THE ECG

Dr. George John
Critical Care,
Christian Medical College,
Vellore

Reading the ECG
Rate
Rhythm
Axis
Chamber Enlargement
Myocardial Damage
Miscellaneous
References:
http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson1/index.html

ECG – BASIC NOMENCLATURE

Rate

Axis .

2 LEAD L1 LEAD aVF NORMAL POSITIVE POSITIVE RAD NEGATIVE POSITIVE LAD POSITIVE NEGATIVE INDETERMINATE NEGATIVE NEGATIVE . Axis .

which means if the criteria are met. Chamber Enlargement The ECG criteria for diagnosing right or left ventricular hypertrophy are very insensitive (i. sensitivity ~50%.. However. the criteria are very specific (i. specificity >90%..e. it is very likely that ventricular hypertrophy is present). which means that ~50% of patients with ventricular hypertrophy cannot be recognized by ECG criteria).e. .

1 • S in V1 + R in V5 or V6 > 35 mm • R in aVL >11 mm or. if left axis deviation. specificity = 95%) S in V3 + R in aVL > 24 mm (men) S in V3 + R in aVL > 20 mm (women) . R in aVL >13 mm plus S in III >15 mm • CORNELL Voltage Criteria for LVH (sensitivity = 22%. LVH .

09sec 1 point Delayed intrinsicoid 1 point deflection in V5 or V6 > 0. 4 points) ST – T abnormalities Without digoxin 3 points With digoxin 1 point Left Atrial Enlargement 3 points inV1 Left Axis Deviation 2 points QRS duration 0.05SEC . >5 points. LVH . R in V5 or V6 > 30mm "probable".2 ECG Criteria Points R or S in limb leads Any criteria positive ESTES Criteria for LVH > 20mm 3 points S in V1 or V2 > 30mm ("diagnostic".

R > 6 mm.R/S ratio > 1 and negative T wave . RVH • V1 Lead: . or S < 2mm.R in V5 or V6 < 5 mm .R/S ratio in V5 or V6 < 1 . .S in V5 or V6 > 7 mm .rSR' with R' >10 mm • R in V1 + S in V5 (or V6) > 10 mm • V5 or V6 .

e. depth >1 mm. "P- terminal force") duration >0. LAE Sensitivity = 50%. .. Specificity = 90% • P wave duration > 0.04s.12s in frontal plane (usually lead II) • Terminal P negativity in lead V1 (i.

and the RV displacement by an enlarged right atrium. RAE • P wave amplitude >2.5 mm in II and/or >1. . Specificity = 90%) • QRS voltage in V1 is <5 mm and V2/V1 voltage ratio is >6 (Sensitivity = 50%.5 mm in V1 (Sensitivity = 50%. Specificity = 90%) Criteria derived from the QRS complex are due to both the high incidence of RVH when RAE is present.

Myocardial Damage • Type of damage: Change in ECG • Location: Leads involved .

V4: Septal V5. Myocardial Damage Location Limb Leads: L2. aVL: Lateral aVR: Cavity Chest Leads: V1. aVF. L3: Inferior L1. V2: Anterior V3. V6: Lateral .

Infarct / Necrosis • Q Wave • Non Q Wave Pathologic Q waves are usually defined as duration >0.04 s or >25% of R-wave amplitude) .

ST elevation. upright T waves (fibrosis) . Q Wave Infarcts Pathologic Q waves. T wave inversion (acute necrosis) Pathologic Q waves. T wave inversion (necrosis and fibrosis) Pathologic Q waves.

Recognized by evolving ST-T changes over time without the formation of pathologic Q waves (in a patient with typical chest pain symptoms and/or elevation in myocardial-specific enzymes) . most having ST segment depression or T wave inversion. Non Q MI Two-thirds of MI's presenting to emergency rooms evolve to non Q wave MI's.

tricyclics.g. hemorrhage. and many others) Electrolyte abnormalities of potassium. ST .T Changes 1 PRIMARY ST-T Changes: Intrinsic myocardial disease (e. calcium Neurogenic factors (e. magnesium. infiltrative or myopathic processes) Drugs (e.g.. trauma.g. etc.) Metabolic factors (e. hyperventilation) . digoxin. quinidine. hypoglycemia. tumor.g... stroke. myocarditis. ischemia. infarction..

and ventricular paced beats . ST-T Changes 2 "SECONDARY" ST-T Wave changes: ST-T changes seen in bundle branch blocks (generally the ST-T polarity is opposite to the major or terminal deflection of the QRS) ST-T changes seen in fascicular block ST-T changes seen in nonspecific IVCD ST-T changes seen in WPW preexcitation ST-T changes in PVCs. ventricular arrhythmias.

T & U Waves • The T wave is the most labile wave in the ECG • The U wave is the only remaining enigma of the ECG The normal U wave has the same polarity as the T wave and is usually less than one-third the amplitude of the T wave. .

Vellore . George John. Critical Care. ELECTROCARDIOGRAMS Dr. Christian Medical College.

ECG .A .

B .ECG .

C .ECG .

ECG .D .

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I .ECG .

ECG .J .

K 70 YEAR OLD MAN WITH GIDDINESS: . ECG .

ECG .L .

THE ANSWERS FOLLOW!! .

ECG .A .

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ECG .C .

D .ECG .

ECG .E .

ECG .F .

G .ECG .

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ECG .I .

ECG .J .

K .ECG .

ECG .L .

THE END THANK YOU!! Acknowledgement: http://www.ecglibrary. .com/ Dean Jenkins and Stephen Gerred.