NORMAL ECG

Nur Zamiatun Qomara

 Definition

• Electrocardiograph – is the instrument

that records of potential cahnges at
the skin surface that result from
depolarization and repolarization of
heart muscle.

• Electrocardiogram (ECG) is the record

of that activity

Levick, JR. An introduction of cardiovascular physiology. Blackwell. UK : 2003

 Introduction to the ECG

• The method was developed at the start of 20th

century by Willem Einthoven in Leiden, who invented
the string galvanometer, and Augustus Wallerr in
London, who applied the method to man, and whose
demonstration to Royal Society in 1909

• It can provide evidence to support a diagnosis, but

remember…..LOOK AT THE PATIENT NOT JUST THE
PAPER

• Is essential in the diagnosis of chest pain and

abnormal heart rhythms
• Is helpful in diagnosing breathlessness
Levick, JR. An introduction of cardiovascular physiology. Blackwell. UK : 2003
THE CONDUCTING
SYSTEM
• Sinoatrial node
– Electrical pace maker
myofibril path
Bachmann bundle
Wekenbach path
Thorel path
• Atrioventricular node
– Receives impulses originating from SA
node
• Bundle of His
Electrical link between atria and ventr
• Bundle branches
Left Bundle Branch
Anterior + Posterior Fasicle
Right Bundle Branch
• Purkinje fibres 4
– Distribute impulses to ventricles
The intervals of impulse
time through the heart

Guyton SA,Textbook of Medical Physiology ,11th ed Philadelphia,2006

RELATIONSHIP

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Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008
7
 ECG

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Jones SA , ECG Success Exercises in ECG Interpretation, Philadelphia : 2008
HOOKING UP THE
12-LEAD ECG

• Proper skin prep

• Placement of the limb electrodes
• Placement of the chest
electrodes

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SKIN PREPARATION

• REASON FOR SKIN

PREPARATION

• 2 STEP METHOD

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ELECTRODE
PLACEMENT

• 6 LIMB LEADS

• 6 CHEST LEAD

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Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008
LIMB LEADS

• Bipolar leads
I II III

• Augment leads
aVR aVL aVF

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 STANDART CHEST
LEADS
• 6 UNIPOLAR
LEADS
• V1
• V2
• V3
• V4
• V5
• V6
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Jones SA , ECG Success Exercises in ECG Interpretation, Philadelphia : 2008
 The Right Sided 12 Lead
ECG

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Jones SA , ECG Success Exercises in ECG Interpretation, Philadelphia : 2008
 The 15 Lead ECG

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Jones SA , ECG Success Exercises in ECG Interpretation, Philadelphia : 2008
Teritory
WHAT YOU NEED TO
LOOK FOR

• Are the limb leads hooked up

correctly?
• Are the chest leads hooked up
correctly?
• Is the ECG free of artifact.
• Is this ECG a Critical Value
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IS the ECG HOOKED UP
CORRECTLY?
LIMB LEADS CHEST LEADS
Normal 12-lead COLUMN III
• aVR – always • R wave progression
negative • Small to Tall
• Lead I – always
positive
• Lead II, III –
positive or
biphasic

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RULING OUT LIMB LEAD
REVERSAL

• aVR is always negative

• Lead I is always positive

• Lead II and III positive for the P

wave and usually the QRS
complex
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CHEST LEADS
CHEST LEADS
COLUMN III
• R wave progression
• Small to Tall

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OTHER PROBLEMS
WITH THE ECG

• Artifact
• Electrical interference
• Somatic tremor
• Wandering baseline

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ARTIFACT ON THE ECG

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WANDERIN BASELINE

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SOMATIC TREMOR

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ELECTRICAL
INTERFERANCE

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Dextrocardia

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BASIC CRITICAL
VALUES

• Severe Bradycardia – HR <

40bpm
• Severe Tachycardia HR >
120bpm
• PVC’s - 4 or more in a row
• ST Elevation
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 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q
waves
• ST segment
• T wave
• QT interval
Quality of the ECG
• Patient name
• Date of the ECG
• Is there any interference?
• Is there electrical activity from all 12
leads?

• Calibration:
- speed = 25mm/second
- height = 1cm/mV

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

Calibration
Calibration
 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q
waves
• ST segment
• T wave
• QT interval
Rate
• 300/number of big squares between R
waves (regular)
• Number of beats in 6 seconds x 10 (ir)

• Rate is either:
- normal
- bradycardic (≤60bpm/≤50bpm)
- tachycardic (≥100bpm)

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

Rate
Rhythm
• Sinus
– Originating from SA node
– P wave before every QRS
– P wave in same direction as QRS
AXIS

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Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008
Axis

Positive in I and II =
NORMAL

Positive in I and
negative in II = LAD

Negative in I and
positive in II = RAD
ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q
waves
• ST segment
• T wave
• QT interval
P wave

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

 41
Guyton SA,Textbook of Medical Physiology ,11th ed Philadelphia,2006
PR interval

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q
waves
• ST segment
• T wave
• QT interval
QRS complex

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

QRS complex

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Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008
Q waves
• Q waves are allowed in V1, aVR & III
• Pathological Q waves can indicate
previous MI
ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q
waves
• ST segment
• T wave
• QT interval
ST segment

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

T wave

Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008

QT interval
• Start of QRS to end of T wave

• Needs to be corrected for HR

• Normal QTc = < 460ms

• Long QT can be genetic or

iatrogenic
QT interval

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Morris F , ABC of Clinical Electrocardiography,second edition UK : 2008
 Normal ECG

• A normal ECG will contain regular

complexes
• Each complex will be made up of a
P wave, swiftly followed by a QRS
• The QRS should be pointed
• The complexes should be of
uniform appearance
Normal ECG
THANK YOU

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