Part 1 ECG 2019 slide share

1. How to read and interpret ECG
DR Ihab Suliman FESC
Consultant Cardiologist
Advanced Cardiac Imaging division
King Abdul-Aziz Cardiac Centre

2. The Normal Conduction System

4. SA Node Sino Atrial Node
• This is a collection of self-excitory (pacemaker) cells
that normally fi re at a rate of between 60 and 100
Beats Per Minute (BPM).
• The “wave” of Depolarisation moves from the SAN
through an intra-atrial tract called Bachmanns bundle
into the left atrium and to the Atrioventricular (AV)
node. From here the impulse travels down the bundle
of His into the right and Left bundle branches and
finally into the Purkinje fi bres activating the ventricles.

5. Lead Position
• A typical ECG report shows the cardiac cycle from 12
different vantage points (I, II, III, aVR, aVL, aVF, V1-V6),
like viewing the event electrically from 12 different locations
(like a 3D perspective).BUT only 10 electrodes are used.
• Lead I represents activity that is going from the right arm to
the left arm
• Lead II represents activity that is going from the right arm to
the left leg
• Lead III represents activity that is going from the left arm to
the left leg
• aVL is placed on the left arm (or shoulder)
• aVF is placed on the left leg (or hip)
• aVR is placed on the right arm (or shoulder)
• V1- 4th intercostal space to the right of sternum
• V2- 4th intercostal space to the left of sternum
• V3- halfway between V2 and V4
• V4- 5th intercostal space in the left mid-clavicular line
• V5- 5th intercostal space in the left anterior axillary line
• V6- 5th intercostal space in the left mid axillary line

6. NSR

7. Normal ECG

8. ECG showed
?? LBBB ?? RBBB

9. • LBBB in NSR
• If acute Chest pain Go to The cath lab

10. 55 male with Psychiatry disorder

11. •LBBB +inferior
STEMI

12. •VTACH

13. 35 lady with Occasional palpitations
2005
•WPW

14. What happened
•WPW after
ablation
needed dual
PPM

20. • NSR , Juvenile T-wave inversion.

21. WPW Syndrome

23. AF, Inferior Q waves

24. RBBB

25. 28 years with palpitations

26. • SVT/ AVNRT

28. • Atrial Flutter

29. 50 years old with mild CAD

30. • VT,THIS PT HAD SEVERE DCM,waiting for
AICD

32. • Paced Rhythm

33. Waveforms and Intervals

35. The 10 rules for a normal ECG
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
.2

36. Rule 1
PR
interval
Millivolts
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
P
R
T
Q
S
PR interval should be 120 to
200 milliseconds or 3 to 5 little
squares

37. Rule 2
Millivolts
Milliseconds
0 200 400 600
-0.5
0
0.5
1.0
QRS
P
R
T
Q
S
The width of the QRS complex
should not exceed 110 ms, less
than 3 little squares

38. Rule 3
I II III aVR aVL aVF
The QRS complex should be
dominantly upright in leads I and II

39. Rule 4
I II III aVR aVL aVF
QRS and T waves tend to have the
same general direction in the limb
leads

40. Rule 5
P
Q
T
S
All waves are negative in lead aVR

41. Rule 6
V1
V2
V3
V4
V5
V6
The R wave in the precordial leads must grow from V1 to at least V4

42. I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Rule 7
The ST segment should start isoelectric except in V1 and
V2 where it may be elevated

43. Rule 8
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The P waves should be upright in I, II, and V2 to V6

44. Rule 9
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
There should be no Q wave or only a small q less than
0.04 seconds in width in I, II, V2 to V6

45. Rule 10
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
The T wave must be upright in I, II, V2 to V6

47. Necrobiosis Lipoidica Diabeticorum
• An inflammatory skin disorder characterized by
irregularly shaped, callous lesions with reddish-
brown pigmentation and central atrophy — was
made on the basis of visual inspection. In
necrobiosis lipoidica diabeticorum, the shins,
ankles, and feet are typically affected, but 15% of
patients may have lesions elsewhere. The disorder
is more common among women than men and is
more common among persons with diabetes than
those without.

49. • Idiopathic DCM

50. What is the heart rate?
•(300 / 6) = 50 bpm
•www.uptodate.com

51. What is the heart rate?
•(300 / ~ 4) = ~ 75 bpm
•www.uptodate.com

52. What is the heart rate?
•(300 / 1.5) = 200 bpm

53. 10 Second Rule
As most EKGs record 10 seconds of rhythm per page,
one can simply count the number of beats present on the
EKG and multiply by 6 to get the number of beats per 60
seconds.
This method works well for irregular rhythms.

54. What is the heart rate?
•33 x 6 = 198 bpm
•The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

55.  Left axis deviation - negative QRS in lead AVF
 Right axis deviation - negative QRS in lead I
 Severe Right axis deviation negative QRS in BOTH
lead I and AVF
Quick & Easy AXIS DETERMINATION
AVF
AVF
AVF
AVF
AVF
AVF
I
I
I
I
I
I

56. The QRS Axis
By near-consensus, the normal
QRS axis is defined as ranging
from -30° to +90°.
-30° to -90° is referred to as a left
axis deviation (LAD)
+90° to +180° is referred to as a
right axis deviation (RAD)

57. Determining the Axis
Predominantly
Positive
Predominantly
Negative
Equiphasic

58. The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine if they
are predominantly positive or predominantly negative. The
combination should place the axis into one of the 4 quadrants
below.

59. Quadrant Approach: Example 1
Negative in I, positive in aVF  RAD
The Alan E. Lindsay ECG
Learning Center
http://medstat.med.utah.ed
u/kw/ecg/

60. Quadrant Approach: Example 2
Positive in I, negative in aVF  Predominantly positive in II 
Normal Axis (non-pathologic LAD)
The Alan E. Lindsay ECG
Learning Center
http://medstat.med.utah.ed
u/kw/ecg/

61. Thank U Very Much