ECG IN ANAESTHESIA PRACTICE – I

Basics of ECG (Part-A):- Dr. Naveen Mathew

Diagnosis of Common Rate and Rhythm Disorders

(Part-B) :- Dr. Pragya

Moderator:- Dr. Mahendra Kumar

Dr. Zainab Ahmed
BASICS OF ECG

BONJOUR
Calculate the heart rate :

A. 120 B.90-100 C.150-160 D.60-70

 Identify the AXIS :

A. RAD
B. LAD -60 º
C. EXTREME AXIS
D. NORMAL AXIS/
PHYSIOLOGICAL
LAD -30º
IDENTIFY THE AXIS !!!
Young, black, athletic
asymptomatic, male,
clinically normal

CLOSEST DIAGNOSIS:

A.POST MI
B. ACUTE PERICARDITIS
C. EARLY
REPOLARISATION
SYNDROME
D. HYPERKALEMIA
 ECG Introduction

• The Electrocardiogram is a representation of the electrical events of the

cardiac cycle

• Each event has a distinctive waveform

• The study of waveform can lead to greater insight into a patient’s cardiac
pathophysiology
 HISTORICAL MILESTONES IN ECG

• 1887 : Augustus Desire Waller, recorded electric current

preceding cardiac contraction
AD Waller
• 1895 : William Einthoven - invented ECG and won nobel prize
in medicine - 1924

• 1932 : Wolferth CC and Wood CC, introduced chest leads

• 1942 : Goldberger E, introduced unipolar limb leads

Einthoven
 Each 1 mV gives a 10 mm deflection

 Standard paper speed : 25 mm/sec

1 mv(10 mm high)
 Each small square 1 x 1 mm =
40msec = 0.04 sec

 Each large square 5 x 5 mm =

200msec = 0.2 sec
1 small box = 0.04 s
 Each minute = 60 sec = 1500 small
boxes = 300 large boxes
1 large box = 0.2 s
 ECG LEADS

There are 12 conventional leads,

• 6 in frontal plane (I, II, III, aVR, aVL & aVF)

• 6 in horizontal plane (V1 to V6)

Bipolar leads : I, II, III

Unipolar leads : Augmented limb leads (aVR, aVL, aVF)

Precordial leads (V1-V6)

LIMB LEADS
Precordial chest leads • Lead V1 : Over the fourth intercostal space, just to

the right of sternal border.

• Lead V2 : Over the fourth intercostal space, just to

the left of sternal border.

• Lead V3 : Over a point midway between V2 and V4

• Lead V4 : Over the fifth intercostal space in the

midclavicular line.

• Lead V5 : Over the anterior axillary line, at the same

level as lead V4.

• Lead V6 : Over the midaxillary line, at the same

level as leads V4 and V5.

 Right sided chest leads

• V1R : 4th intercostal space to left of sternum.

• V2R : 4th intercostal space to right of sternum.

• V4R : 5th intercostal space in midclavicular line, and so on.

• Acute inferior wall myocardial infarction (to diagnose right

ventricular infarction).

• ST elevation in V4R has a sensitivity of 88%, specificity of

78% and diagnostic accuracy of 83% in the diagnosis of RV
MI
 3 ELECTRODE SYSTEM
Three electrodes are placed :

• (RA)right arm and left arm (LA) are placed on

right and left infraclavicular fossa respectively

• Left leg (LL) electrode is placed on left lower rib

cartilage

• Most commonly used in operation theatre and ICU

• Anterior wall myocardial ischaemia is not suitably

monitored by this system.
 5 ELECTRODE SYSTEM

Out of total five electrodes, one is placed

on each limb and one on the chest wall.
(Usually V5 position ) advantages
a)Seven leads can be monitored
b) All except posterior wall ischemia can
be monitored
c) Up to 95% of ischemic events can be
diagnosed
d) Useful in differentiating atrial vs.
ventricular dysrhythmias
 Invasive and Epicardial leads
Oesophageal leads : Incoporated in oesophageal stethoscope

• help in diagnosis of atrial dysrhythmias in 100% of cases compared to 54% for lead II

• detecting posterior wall ischaemia.

Endotracheal ECG : through endotracheal tube, useful in paediatric patients for atrial
dysrhythmia detection.

Intracardiac ECG : through pulmonary catheter help in recording of intracavitary ECG

• diagnosis of atrial, ventricular and atrioventricular dysrhythmias and conduction blocks

Epicardial leads : Cardiac surgeons before sternal closure place epicardial leads in the form of
pacing wires. They help in atrial and ventricular pacing.
 LEADS Corresponding region
of the heart

Lead I and AVL Left side of the heart

(Lateral)

aVF, Lead II and Lead Inferior wall of the

III heart

V1 and V2 Septal area

V2, V3 and V4 Anterior surface of the

heart

V5 and V6 Apical surface

Mirror image changes Posterior surface

in leads V1 – V4
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• RATE
• Rhythm
• Axis
• P wave
• PR interval
• QRS complex
• ST segment
• T wave
• QT interval
• Conclusion
 HEART RATE

When rhythm is regular:

• Divide 1500 by the number of small squares between one R-R interval or

• Divide 300 by number of large squares between one R-R interval.

1500/17 =88/min

300/3.4 = 88/min
 HEART RATE

When rhythm is irregular:

• Count the number of QRS complex in 3 sec (15 large squares) and x by 20
Or
• Count the number of QRS complex in 6 sec (30 large squares) and x by 10

9 QRS complex in 6 sec

HR = 9 x 10 = 90/ min
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• RHYTHM
• Axis
• P wave
• PR interval
• QRS complex
• ST segment
• T wave
• QT interval
• Conclusion
 RHYTHM
• The rhythm refers to the part of the heart which controls the activation sequence.
• A cardiac rhythm originating from the SA node is called sinus rhythm.
• Normal Sinus Rhythm :
1. The rhythm is regular
2. The rate ranges between 60-100/min
3. P wave precedes every QRS complexes in ratio 1:1
4. P wave is upright, PR interval is normal and QRS is normal
Rhythm abnormalities- Irregular rhythm, ectopics, atrial, junctional and ventricular
rhythm
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
• Axis
• P WAVE
• PR interval
• QRS complex
• ST segment
• T wave
• QT interval
• Conclusion
 P wave

Lead II : pyramidal and rounded apex

no notching or peaking
height < 2.5 mm
Lead V1 : biphasic P wave
width < 2.5 mm
(duration between 0.06 to 0.08 second)
LA enlargement :

• Lead II - P width > 2.5 mm notched/bifid ‘P’ • Lead V1

MITRALE  Area of –ve phase of P wave ↑ (LA)

 Morris Index = depth (mm) x width

(sec) of –ve phase >0.04 mm sec
RA enlargement :

• Lead II : P wave height > 2.5 mm • Lead V1 :

‘P’ PULMONALE  +ve deflection of P wave > 1.5mm in amplitude
 Area of +ve deflection > 0.06 mm sec
( height in mm x depth in sec)
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
• Axis
• P wave
• PR INTERVAL
• QRS complex
• ST segment
• T wave
• QT interval
• Conclusion
 PR interval

• PR interval is measured from the beginning of the

P wave to the beginning of the QRS complex

• Represents the time taken by the electrical impulse

to travel from the sinus node through the AV node
to bundle of His

• Duration : 0.12 to 0.2 s (3-5mm)

Prolonged PR interval >0.2 sec
• First degree AV node Block

• Drugs: Beta blocker, Digoxin

• Dyselectrolemia : ↑K+ >7.5 meq/L

• AV node inflammation : Acute Rheumatic

fever , diphtheria

• AV node infiltration : Amyloidosis,

Hemochromatosis **ATHLETIC, **increased vagal tone, vagomimetic drugs
 Short PR Interval

• Lown ganong levine syndrome

Atrial impulse joins bundle of his via.
James pathway

• Wolf Parkinson white syndrome

Atrial impulse bypass AV node and
depolarize Ventricle directly via.
Bundle of KENT.

**Vagolytic drugs
WOLF PARKINSON WHITE SYNDROME

Short PR interval,
Delta wave,
Wide QRS complex

LOWN GANONG LEVINE SYNDROME

Short PR interval,
No Delta wave
Normal QRS complex
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
 Axis
• P wave
• PR interval
• QRS COMPLEX
• ST segment
• T wave
• QT interval
• Conclusion
 QRS Complex

• Represents ventricular depolarization

• Normal width : 0.08–0.12s (2-3mm)

• In V1, S wave is greater than the R wave and R wave amplitude does not exceed 4 mm

• In V5 or V6, the height of R wave is less than 25mm , S wave < 7mm

• V5 or V6 may show Q wave (but < 1mm across , < 2mm depth)

• Normal R wave progression

 PROGRESSION OF R WAVE
NORMAL R WAVE PROGRESSION NON PROGRESSION OF R WAVE

Chronic lung disease, Old anteroseptal infarction ,

Diffuse myocardial disease, LVH, LBBB
 QRS complex - Significance

1. Abnormal width : LVH,RVH,RBBB,LBBB,WPW syndrome,

Hyperkalemia (>7.5 meq/L) , Idioventricular rhythm

2. Abnormal morphology : RBBB,LBBB

3. Abnormal Axis : RAD/LAD/extreme axis deviation

RV * R wave in V1 > 4 mm * S wave in V6 >7 mm.
H * R in V1 + S in V6 more than 10 mm
 • S wave in V1 + R wave in V5 or V6 > 35mm (Sokolow)
LVH • R wave in V5 or V6 >25mm (Framingham)
RBBB LBBB

rSR’ Deep and Deep S Broad and

slurred S wave clumsy R
wave wave
The Cardiac Axis

QRS axis Range in degrees

Normal axis – 30° to +90°

Left axis deviation – 30° to –90°

Right axis deviation + 90° to +180°

Indeterminate axis – 90° to –180°

Determination of axis
Method 1 : Isoelectric method
• Find the lead with smallest or
equiphasic deflection.
• The cardiac axis lies at right angles
to that equiphasic lead .
• Determine the lead at right angles to
the first lead.
• See the net deflection in the
perpendicular lead.
Determination of Axis- Quadrant method
Main QRS deflection QRS axis quadrant

Lead I aVF

+ve +ve 0 to +90°

Normal
+ve –ve 0 to –90°
**LAD
–ve +ve +90 to +180°
RAD
–ve –ve –90 to –180°
Northwest
RAD

Thin tall built,Chronic lung disease, Ostium secondum ASD

Right ventricular hypertrophy, Left posterior hemiblock,lateral wall infarction
Physiological LAD deviation/Normal Axis

OBESITY,pregnant female,Ascites
 LAD

Obese stocky built, Ostium primum ASD,Left ventricular hypertrophy

Left anterior hemiblock,Inferior wall infarction
Q Wave : Septal depolarization

Physiological Q waves : I,avL,V5,V6

Pathological Q waves

• More than or equal to 0.04 sec in duration

• More than one-fourth of R wave amplitude

• Seen in necrosis of heart muscle or previous

myocardial infarction, Severe reversible
myocardial ischemia as in severe angina,
hypoxia, hypothermia or hypoglycemia.
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
• Axis
• P wave
• PR interval
• QRS complex
• ST SEGMENT
• T wave
• QT interval
• Conclusion
 ST SEGMENT

• It is the time at which the entire ventricle is depolarized and roughly corresponds
to the plateau phase of the ventricular action potential

• The portion of the isoelectric line between the termination of the S wave (J point)
and the onset of the T wave is called the S-T segment.

• ST-T segment depression (>1mm from the baseline) : coronary ischemia,

hypokalemia, ventricular hypertrophy, digitalis(reverse tick sign),
• ST SEGMENT ELEVATION (>1mm from the baseline):

Acute MI :

convex upward, in specific leads

Artery involved:-
• V1,V2, V3, V4- LAD Artery
• V5, V6, L1, avL- LCX Artery
• II, III, avF- RCA

Acute pericarditis :

concave upward, Almost all leads

 J point
• The J point is the junction between the termination of the QRS
complex and the beginning of the ST segment.

EARLY REPOLARIZATION
SYNDROME :
• Young, athletic, black male, asymptomatic
• The clinical evaluation is entirely normal
• tall R waves in leads V4 to V6
• concave-upward ST segment elevation
• initial slur on ST segment; the J wave
• tall and upright symmetrical T waves
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
• Axis
• P wave
• PR interval
• QRS complex
• ST segment
• T WAVE
• QT interval
• Conclusion
 T WAVE
• The T wave is produced by the rapid phase of
ventricular repolarization and follows the QRS
complex

• Asymmetric and slightly rounded without sharps

• It is upright in most leads (except aVR, LIII, V1)

• It does not exceed 5 mm in height in the limb leads

and 10 mm in precordial leads
 T wave significance
• Tall T wave Hyperkalemia (>6 meq/l) Acute MI

Symmetrical Symmetrical
Broad base
Narrow base
Blunt apex
Pointed apex

• Giant inverted T Wave : HOCM

Flat T wave or inverted T waves : Hypokalemia, Subendocardial ischemia,
strain pattern of LVH or RVH, hypocalcemia,
 ECG Interpretation
Standardized sequence of steps to analyze the ECG are:
• Rate
• Rhythm
• Axis
• P wave
• PR interval
• QRS complex
• ST segment
• T wave
• QT INTERVAL
• Conclusion
 QT INTERVAL
• Measured from the beginning of the QRS complex to the end of the T wave.

• Represents the time for both ventricular depolarization and repolarization (ventricular
action potential).

• DEPENDS ON HEART RATE :

HR ↑= QT short. HR ↓= QT long

• The corrected interval (QTc) can be calculated using

Bazett’s formula: QTc = QT ÷√(R–R interval in sec)

• NORMAL VALUES : 0.35-0.43 sec

Long QT interval : Q-Tc interval > 0.43 sec Long QT interval

Prone for TORSADES DE POINTES ventricular fibrillation

• DRUGS : antiarrhythmics, tricyclics, phenothiazines, Ondansetron, Terfenadine, cisapride,

macrolides, quinolones

• Electrolyte abnormalities (decreased K+ or Ca++ or Mg+)

• CNS disease (especially SAH, stroke, trauma)

• Hereditary LQTS (e.g. Romano-Ward Syndrome)

• Coronary Heart Disease (post-MI patients).

Shortened QT interval : Q-Tc interval < 0.35 sec

• Hyperkalemia ,Hypercalcemia ,Digitalis effect ,Acidosis

• Hyperthermia
REFERENCES:-

• An introduction to electrocardiography, 7th Edition, Leo Schamroth

• The ECG Made Easy, 8th edition, John R. Hampton
• ECG Made Easy, 4th edition, Atul Luthra
• Harrison’s principles of Internal Medicine-18th edition
MERCI BEAUCOUP
ANSWERS
Calculate the heart rate :

A. 120 B.90-100 C.150-160 D.60-70

 Identify the AXIS :
A. RAD
B. LAD -60 º
C. EXTREME AXIS
D. NORMAL AXIS/
PHYSIOLOGICAL
LAD -30º
IDENTIFY THE AXIS !!!
Young, black, athletic
asymptomatic, male,
clinically normal

CLOSEST DIAGNOSIS:

A.POST MI
B. ACUTE PERICARDITIS
C. EARLY
REPOLARISATION
SYNDROME
D. HYPERKALEMIA