ECG Interpretation

By: Deepak Kapoor

Clinical Training (Simulation) & Education, M.Sc.N Critical Care, M.Sc. (HQM)),
Leadership Program-IIM-A, BSN, DCCN, CPQIH, AHA- BLS, ACLS Provider, Certified
Diabetic Educator, Certified Palliative Care Professional, B.Com(Delhi University)
Ph-9717170871
Anatomy and Physiology

• Located in the middle of

the thoracic cavity

• It lies left of the midline of

the mediastinum and just
above the diaphragm.

• The heart is protected

anteriorly by the sternum
and posteriorly by the
spine.

• Lungs are located on either

side.
Electrical Activity of the Heart

• The sinoatrial (SA), or sinus

node initiates a self-
generating impulse and is the
primary pacemaker which sets
a rate of 60 to 100 beats per
minute (bpm).

• The SA node is located at the

border or junction of Superior
Vena Cava and Right Atrium.
Once generated, the electrical
impulse sets the rhythm of
contractions and travels
through both atria over a
specialized conduction
network to the
Atrioventricular (AV) Node.
Electrical Activity of the Heart

• The AV node is located in the

floor of the Right Atrium and
receives the impulse and
transmits to the Bundle of
His.

• The Bundle of His then

divides into a right bundle
branch and two left bundle
branches.

• These terminate in a complex

network called the Purkinje
Fibers, which spread
throughout the ventricles.
 What is an ECG?
An electrocardiogram (EKG or ECG) is a test that checks for problems with
the electrical activity of your heart. An EKG translates the heart's electrical
activity into line tracings on paper. The spikes and dips in the line tracings
are called waves.
Leads Placement
ECG Scale

Remember this :-

One Small Box = 0.04sec

One Large Box (5 small
box)=0.20sec
One Big Box (5 large box) =1 sec
 Types of waves
WAVES:
•P
•Q
•R
•S
•T
•U
 Waves and Heart’s Functions
LET’s CAPTURE THE SNAPSHOTS OF CARDIAC CONDUCTION SYSTEM AND
CO-RELATION BETWEEN WAVES AND PHYSIOLOGY OF CARDIAC SYSTEM

• P
• Q
• R
• S
• T
• U
Let’s study waves on ECG paper
 5 things to remember
• Rhythm – Regular or not?
(num of R waves in 10 sec X 6 = Heart
Beats/Min)
• Rate – 60-100 beats/min
• QRS duration - it normally lasts 0.06–
0.10 sec
• P wave - Visible before each QRS
complex?
• P-R Interval - Normal (<5 small
Squares. Anything above and this
would be 1st degree block)
 Heart Rate Calculation
The 6 Second Rule:

At a paper speed of 25mm/sec, a 6 second strip is selected between the

black arrows. The number of heart cycles counted is 7. HR= 7 x 10= 70
bpm.
 Normal Sinus Rhythm

Looking at the ECG you'll see that:

Rhythm - Regular
Rate - (60-99 bpm)
QRS Duration - Normal
P Wave - Visible before each QRS complex
P-R Interval - Normal
 Sinus Bradycardia

A heart rate less than 60 beats per minute (BPM). This in a healthy
athletic person may be 'normal', but other causes may be due to
increased vagal tone from drug abuse, hypoglycaemia and brain injury
with increase intracranial pressure (ICP) as examples

Looking at the ECG you'll see that

Rhythm – Regular
Rate - less than 60 beats per minute
QRS Duration – Normal
P Wave - Visible before each QRS complex
P-R Interval – Normal

Usually benign and often caused by patients on beta blockers

 Sinus Tachycardia

An excessive heart rate above 100 beats per minute (BPM) which
originates from the SA node. Causes include stress, fright, illness and
exercise. Not usually a surprise if it is triggered in response to regulatory
changes e.g. shock. But if their is no apparent trigger then medications
may be required to suppress the rhythm

Looking at the ECG you'll see that:

Rhythm – Regular
Rate - More than 100 beats per minute
QRS Duration – Normal
P Wave - Visible before each QRS complex
P-R Interval – Normal
The impulse generating the heart beats are normal, but they are
occurring at a faster pace than normal. Seen during exercise
Supraventricular Tachycardia (SVT)
Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in

the 'atria' but is not under direct control from the SA node. SVT can
occur in all age groups
Looking at the ECG you'll see that:

Rhythm – Regular
Rate - 140-220 beats per minute
QRS Duration - Usually normal
P Wave - Often buried in preceding T wave
P-R Interval - Depends on site of supraventricular pacemaker

Impulses stimulating the heart are not being generated by the sinus
node, but instead are coming from a collection of tissue around and
involving the atrioventricular (AV) node
 Atrial Fibrillation

Many sites within the atria are generating their own electrical impulses, leading
to irregular conduction of impulses to the ventricles that generate the heartbeat.
This irregular rhythm can be felt when palpating a pulse

It may cause no symptoms, but it is often associated with palpitations, fainting,

chest pain, or congestive heart failure.

Looking at the ECG you'll see that:

Rhythm - Irregularly irregular
Rate - usually 100-160 beats per minute but slower if on medication
QRS Duration - Usually normal
P Wave - Not distinguishable as the atria are firing off all over
P-R Interval - Not measurable
The atria fire electrical impulses in an irregular fashion causing irregular heart
rhythm
 Atrial Flutter

Looking at the ECG you'll see that:

Rhythm – Regular
Rate - Around 110 beats per minute
QRS Duration - Usually normal
P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F -
1QRS) but sometimes 3:1
P Wave rate - 300 beats per minute
P-R Interval - Not measurable

As with SVT the abnormal tissue generating the rapid heart rate is also in the
atria, however, the atrioventricular node is not involved in this case.
 1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but
all electrical signals reach the ventricles. This rarely causes any problems by
itself and often trained athletes can be seen to have it. The normal P-R interval
is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG.
Looking at the ECG you'll see that:

Rhythm – Regular
Rate – Normal
QRS Duration – Normal
P Wave - Ratio 1:1
P Wave rate – Normal
P-R Interval - Prolonged (>5 small squares)
 2nd Degree Block Type 1
(Wenckebach)

Another condition whereby a conduction block of some, but not all atrial beats
getting through to the ventricles. There is progressive lengthening of the PR
interval and then failure of conduction of an atrial beat, this is seen by a
dropped QRS complex.

Looking at the ECG you'll see that:

Rhythm - Regularly irregular

Rate - Normal or Slow
QRS Duration – Normal
P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
P Wave rate - Normal but faster than QRS rate
P-R Interval - Progressive lengthening of P-R interval until a QRS complex is
dropped
 2nd Degree Block Type 2

When electrical excitation sometimes fails to pass through the A-V node or
bundle of His, this intermittent occurance is said to be called second degree
heart block. Electrical conduction usually has a constant P-R interval, in the
case of type 2 block atrial contractions are not regularly followed by ventricular
contraction

Looking at the ECG you'll see that:

Rhythm – Regular
Rate - Normal or Slow
QRS Duration – Prolonged
P Wave - Ratio 2:1, 3:1
P Wave rate - Normal but faster than QRS rate
P-R Interval - Normal or prolonged but constant
 3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are
'normal' but no electrical conduction is conveyed to the ventricles. The
ventricles then generate their own signal through an 'escape mechanism' from
a focus somewhere within the ventricle. The ventricular escape beats are
usually 'slow‘
Looking at the ECG you'll see that:

Rhythm – Regular
Rate – Slow
QRS Duration – Prolonged
P Wave – Unrelated
P Wave rate - Normal but faster than QRS rate
P-R Interval – Variation
Complete AV block. No atrial impulses pass through the atrioventricular node
and the ventricles generate their own rhythm
 Bundle Branch Block

Abnormal conduction through the bundle branches will cause a depolarization

delay through the ventricular muscle, this delay shows as a widening of the
QRS complex. Right Bundle Branch Block (RBBB) indicates problems in the
right side of the heart. Whereas Left Bundle Branch Block (LBBB) is an
indication of heart disease. If LBBB is present then further interpretation of the
ECG cannot be carried out.

Looking at the ECG you'll see that:

Rhythm – Regular
Rate – Normal
QRS Duration – Prolonged
P Wave - Ratio 1:1
P Wave rate - Normal and same as QRS rate
P-R Interval - Normal
Premature Ventricular Complexes

Looking at the ECG you'll see that:

Rhythm –Regular
Rate – Normal
QRS Duration – Normal
P Wave - Ratio 1:1
P Wave rate - Normal and same as QRS rate
P-R Interval – Normal
Also you'll see 2 odd waveforms, these are the ventricles depolarising
prematurely in response to a signal within the ventricles.(Above - unifocal
PVC's as they look alike if they differed in appearance they would be called
multifocal PVC's, as below)
 Junctional Rhythms

In junctional rhythm the sinoatrial node does not control the heart's rhythm - this
can happen in the case of a block in conduction somewhere along the pathway.
When this happens, the heart's atrioventricular node takes over as the
pacemaker.
Looking at the ECG you'll see that:
Rhythm – Regular
Rate - 40-60 Beats per minute
QRS Duration – Normal
P Wave - Ratio 1:1 if visible. Inverted in lead II
P Wave rate - Same as QRS rate
P-R Interval - Variable
Below - Accelerated Junctional Rhythm
 Ventricular Tachycardia (VT)
Abnormal

Looking at the ECG you'll see that:

Rhythm – Regular
Rate - 180-190 Beats per minute
QRS Duration – Prolonged
P Wave - Not seen

Results from abnormal tissues in the ventricles generating a rapid and irregular
heart rhythm. Poor cardiac output is usually associated with this rhythm thus
causing the pt to go into cardiac arrest. Shock this rhythm if the patient is
unconscious and without a pulse
 Ventricular Fibrillation (VF)
Abnormal

Disorganised electrical signals cause the ventricles to quiver instead of contract

in a rhythmic fashion. A patient will be unconscious as blood is not pumped to
the brain. Immediate treatment by defibrillation is indicated. This condition may
occur during or after a myocardial infarct.

Looking at the ECG you'll see that:

Rhythm – Irregular
Rate - 300+, disorganised
QRS Duration - Not recognisable
P Wave - Not seen
This patient needs to be defibrillated!! QUICKLY
 Asystole - Abnormal

A state of no cardiac electrical activity, as such no contractions of the

myocardium and no cardiac output or blood flow are present.

Looking at the ECG you'll see that:

Rhythm – Flat
Rate - 0 Beats per minute
QRS Duration – None
P Wave – None

Carry out CPR!!

 Myocardial Infarct (MI)

Looking at the ECG you'll see that:

Rhythm – Regular
Rate - 80 Beats per minute
QRS Duration – Normal
P Wave – Normal

S-T Element does not go isoelectric which could indicate infarction. However
this is NOTdiagnostic unless associated with a 12 lead ECG
 Any questions?
Please connect…..

Ph-9717170871
Email- deepak.kapoor@live.co.uk
Thanks!