pathway

Rhythmic rate : 60 100 bpm

Anterior, middle, posterior
pathways

Atrioventricular Node (AV Node)

Regions : atrionodal (AN), nodal
(N),
nodal-His (NH)
Delays the impulse

CONDUCTION SYSTEM

Bundle of His

Rate : 40 60 bpm

Bundle Branches
LBB & RBB
LBB : anterior, posterior, septal
fascicles

Purkinje Fibers

Rate : 20 40 bpm

CONDUCTION SYSTEM

CONDUCTION SYSTEM

LEADS

Standard Limb Leads

Augmented Limb Leads

Lead I, II, III

aVL, aVR, aVF

Precordial Leads
V1, V2, V3, V4, V5, V6
V1R, V2R, V3R, V4R, V5R, V6R

LEADS

LEADS
LEADS

VIEW OF HEART

I, aVL

Lateral

II, III, aVF

Inferior

V1, V2

Septal

V3, V4

Anterior

V5, V6

Lateral

ECG WAVEFORMS

ECG WAVEFORMS

P wave

No more than 2.5 mm in

height
No more than 0.11 sec in
duration
Positive : I,II,aVF,V2-6
May be positive, negative, or
biphasic : III,aVL,V1

ECG WAVEFORMS

PR interval

0.12 0.20 sec in adult,

may be shorter in children
and longer in elders

ECG WAVEFORMS

QRS Complex

0.06 0.10 sec

Q : 1st negative deflection after P
R : 1st positive deflection after P
S : negative deflection after R

ECG WAVEFORMS

ST Segment

Isoelectric (flat)

ECG WAVEFORMS

T wave

Limb lead : no more than 5 mm (height)

Precordial lead : no more than 10 mm
(height)

ECG WAVEFORMS

RATE MEASUREMENT
Large Boxes 300/R-R interval
Small Boxes 1500/R-R interval
Six-Second Method count the
number of complete QRS
complexes in 6 seconds

AXIS DEVIATION

ABNORMAL
WAVEFORMS

P : tall, notched
PR interval : prolonged, shortened
Q : pathologic Q (>0.04 sec, 25% of the R
wave)
QRS complex : widened (>0.10 sec)
ST segment : depression (>1 mm),
elevation (>1 mm in limb leads or >2mm
in precordial leads)
T : peaked/tall, inverted, flattened
QT interval : prolonged, shortened

ABNORMAL
WAVEFORMS

ST segment : depression (>1

mm), elevation (>1 mm in limb
leads or >2mm in precordial
leads)

ABNORMAL
WAVEFORMS

T wave : peaked/tall, inverted,

flattened

R-WAVE PROGRESSION
Poor R-wave progression :
Infarction (anteroseptal)
LBBB
LVH
Severe COPD (emphysema)

ATRIAL ENLARGEMENT
Left Atrial Enlargement
Notched P wave
Right Atrial Enlargement
Peaked P Wave

VENTRICULAR
HYPERTROPHY

Left Ventricular Hypertrophy

S wave in V1/V2 + R wave in V5/V6 35 mm (mV)

R wave in aVL 12 mm (mV)
Strain pattern in V5 and V6
May be accompanied by LAD

VENTRICULAR
HYPERTROPHY

Right Ventricular Hypertrophy

RAD
Reversed R-wave progression (taller R waves and
smaller S waves in V1 & V2; deeper S waves & small R
waves in V5 & V6

MYOCARDIAL
INFARCTION

MYOCARDIAL
INFARCTION

Acute inferior myocardial infarction

MYOCARDIAL
INFARCTION

Septal wall myocardial infarction

MYOCARDIAL
INFARCTION

Extensive (whole) anterior

myocardial infarction

MYOCARDIAL
INFARCTION

Inferior wall myocardial infarction

with a possible posterior wall
infarction

MYOCARDIAL
INFARCTION
Evolutionary changes in
anteroseptal myocardial
infarction

A.
B.
C.

At admission
At 24 hours
At 48 hours

MYOCARDIAL
INFARCTION
Evolutionary changes in
inferior and right
ventricular infarction

A.
B.
C.

At admission
At 12 hours
Right chest leads

CAUSES OF
DYSRHYTHMIAS

Enhanced Automaticity
Reentry
Escape Beats
Conduction Disturbances

SUPRAVENTRICULAR
ARRHYTHMIAS

Supraventricular Tachycardia

Rate : 150-250 bpm

Rhythm : regular
P waves : frequently buried in preceding T waves
PR interval : usually not possible to measure
QRS : normal

SUPRAVENTRICULAR
ARRHYTHMIAS

Atrial Flutter

Rate : atrial : 250 350 bpm; ventricular : slow/fast

Rhythm : usually regular
P waves : saw teeth appearance
PR interval : variable
QRS : usually normal, may be widened
Conduction ratio : 2:1, 4:1, 6:1

SUPRAVENTRICULAR
ARRHYTHMIAS

Atrial Fibrillation (AFib)

Rate : atrial : > 350 bpm; ventricular : slow/fast

Rhythm : irregular
P waves : no true P waves; chaotic atrial activity
PR interval : none
QRS : normal

VENTRICULAR
ARRHYTHMIAS

Ventricular Tachycardia

Rate : 100 250 bpm

Rhythm : regular
P waves : none or not associated with
QRS
PR interval : none
QRS : wide (>0.10 sec), bizarre
appearance

VENTRICULAR
ARRHYTHMIAS

Ventricular Fibrillation

Rate : indeterminate
Rhythm : chaotic
P waves : none
PR interval : none
QRS : none

VENTRICULAR
ARRHYTHMIAS

Torsades de Pointes

Rate : 200 250 bpm

Rhythm : irregular
P waves : none
PR interval : none
QRS : wide (>0.10 sec), bizarre appearance

EXTRASYSTOLE

Atrial Extrasystole (AES) / Premature Atrial

Contraction (PAC)

Rhythm
: irregular due to the premature beat
Rate
: depends on its basic rhythm
P
wave
: unusual compare to basic rhythm
PR interval
: normal, maybe shorten
QRS
: normal

EXTRASYSTOLE

Ventricular Extrasystole (VES) / Premature

Ventricular Contraction (PVC)

Rhythm
: irregular due to the premature beat
Rate
: depends on its basic rhythm
P
wave
: none
PR interval
: none
QRS
: > 0.12 sec
Threatening VES :
R on T VES
VES > 6 times/min
Bigemini VES
Multifocal VES
Consecutive VES

EXTRASYSTOLE

BLOCKS

1st Degree AV Block

Rate : normal
Rhythm : regular
P waves : normal
PR interval : prolonged (>0.20 sec) but constant
QRS : usually 0.10 sec or less

BLOCKS

2nd Degree AV Block Type I/Mobitz Type

I/Wenckebach

Rate : atrial > ventricular

Rhythm : atrial regular; ventricular irregular
P wave : normal
PR interval : lengthen with each cycle until P wave
appears without a QRS complex
QRS : usually 0.10 sec or less

BLOCKS

2nd Degree AV Block Type II/Mobitz Type II

Rate : atrial > ventricular

Rhythm : atrial regular; ventricular irregular
P wave : normal
PR interval : normal or slightly prolonged but constant
for the conducted beats; there maybe some shortening
of the PR interval that follows a non-conducted P wave
QRS : usually 0.10 sec or less
Conduction ratio 2:1, 3:1, 4:1

BLOCKS

3rd Degree AV Block/Complete AV Block/Total Heart

Block

Rate : atrial > ventricular.

Rhythm : atrial regular; ventricular regular (AV
dissociation)
P wave : normal
PR interval : none; the atria and ventricles beat
independently
QRS : narrow or wide

BLOCKS

Left Bundle Branch Block (LBBB)

BLOCKS

Right Bundle Branch Block (RBBB)

BLOCKS

Fascicular Block/Hemiblock

Left Anterior Fascicular Block (LAFB) :

LAD
Left Posterior Fascicular Block (LPFB) :
RAD

PULSELESS ELECTRICAL
ACTIVITY (PEA)
Electrical activity is seen in ECG but
no pulse is detected when palpating
the artery

Danke !