Professional Documents
Culture Documents
As with all investigations the most important things are your findings
on history, examination and basic observations. Having a good system
will avoid making errors.
To start with we will cover the basics of the ECG, how it is recorded and
the basic physiology. The 12-lead ECG misleadingly only has 10
electrodes (sometimes also called leads but to avoid confusion we will
refer to them as electrodes).
o V1, V2 = RV
o V3, V4 = septum
o V5, V6 = L side of the heart
o Lead I = L side of the heart
o Lead II = inferior territory
o Lead III = inferior territory
o aVF = inferior territory (remember ‘F’ for ‘feet’)
o aVL = L side of the heart
o aVR = R side of the heart
1. Patient details
2. Situation details
3. Rate
4. Rhthm
5. Axis
6. P-wave and P-R interval
7. Q-wave and QRS complex
8. ST segment
9. QT interval
10. T-wave
1. Count the number of QRSs on one line of the ECG (usually lead II
– running along the bottom) and multiply by six.
2. Count the number of large squares between R waves and divide
300 by this number (if the patient is in atrial fibrillation it is more
accurate to report a rate range rather than a single value).
o Q-wave
o A q-wave is an initial downward deflection in the QRS complex.
These are normal in left-sided chest leads (V5, 6, lead I, aVL)
as they represent septal depolarization from left to right. This is
as long as they are <0.04secs long (1 small square) and <2mm
deep.
o If q-waves are larger than this or present in other leads they are
pathological.
o QRS complex
o Width
o The QRS complex normally lasts for < 0.12 secs (3 small
squares).
o Causes of a wide QRS:
o Bundle branch blocks (LBBB or RBBB)
o Hyperkalaemia
o Paced rhythm
o Ventricular pre-excitation (e.g. Wolf Parkinson White)
o Ventricular rhythm
o Tricyclic antidepressant (TCA) poisoning
o Shape and height
o The QRS may be small (or low voltage) in pericardial
effusion, high BMI, emphysema, cardiomyopathy and cardiac
amyloid.
o The QRS is tall in left ventricular hypertrophy (LVH)
o The criteria suggestive of LVH on the ECG is if the height
of the R wave in V6 + the depth of the S wave in V1. If this
value is >35mm this is suggestive of LVH.
o The QRS can also be tall in young, fit people (especially if
thin).
8. ST segment
NB: High-takeoff
o A mimic of ST elevation is high-takeoff. High-takeoff is also known
as benign early repolarization.
o High-takeoff is where there is widespread concave ST elevation,
often with a slurring of the j-point (start of the ST segment). It is
most prominent in leads V2-5, is usually in young health people
and is benign.
o The best ways to differentiate it from myocardial infarction are:
o The ST segments are concave; they are most prominent in V2-
5; they have a slurred start (j-point); the ST elevation is usually
minimal compared to the amplitude of the t-wave; there are no
reciprocal changes; the ST segments do not change over time.
9. QT interval
o The QT interval is the time between the start of the q-wave and
the end of the t-wave.
o The QT interval is corrected for heart rate giving the QTc.
o As a quick check, if the t-waves occur over half way between
the QRS complexes the QTc may be lengthened
o Not an accurate method but very quick!
o A long QTc interval (known as “long QT”) is especially important
to identify in patients with a history of collapse or transient loss of
consciousness.
10. T-wave
o Normal variant
o Commonly inverted in aVR and V1 and often in V2 and V3 in
people of afro-Caribbean descent.
o Ischaemia
o Ventricular hypertrophy (strain pattern) usually in lateral leads
o LBBB (t-wave inversion in the anterolateral leads)
o Digoxin
o Hypokalaemia (can cause flattened t-waves)
o Small p-wave
o Tall, tented (peaked) t-wave
o Wide QRS
o Widening of the QRS indicates severe cardiac toxicity
Summary
Following steps 1-10 above give the ideal system for interpreting
an ECG. If you work through these steps you will be unlikely to
miss anything significant.