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ECG INTERPRETATION:ECG INTERPRETATION: the basics
Damrong Sukitpunyaroj MDDamrong Sukitpunyaroj, MDPerfect Heart Institue, Piyavate Hospital
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OverviewOverview• Conduction Pathways • Systematic Interpretation• Common abnormalities in Critical Care
– Supraventricular arrhythmiasVentric lar arrh thmias– Ventricular arrhythmias
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Conduction PathwaysConduction Pathways
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Conduction PathwaysConduction Pathways
P wave = atrial depolarisation.
PR Interval = impulse from atria to ventriclesto ventricles.
QRS complex = ventricular depolarisation.
ST segment = isoelectric - part of repolarisation.
T wave = usually same directionT wave = usually same direction as QRS - ventricular repolarisation.
QT Interval = This intervalQT Interval = This interval spans the onset of depolarisation to the completion of repolarization of the ventriclesof the ventricles.
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InterpretationInterpretation
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InterpretationInterpretation1. Rate = Number of P’s (atrial) R’s (ventricular) per
minute (6 second [30 squares] X 10 = minute rate).
P rate: 8 x 10 = 80 R rate: 8 x 10 = 80
2. Rhythm = Regular or irregular. Map P-P and R-R intervalsintervals.
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Interpretation3 P t 1 QRS h d ti lt
Interpretation3. P wave = present, 1 per QRS, shape, duration, voltage.
4. P-R interval = length (0.12 - 0.2 sec = <1 big square), isoelectric.
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InterpretationInterpretation5. QRS = duration (0.06 - 0.10 ), voltage, q or Q waves
6. ST Segment = shape, isoelectric with PR segment
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InterpretationInterpretation7. T wave = shape, direction
8. QT interval = length (R-R/2 or QTc <0.40 sec)
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Abnormalities: Supraventricular arrhythmias
• Atrial Fibrillation• Atrial Flutter • Supraventricular Tachycardia (SVT)
Abnormalities: V t i l h th i
• Premature Ventricular Complexes (PVCs)Ventricular arrhythmias
• Ventricular tachycardia (VT)
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Conduction PathwaysConduction PathwaysSupraventricular Narrow QRS complex
V t i lVentricular Wide QRS complex
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Abnormalities: atrial fibrillation
Rhythm: IrregularRate: A: 350 – 650; V: variesP: poorly definedP-R: N/AQRS: narrow complexS-T: normalT: normalQ-T: normal
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Abnormalities: atrial flutter
Rhythm: Regular / IrregularRate: A: 220 – 430; V: <300 (2:1, 3:1 or sometimes 4:1)
P: Saw toothed appearance P-R: N/AQRS: narrow complexS-T: normalT: normalQ-T: normal
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Abnormalities: supraventricular tachycardia (SVT)
Rhythm: RegularRate: >100P: not visibleP-R: not definedQRS: narrow complexS-T: depression (sometimes)T: normalQ-T: prolonged (sometimes)
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Abnormalities: premature ventricular complexes
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ExamplesExamples
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ExamplesExamples
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ECG INTERPRETATION:ECG INTERPRETATION: 12 Lead
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OverviewOverview• Lead Placement• Axis• Common abnormalities in Critical Care
– Heart blockB ndle branch blocks– Bundle branch blocks
– Life threatening arrhythmias
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Lead PlacementLead PlacementV1 4th ICS i ht tV1 = 4th ICS right sternumV2 = 4th ICS left sternumV3 = midway between V2V3 = midway between V2
and V4V4 = 5th ICS midclavicularV4 5th ICS midclavicularV5 = between V4 and V6
anterior auxiliary lineV6 = midauxillary line
lateral to V4 and V5
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Lead PlacementLead Placement• Electrical activity towards = ↑• Electrical activity away = ↓
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Lead PlacementLead Placement
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AxisAxis• The direction of an ECG
waveform in the frontal plane measured inplane measured in degrees
• Represents the flow of pthe majority of electrical activity N ll h QRS• Normally the QRS complex is measured
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AxisAxis• Each lead has its own axis
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Lead PlacementLead PlacementCh t L dStandard Leads (bipolar)
• I - lateral wallChest Leads (unipolar)
• V1 - septal wall• V2 septal wall• II - inferior wall
• III - inferior wall
• V2 - septal wall• V3 - anterior wall• V4 - anterior wall
Augmented leads (unipolar)
• V4 - anterior wall• V5 - lateral wall• V6 - lateral wall
• aVR - no mans land• aVL - lateral wall
V6 lateral wall
• aVF - inferior wall
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Lead PlacementLead PlacementNo-mans land, inferior, lateral, anterior, septal,
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Abnormalities: bundle branch blocks
• QRS widened, greater than 0.12 secs• Change in axis • Difficult to interpret ECG• Right or Left• Normal P wave• Followed by a T wave
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Abnormalities: right bundle branch blocks
• Indicates conduction problems in the right side of the heartthe heart
• May be normal in healthy peoplepeople
• R wave in V1, ie two R waves in V1in V1
• Q wave in V6 • Lead V1 cats earsLead V1 cats ears
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Abnormalities: left bundle branch blocks
• Always indicates heart disease, usually of the left side of the heartside of the heart
• Hard to interpret an ECG with LBBBLBBB
• Lead V1 Q wave and an S wavewave
• Lead V6 an R wave followed by another R wavey
• Lead V6 Rabbit ears
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Abnormalities: heart block
• SA block (exit block)• 1st degree AV block• 2nd degree AV block
– Wenckeback (type I)Mobit (t pe II)– Mobitz (type II)
• 3rd degree AV block
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Abnormalities: heart block – SA block
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Abnormalities: heart block – 1st degree AV
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Abnormalities: heart block – 2nd degree AV
W k b kWenkeback
Mobitz
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Abnormalities: heart block – 3rd degree AV
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Abnormalities: life threatening arrhythmias
• Ventricular Tachycardia• Ventricular Fibrillation• Asystole
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Abnormalities: life threatening arrhythmias - VT
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Abnormalities: life threatening arrhythmias - VF
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Abnormalities: life threatening arrhythmias – Asystole
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ExamplesExamples
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ExamplesExamples