This document provides guidelines for reporting electrocardiograms (ECGs). It describes how to report heart rate, rhythm, P wave morphology, PR interval, QRS complex width and axis, ST segment and T wave changes, and other key elements. Abnormal findings are defined, such as the thresholds for diagnosing ST elevation myocardial infarction. Proper ECG reporting is important for clinical decision making in emergency situations.

1. REPORTING OF ECG
Dr. Ajith Venugopalan.
MBBS, MD(Emergency Medicine),
Fellow of Academic College of Emergency Experts (FACEE),
Fellowship in Intensive Care Medicine (FICM).
Head of the Department
Department of Emergency Medicine
MOSC Medical College Hospital, Kolenchery, Ernakulam, Kerala
Lead, National EM Residency Network,
Emergency Medicine Association (EMA) of India

2. REPORTING OF AN ECG
1. Rate : ………./mt
2. Rhythm : Sinus /arrhythmia ,
Regular/ irregular
3. P wave morphology : Normal/ broad /tall
4. PR interval : …….msec
5. PR segment : Normal/ depressed/ elevated
6. QRS
 Width : …….msec
 Axis : …….degree – Normal / Left / Right
 Morphology :
7. ST segment : Normal/ depressed/ elevated
8. T wave morphology : Normal / tall / inverted
9. U wave : Normal / prominent / absent
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

3. HEART RATE
300_______
No. of Large squares
between RR
OR
1500______
No. of small squares
between RR
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

4. What is the approximate heart rate?
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

5. 1. Rate
2. Rhythm : Sinus /arrhythmia ,
Regular/ irregular
3. P wave morphology : Normal/ broad /tall
4. PR interval : _____msec
300/4 = 75 beats /mt
Sinus
Regular
- Normal
- 120msec
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

6. NORMAL ECG ( SINUS )
 Normal rate – Between 60 bpm and 100bpm
 Sinus rhythm - Normal P wave before each QRS
complex
Regular QRS complexes
May be a variation with respiration
P wave - May be negative in Lead V1 and aVR
Normal morphology
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

7. P WAVE
Normal
 3 x 3
 3 small box – height
 3 small box – width
Abnormal
 > 3small box height – P pulmonale
 > 3small box width – P mitrale.
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

8. PR INTERVAL
 PR Interval – Onset of P to onset of QRS
 Normal – 120 –200msec or 3 –5 small squares
 > 200msec (> 5 small squares) Prolonged PR Interval -
1st Degree HB
 Narrow – WPW syndrome Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

9. 5. PR segment : Normal/ depressed/ elevated
6. QRS
 Width : …….msec
 Axis : …….degree – Normal / Left / Right
 Morphology :
7. ST segment : Normal/ depressed/ elevated
8. T wave morphology : Normal / tall / inverted
9. U wave : Normal / prominent / absent
- 3 small box - Normal
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

10. QRS COMPLEX
 QRS Complex
 Normal width -
< 120msec
3 small squares
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

11. QRS COMPLEX
 Wide QRS Complex
 QRS > 120ms
 Narrow QRS Complex
 QRS < 120ms

12. AXIS

13. AXIS
 Normal Axis = QRS axis between -30 and +90 degrees.
 Left Axis Deviation = QRS axis less than -30 degrees.
 Right Axis Deviation = QRS axis greater than +90 degrees.
 Extreme Axis Deviation = QRS axis between -90 and 180
degrees (AKA “Northwest Axis”).
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

14. Normal
Axis
Left
Axis
Right
Axis

15. RIGHT AXIS DEVIATION
 Right ventricular hypertrophy
 Acute right ventricular strain, e.g. due to pulmonary embolism
 Lateral STEMI
 Chronic lung disease, e.g. COPD
 Hyperkalaemia
 Sodium-channel blockade, e.g. TCA poisoning
 Wolff-Parkinson-White syndrome
 Dextrocardia
 Ventricular ectopy
 Secundum ASD – rSR’ pattern
 Normal paediatric ECG
 Left posterior fascicular block – diagnosis of exclusion
 Vertically orientated heart – tall, thin patient
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

16. LEFT AXIS DEVIATION
 Left ventricular hypertrophy
 Left bundle branch block
 Inferior MI
 Ventricular pacing /ectopy
 Wolff-Parkinson-White Syndrome
 Primum ASD – rSR’ pattern
 Left anterior fascicular block – diagnosis of exclusion
 Horizontally orientated heart – short, squat patient
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

17. EXTREME AXIS DEVIATION
 Ventricular rhythms – e.g.VT, AIVR, ventricular ectopy
 Hyperkalaemia
 Severe right ventricular hypertrophy
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

18. 5. PR segment : Normal/ depressed/ elevated
6. QRS
 Width : …….msec
 Axis : …….degree – Normal / Left / Right
 Morphology :
7. ST segment : Normal/ depressed/ elevated
8. T wave morphology : Normal / tall / inverted
9. U wave : Normal / prominent / absent
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

19. ST SEGMENT ELEVATION
 Acute myocardial infarction
 Coronary vasospasm
(Printzmetal’s angina)
 Pericarditis
 Benign early repolarization
 Left bundle branch block
 Left ventricular hypertrophy
 Ventricular aneurysm
 Brugada syndrome
 Ventricular paced rhythm
 Raised intracranial pressure
 Takotsubo Cardiomyopathy
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

20. ST SEGMENT DEPRESSION
 Myocardial ischaemia /
NSTEMI
 Reciprocal change in STEMI
 Posterior MI
 Right bundle branch block
 Left bundle branch block
 Left ventricular hypertrophy
 Ventricular paced rhythm
 Digoxin effect
 Hypokalaemia
 Supraventriculartachycardia
 Right ventricular hypertrophy
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

21. PATHOLOGICAL T WAVE
More than half the size of the preceding QRS complex
Tall T wave:
 Hyperkalaemia –tall tented T
 Acute MI – Hyperacute T waves
 Prinzmetal angina
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

22. T WAVE INVERSION
 Normality
 Ischaemia
 Ventricular hypertrophy
 Bundle branch block
 Digoxin treatment.
 Idiopathic apical hypertrophy (a
rare form of hypertrophic
cardiomyopathy)
 Mitral valve prolapse
 Digoxin effect
 RVH and LVH with "strain"
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

23. OTHER DANGEROUS T WAVE CHANGES
 Biphasic T wave
 Deep T wave inversion
 Remember Wellens T waves

24. U WAVE
 Sinus Bradycardia can accentuates the U wave
 Hypokalemia (ST segment depression, low amplitude T waves,
and prominent U waves)
 LVH (right precordial leads with deep S waves)
 Quinidine and other type 1A antiarrhythmics
 CNS disease with long QT intervals (often the T and U fuse to
form a giant "T-U fusion wave")
 Hyperthyroidism
 Mitral valve prolapse (some cases)
U waves are usually best seen in the right precordial leads especially V2 & V3.
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

25. ECG IN STEMI
 Definition of STEMI –
 New ST elevation at the J point in two contiguous leads of >0.1
mV in all leads other than leads V2-V3 –
 For leads V2-V3 the following cut points apply:
 ≥0.2 mV in men ≥40 years, ≥0.25 mV in men < 40years
 >0.15mv in women.
 Other conditions which are treated as a STEMI –
 New or presumed new LBBB
 Isolated posterior MI
 The presence of reciprocal ST depression helps confirm the diagnosis
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

26. REPORTING OF AN ECG
1. Rate : ………./mt
2. Rhythm : Sinus /arrhythmia ,
Regular/ irregular
3. P wave morphology : Normal/ broad /tall
4. PR interval : …….msec
5. PR segment : Normal/ depressed/ elevated
6. QRS
 Width : …….msec
 Axis : …….degree – Normal / Left / Right
 Morphology :
7. ST segment : Normal/ depressed/ elevated
8. T wave morphology : Normal / tall / inverted
9. U wave : Normal / prominent / absent
Reporting of ECG - Dr. Ajith Venugopalan, EM, Kerala

27. …..THANK YOU…..
Dr. Ajith Venugopalan
9496339347
ajith.v123@gmail.com