ECG basics

An ECG is
A recording of the electrical activity of the heart,
taken from electrodes placed on the body surface.
10 electrodes used to generate a 12-lead ECG and
rhythm strip.
Can be performed at rest, or during or immediately
after exercise.

An ECG is
Used to aid in the diagnosis of:
Structural abnormalities
Hypertrophy, HOCM, accessory pathways,
chamber size
Rate abnormalities
Rhythm abnormalities
Including conduction deficits
Ischaemia and infarction (*)
Infection / peri- and myo-carditis / tamponade

ECG Interpretation

Rate
Rhythm
Axis
Intervals (PR, QRS, QT)
QRS complex
ST segment

Finally, state diagnosis (or whether it is normal /

abnormal)

Waveforms and Intervals

Estimating the Rate; The Rule of

300
Estimate rate by:
300 number of big boxes between R-R
No. of big
boxes

Rate

300

150

100

75

60

50

Normal is 3-5
big boxes
between QRS
complexes.
Average is 4
(this would be
0.8s per beat,
giving ~72bpm)

 Division of Nursing, University of

Nottingham 2012

 Division of Nursing, University of

Nottingham 2012

Precordial Leads

Adapted from: www.numed.co.uk/electrodepl.html

Axis

Coronal vs. Axial plane

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ECG Territories

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ECG Territories

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Rhythm 1

1 Degree HB
st

1st degree heart block occurs when there is a

conduction problem somewhere between the
SA node and the ventricles
PR interval is prolonged in 1st degree heart
block. Normally PR is no greater than 200ms
(1 large square)
May be a sign of coronary artery disease,
acute rheumatic carditis, digoxin toxicity or
electrolyte disturbances

nd

+ 3 Degree HB
rd

3rd degree = complete AV dissociation

No relationship between P-R, but R-R
interval is constant (can be hard to spot!)
2nd degree HB:
Mobitz type 1 (Wenkebach)
Progressive PR lengthening until a QRS
is dropped
Mobitz type 2
Regular PR interval with skipped beats
Usually 2:1 or 3:1
More serious > risk of syncope or CHB

Rhythm 2

LBBB

Conduction problem in the left bundle branch

Wide QRS complex (should be <120 ms or 3 small
squares)
RBBB may occur in healthy people but LBBB is
always an indication of heart disease, usually leftsided
LBBB is associated with T wave inversion in the
lateral leads (I, aVL and V5-V6) though not
necessarily all of these
WILLIAM LBBB is best seen in V6 with an M
pattern and a W pattern may be seen in V1
although this is often not fully developed

LBBB vs. RBBB

WiLLiaM M pattern in V6 and a W pattern
may be seen in V1 although this is often not fully
developed
MoRRoW RBBB has an M pattern in V1 and W
pattern in V6
Real explanation is RSR pattern in the leads
corresponding to the location of the BBB. The R is
a second wave of depolarisation

LBBB on 12-lead ECG

Rhythm 3

Sinus bradycardia
Rate <60 bpm
Only concerning if symptomatic
Causes: Medication (*), physical fitness, vasovagal
attacks, hypothermia, hypothyroidism
Rx: Pacemaker

Rhythm 4

Ventricular Fibrillation
When the ventricular muscle fibres contract
independently, no QRS complex can be
identified and the ECG is totally disorganised
Patient will have lost consciousness before the
ECG shows this pattern!
Causes: MI, cardiomyopathy, heart surgery,
congenital heart disease, trauma, electric shock

ECG 1

Atrial flutter
Sawtooth appearance (atrial rate usually
>300bpm, but not every beat conducted to
ventricles)
Variable block (3:1 4:1)
Block increased by carotid sinus pressure
Causes: Cardiac ischaemic heart disease,
cardiomyopathy, valvular heart disease, mitral
valve prolapse, atrial septal defect,
myopericarditis, sick sinus syndrome, post CV
surgery, post atrial fibrillation ablation. Other
thyrotoxicosis, PE, COPD, acute infection,
hypoxaemia.

ECG 2

ECG 3

Ventricular tachycardia
Polymorphic ventricular tachycardia is VT with a beatto-beat variation
If a focus in the ventricular muscle depolarises with
high frequency, the rhythm is called ventricular
tachycardia
Excitation spreads by an abnormal path through the
ventricular muscle so the QRS complexes are wide
and abnormal. This is seen in all leads.
Intervals, P waves and T waves cannot be determined
Causes: Usually due to acute MI. Cardiomyopathy,
heart failure, heart surgery.

ECG 4

Acute STEMI
Patients with STEMI need thrombolysis or
immediate angioplasty
Inferior leads = II, III, aVF
Treatment MONA morphine, oxygen 100%, nitrates
2 puffs SL, 300mg aspirin

ECG 5

Atrial fibrillation
When the atrial muscle fibres contract
independently there are no P waves on the ECG,
only an irregular line
QRS complexes are normal because conduction to
the ventricles is by the normal route
Fibrillation is often seen better in some leads than
others
The AV node is continuously bombarded with
depolarisation waves of varying intensity and
depolarisation occurs at irregular intervals down the
bundle of His so the ventricular contraction is
irregular
Causes: Drugs, stress, MI, pain, anxiety, infection,

ECG 6

Prolonged QT
The QT interval varies with heart rate
It is prolonged in patients with some electrolyte
abnormalities, and more importantly it is prolonged
by some drugs
A prolonged QT interval (> 450 ms) may lead to
ventricular tachycardia
Note PVCs