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Basics of ECG Pre-Workshop: Dr. Nancy Selfridge Chair, Department of Clinical Medicine Semester 4 2019

This document outlines the learning objectives and content for a pre-workshop on basics of ECG interpretation. The objectives include determining key parameters like heart rate, conduction times, and axis from ECG traces, as well as recognizing normal ECG patterns and common abnormalities. The content reviews ECG calibration, calculating intervals, determining rhythm, lead placement, axis, and identifying features indicating conditions like ischemia, injury or infarction. Practice examples are provided to allow trainees to systematically analyze ECG strips based on rate, rhythm, axis, hypertrophy and ischemia/injury.

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Tom Tsou
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59 views

Basics of ECG Pre-Workshop: Dr. Nancy Selfridge Chair, Department of Clinical Medicine Semester 4 2019

This document outlines the learning objectives and content for a pre-workshop on basics of ECG interpretation. The objectives include determining key parameters like heart rate, conduction times, and axis from ECG traces, as well as recognizing normal ECG patterns and common abnormalities. The content reviews ECG calibration, calculating intervals, determining rhythm, lead placement, axis, and identifying features indicating conditions like ischemia, injury or infarction. Practice examples are provided to allow trainees to systematically analyze ECG strips based on rate, rhythm, axis, hypertrophy and ischemia/injury.

Uploaded by

Tom Tsou
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Basics of ECG Pre-workshop

Dr. Nancy Selfridge


Chair, Department of Clinical Medicine
Semester 4
2019
Learning Objectives
• Determine the following parameters from a
typical ECG trace:
– heart rate
– AV conduction time = PR interval
– ventricular depolarization time = QRS interval
– ventricular de + repolarization time = QT interval
– R and S wave amplitude
• Define and determine or estimate mean
electrical axis of the heart on ECG and identify
– Normal mean axis
– Left and right axis deviation
Learning Objectives, continued
• Demonstrate a systematic approach to a 12 lead
electrocardiogram (rate, rhythm, axis, hypertrophy,
ischemia-injury-infarction)
• Recognize a normal ECG
• Identify the following on an ECG trace
– From CV 1 module: sinus tachycardia; sinus bradycardia;
AV blocks (1st, 2nd, 3rd); atrial fibrillation; ventricular
fibrillation
– Plus: Increased R and S amplitude; ST segment elevation
and depression; T wave changes; abnormal Q waves
Review: Recording the ECG
ECG trace paper is
standardized worldwide

0.04 sec 0.2 sec

0.1 mV

0.5 mV

Time (sec)
Calibration
• ECG tracings have a calibration mark
• This allows the reader to know if the
calibration is standard
• A 5 mm wide by 10 mm high calibration box is
normal
• If QRS amplitude is high in the precordial leads
(due to hypertrophy), then we may use a
different calibration for recording the ECG
This is standard calibration. With the high amplitude
QRS in the precordial leads, the ECG is hard to read.
A. Standard (normal) calibration
B. ½ standard (normal) calibration
C. 2X standard (normal) calibration
Review: ECG Waves, Segments and
Intervals
Review: Calculate Heart Rate from an ECG

R R

paper speed = 25mm/s

20 x 0.04 sec = 0.80 seconds per beat


(60 seconds/minute) / (0.80 seconds/beat) = 75 bpm
Exact measure of heart rate
1. Determine time interval for one heart beat
– from R wave to R wave (R-R interval).
2. Time interval divided into 60 sec/min = HR (bpm)
Calculate Heart Rate from an ECG
• Quick estimate of heart rate
300 150 100 75 60 50 43

R R

If you will just memorize: “300, 150, 100, 75, 60, 50” then you won’t need to
do any annoying math.
When the Rate is Slow or the Rhythm is Irregular

1) Count the number of QRS complexes in 6


seconds (30 big boxes) and multiply this
number by 10
2) Count the number of QRS complexes in a
standard 12-lead ECG and multiply by 6.
Calculate Intervals from an ECG
R-R interval = .80 sec

R R

0.06 sec 0.16 sec 0.32 sec

– PR interval should be 0.12 – 0.20 seconds


– QRS complex should be less than 0.10 sec
– QT interval is less than half of one R-R interval
Review: Determine rate and interpret

Rate: 100

Sinus tachycardia

Rate: 50

Sinus bradycardia
Determine Rhythm
• Note the distance between identical waves
• Note any irregularities in this distance or in wave
forms, ie, is the rhythm regular or irregular?
• Are there p waves?
• Is there a p for every QRS?
• Is there a QRS for every p?
• Is the PR interval normal?
• Is the QRS wide or narrow?
• Is the QT interval normal?
• Are there any “extra” or strange appearing beats?
Review
For each of these:

Regular?

p?
Atrial fibrillation
p for QRS, QRS for p?

QRS wide or narrow?

Ectopic beats?
Ventricular fibrillation
Review: AV block
p for QRS, QRS for p?
PR normal?

PR interval = too long (> .20 sec)

PR intervals lengthen until QRS “drops”

Second-degree Mobitz Type II


PR interval appears OK, but
spontaneous dropped QRS

Third-degree complete heart block


Complete dissociation between the
atrial and ventricular conduction
Review: ECG Lead Placement and Polarity

These standard
and augmented
limb leads record
electrical activity
in a frontal plane
through the heart.
Where do the net positive electrical forces go for each
limb and augmented lead?

If you memorize this, you will have less trouble interpreting an ECG trace.
Six Precordial Leads

These “chest” leads record electrical activity in a


transverse plane through the heart.
Remember
• For any lead, a depolarizing wave moving
toward a positive pole gives a positive
deflection on the ECG tracing.

• A depolarizing wave moving toward a negative


pole or away from a positive pole gives a
negative deflection on the ECG tracing.
How would a normal heart appear on ECG?
Normal 12 Lead ECG Tracing
Anything that interferes with normal conduction
will change the appearance of the ECG tracing:
• Congenital anomalies
• Myocardial hypertrophy
• Injury or irritation to the myocardium
• Conduction abnormalities (innate and
acquired)
Review: Mean Electrical Axis
Review: Three ways to determine the MEA

• Quick & Dirty Approximation: from the net direction


of QRS complexes in Leads I and aVF.

• Net Zero Lead Method: can only use easily if a lead has
a net zero QRS complex.

• Semi-Quantitative Method: from the net direction of


QRS complexes of all six limb leads (but this takes too
long!)
Quick & Dirty Method
Use the net direction of QRS complexes in Leads I & aVF

Lead I aVF Axis

Normal

Left Axis
Deviation

Right Axis
Deviation
Net Zero Lead Method

• Find the lead with “net


zero” QRS complex
• Find the perpendicular
lead
• The positive or negative
deflection of the
perpendicular lead is
your mean axis
R and S Wave Amplitude

Ventricular
hypertrophy causes
an increase in the
amplitude or height
of the R and S
complexes
Ischemia, Injury, Infarction
• Ischemia, injury and infarction are represented by
depolarization and repolarization abnormalities on
ECG:
– ST segment and T wave changes
– Abnormal Q waves

So, you must become familiar with NORMAL!


A Normal ECG - Clues
• Is there a calibration mark and is it normal?
• Is there a upward “p” in lead 1?
• Is there an upward “T” in lead 1?
• Are there normal appearing complexes
(pQRST) and is there a normal axis?
• Is the pQRST upward in V5 or V6?

Thanks, Dr. Rios!


Let’s Practice
• For the following set of ECGs, just focus on what you can
see.
• Use a methodical approach EVERY TIME:
– Rate
– Rhythm & Conduction
• Regular or irregular?
• p for QRS, QRS for p?
• PR interval?
• QRS narrow or wide?
• Ectopics?
– Axis
– Hypertrophy?
• Axis deviation?
• R & S amplitude?
– Ischemia-Injury-Infarct
• ST segment abnormalities?
• T wave abnormalities?
• Abnormal Q waves?
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm:
Axis:
Rate:
Rhythm
Axis:

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