Electrocardiogram

• Enables physicians to infer the course of the cardiac

impulse by recording the variations in electrical
potential at various loci in the body
• Records the heart’s electrical activity as waveforms
that depict depolarization (contraction) &
repolarization (relaxation)

• to diagnose and monitor certain disorders such as

myocardial infarction and pericarditis

• Allows identification of rhythm disturbances,

conduction abnormalities and electrolyte imbalances
 Electrocardiogram
• The physician gains valuable insight into:
1. The anatomical orientation of the heart
2. The relative sizes of thechambers
3. Various disturbances in rhythm and conduction
4. The extent, location, and progress of ischemic damage to
the myocardium
5. The effects of altered electrolyte concentrations
6. The influence of certain drugs (notably digitablis,
antiarrhytmic agents, and Ca++ channel antagonists)
 ECG
• Standard ECG is recorded in 12 leads
• Six Limb leads
– L1, L2, L3, aVR, aVL, aVF
– Provide information about the frontal plane of the heart
– Maybe unipolar or bipolar

• Six Chest Leads

– V1 V2 V3 V4 V5 and V6
– Provide information about the horizontal plane of the heart
– Unipolar
• L1 between LA and RA
• L2 between LF and RA
• L3 between LF and LA
 ECG Bipolar Limb Leads

- + - -
R L R L

F
+ +
F
 Standard Limb Leads
• Lead 1
– Positive electrode on LA
– Negative electrode on RA
– Positive deflection
– For monitoring atrial rhythms

• Lead 2
– Positive electrode on LL
– Negative electrode on RA
– Positive, high voltage deflection resulting in tall P, R & T waves
– For identifying P waves, detecting sinus node and atrial
arrythmias and monitoring inferior wall of LV
 Standard Limb Leads
• Lead 3
– Positive electrode on LL
– Negative electrode on LA
– Positive deflection
– For monitoring atrial rhythms and inferior wall of LV
 ECG Unipolar Limb Leads

+ +
R L

+ F

Lead aVR Lead aVL Lead aVF

 ECG Unipolar Leads
• Lead aVR
– Positive electrode on the RA
– Negative electrode on the Middle of heart
– Negative deflection
– Axis:-150 deg

• Lead aVL
– Positive electrode on LA
– Negative electrode on the Middle of heart
– Usually a positive deflection
– Axis:-30 deg

• Lead aVF
– Positive electrode on the LL
– Negative electrode on the Middle of heart
– Positive deflection
– For monitoring the inferior wall of the LV
– Axis:+90 deg
 ECG Chest Leads

12
 Precordial Leads
• V1
– Right side of the sternum at the 4th intercostal space
– For monitoring ventricular arrhythmias, ST segment changes and P
wave changes
– For differentiating tachycardia
• V2
– Left of the sternum at the 4th intercostal space
– Negative deflection with a small amount of positive deflection
– For detecting ST-segment elevation
• V3
– Between V2 and V4 at the 5th intercostal space
– Biphasic
– For detecting ST-segment elevation
• V4
– 5th intercostal space at the midclavicular line
– Positive deflection
– For detecting ST-segment & T-wave changes
• V5
– 5th intercostal space at the anterior axillary line
– Positive deflection
– For detecting ST-segment & T-wave changes
• V6
– 5th intercostal space at the midaxillary line
– Positive deflection
 ECG Grid
Y- Axis Amplitude in mill volts

X- Axis time in seconds

 ECG Grid
• Horizontal axis
– Represents time
– Small block = 0.04 second
– Five small blocks form a large block = 0.2 second
– Five large blocks = 1 second

• Vertical axis
– Amplitude in millimeters or electrical voltage in millivolts
– Small block = 1mm or 0.1 mV
– Large block = 5mm or 0.5 mV
APPROACH TO ECG
INTERPRETATION
 HEART RATE
• Regular rhythm
– Heart rate = 1500/# of small squares from R-R

• Irregular rhythm
– Heart rate = # of QRS complexes w/in 30 large boxes x 10
“Eye balling” HR
 RHYTHM
• Sinus Rhythm
– Normal looking P wave
– Followed by a QRS complex
– Distance between R-R intervals should be equal
– HR 60-100 bpm
– Pr interval measures 0.12 - 0.20 seconds
– QRS complex usually measures 0.10 seconds or
less
AXIS
Right Axis deviation: >100° to 180°
Left Axis deviation: -30° to -90°
Normal Axis: -30° to 100°
Extreme Axis deviation: -90° to 180°

Eye-balling method
Normal: QRS  lead I and avF
LAD: QRS  lead I and  avF
RAD: QRS  lead I and  avF
• To determine the heart axis you look at the extremity leads only (not
V1-V6). If you focus especially on leads I, II, and AVF you can make a
good estimate of the heart axis. Lead I looks horizontally from the
left side. Lead II looks from the left leg. Lead III from the right leg
and lead AVF from below towards the heart.
• positive deflection - QRS having a larger 'area under the curve'
above the baseline than below the baseline.
• Positive (the average of the QRS surface above the baseline) QRS
deflection in lead I: the electrical activity is directed to the left (of
the patient)
• Positive QRS deflection in lead AVF: the electrical activity is directed
down.
• This indicates a normal heart axis. Usually, these two leads are
enough to diagnose a normal heart axis! A normal heart axis is
between -30 and +90 degrees.
• A left heart axis is present when the QRS in lead I is positive and
negative in II and AVF. (between -30 and -90 degrees)
• A right heart axis is present when lead I is negative and AVF positive.
(between +90 and +180)
• An extreme heart axis is present when both I and AVF are negative.
(axis between +180 and -90 degrees). This is a rare finding.
 Intervals/Segments
• P wave - <0.12 s (3 small boxes wide)
• PR interval – 0.12 to 0.20 s (3-5 small boxes wide)
• QRS duration – 0.6 to 0.10 s
• ST segment – deflection: -0.5 to +1 mm
• T wave – 0.5mm leads I-III and 0.10mm precordial
leads
• QT interval – 0.36 to 0.44 s
• U wave - <1/3 T wave amplitude
• P wave – atrial depolarization
• PR interval atrial impulse from atria through the AV node
– -pathological prolongation of PR interval associated with disturbances in AV function
– -such disturbances may be produced by inflammatory, circulatory,pharmacological ornervous
mechanism.
• QRS complex – ventricular depolarization
– -an abnormally prolonged QRScomplex ma indicate a block in the normal conduction pathways
through the ventricles( such as a block of the left or right bundle branch block)
• ST segment – end of ventricular depolarization
– -normally lies in the isoelectric line
– -any apprciable deviation of the ST segment from the isoelectric line may indicate ischemic damage
to the myocardium
• T wave – refractory period of repolarization or ventricular recovery at peak
– -in most leads, the T wave is deflected in the same direction from the isoelectric line as the major
component of the QRS complex, although biphasic (oppositely directed) T wavesare perfectly
normal in certain leads
– -deviation of the T wave and QRS complex in the samedirection from the isoelectric line indicates
that the repolarization process is proceeding in a direction counter to that of the repolarization
process
– -T waves that are abnormal either in direction or in amplitude may indicate myocardial damage,
electrolyte disturbances, or cardiac hypertrophy.
• QT interval – time needed for ventricular repolarization and depolarization
– -period of the “electrical systole” of the ventricles
– -closely correlated with the mean action potential duration of the ventricular myocytes
– -duration is about 0.4 second, but it varies inversely with heart rate, mainly because of duration of
the myocadial cell action potential varies inversely with the heart rate
• U wave-repolarization of His-Purkinje system
 Normal ECG tracing

P wave (<0.12 sec.)

QRS complex (<0.10
sec.)
Equal R-R intervals
HR (60-100 bpm)
PR interval (0.12 -
0.20 seconds)
QT interval (0.36-
0.44 sec.)
Normal looking P wave, upright in lead II, one for every
QRS complex, all similar in size and shape/Followed by
a QRS complex/Distance between R-R intervals should
be equal/ PR and QT interval within normal limits/ T
wave normal shape, upright and rounded in lead II
, PR interval within normal limits