ECG – Basics

What is a 12 lead ECG?

 Records the electrical activity of the heart

(depolarisation and repolarisation of the
myocardium)

 Views the surfaces of the heart (left

ventricle) from 12 different angles
 Anatomy Revisited
 Lies in the mediastinum behind the sternum
 between the lungs, just above the diaphragm
 the apex (tip of the left ventricle) lies at the fifth intercostal space,
mid-clavicular line
 EKG Leads
Leads are electrodes which measure the
difference in electrical potential between
either:

1. Two different points on the body (bipolar leads)

2. One point on the body and a virtual reference point

with zero electrical potential, located in the center of
the heart (unipolar leads)
 EKG Leads
The standard EKG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads

The axis of a particular lead represents the viewpoint from

which it looks at the heart.
Limb leads Chest Leads
 Limb Leads
3 Unipolar leads

 avR - right arm (+)

 avL - left arm (+)
 avF - left foot (+)

 note that right foot is a ground lead

 Limb Leads
3 Bipolar Leads
form (Einthovens Triangle)

Lead I - measures electrical potential

between right arm (-) and left arm (+)

Lead II - measures electrical potential

between right arm (-) and left leg (+)

Lead III - measures electrical potential

between left arm (-) and left leg (+)
 Chest Leads
6 Unipolar leads
Also known as precordial leads
V1, V2, V3, V4, V5 and V6 - all positive
Chest Leads
Extreme thoracic leads (optional)

Left extreme thoracic leads (posterior) Right extreme thoracic leads (right thorax)
V7, V8, V9 V3R, V4R, V5R, V6R

In susp of posterior AMI In susp of right ventr. AMI

 Think of the positive
electrode as an ‘eye’…

the position of the positive

electrode on the body
determines the area of the
heart ‘seen’ by that lead.
 Surfaces of the Left Ventricle
 Inferior - underneath

 Anterior - front

 Lateral - left side

 Posterior - back
 Lead Groups

I aVR VI V4

II aVL V2 V5

III aVF V3 V6

Limb Leads Chest Leads

 Inferior Leads
 II, III, aVF
 View from Left Leg 
 inferior wall of left ventricle

I aVR VI V4

II aVL V2 V5

III aVF V3 V6
 Lateral Leads

 1 and AVL
 View from Left Arm 
 Lateral wall of left
ventricle

I aVR VI V4

II aVL V2 V5

III aVF V3 V6
Lateral Leads
 V5 and V6
 Left lateral chest
 Lateral wall of left
ventricle

I aVR VI V4

II aVL V2 V5

III aVF V3 V6
Septal Leads
 V1, V2
 Along sternal borders
 Look through right
ventricle and see septal
wall

I aVR VI V4

II aVL V2 V5

III aVF V3 V6
 Anterior Leads
 V3, V4
 Lateral anterior chest
 + electrode on
anterior chest

I aVR VI V4

II aVL V2 V5

III aVF V3 V6
Depolarization
Anatomy Revisited
Recording an ECG
1. Explain procedure to patient,
obtain consent and check for
allergies
2. Check cables are connected
3. Ensure surface is clean and dry
4. Ensure electrodes are in good
contact with skin
5. Enter patient data
6. Wait until the tracing is free
from artifact
7. Request that patient lies still.
8. Push button to start tracing
12 lead ECG Format
Standard calibration

A = correct standardisation
B = overshooting
C = overdamped
 Reporting an ECG
 Rhythm
 Frequency
 Cardiac axis
 Description of all components
 Rythm

P waves upright in I, II, aVF

Constant P-P/R-R interval
 Determining the Heart Rate
 Rule of 300

 10 Second Rule
 Rule of 300
Take the number of “big boxes” between
neighboring QRS complexes, and divide this
into 300 (or the number of small boxes
divided by 1500). The result will be
approximately equal to the rate

Although fast, this method only works for

regular rhythms.
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
What is the heart rate?

www.uptodate.com

(300 / ~ 4) = ~ 75 bpm
What is the heart rate?

(300 / 1.5) = 200 bpm

 The Rule of 300
It may be easiest to memorize the following table:

# of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
The Rule of 300
The Rule of 300
 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.

 The QRS Axis

The QRS axis represents the net overall

direction of the heart’s electrical activity.

Abnormalities of axis can hint at:

Ventricular enlargement
Conduction blocks (i.e. hemiblocks)
What is the heart rate?

33 x 6 = 198 bpm
 Hexaxial Array for Axis Determination

determination of the
angle of the
main cardiac vector
in the frontal plain
 Determining the Axis

Predominantly Predominantly Equiphasic

Positive Negative
 Vector
 Vector represents magnitude & direction of
force; polarity if electrical force.
+
+

+
 Vectors Summed to Single
Resultant Vector
 Vectors may be translated in space to common
origin without changing magnitude or direction.
Now called Component Vectors, and may be
summed by parallelogram method to produce
Resultant Vector.
Resultant
Vector

= =
Translate Summed
Hexaxial array and ECG
vectors from various
leads.
1. Find net + or – QRS in
lead 1
2. Find net + or _ QRS in
Lead aVF
3. Resultant Vector. This
is Mean Electrical Axis
of Heart or Cardiac
Vector.

Electrical axis is about

+60o
 Axis Determination – Quick Locate Step 1

Lead I

If lead I is mostly
positive, the
axis must lie in the
right half of
of the coordinate
system; the main
vector is moving
mostly toward the
lead’s positive
electrode.
 Axis Determination – Quick Locate Step 2

Lead aVF

If lead aVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system; the main
vector is moving
mostly toward the
lead’s positive
electrode
 Axis Determination – Quick Locate Step 3

I aVF

Combining the two

plots, we see
that the axis must
lie in the bottom
right hand quadrant
 Axis Determination – Quick Locate Step 4
I aVF aVL

Once the quadrant has

been determined, find
the most equiphasic
(smallest net deflection)
or smallest limb lead.
The axis will lie about
90o away from this lead.
Example above; aVL is
the most equiphasic
lead. Axis must be
about 90o from this lead;
here shown to be
approximately 60o.
 Axis Determination – Quick Locate Step 5
I aVF aVL

Since QRS complex in

aVL is a slightly more
positive, the true axis
will lie a little closer to
aVL (the depolarization
vector is moving a little
more towards aVL than
away from it). A better
estimate would be
about 50o (normal axis).
Accuracy + or – 15o.
 Axis Determination – Example 2

Lead I

If lead I is mostly
negative, the
axis must lie in
the left half of
of the coordinate
system.
 Axis Determination – Example 2

Lead aVF

If lead aVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system
 Axis Determination – Example 2

I aVF

Combining the two

plots, we see
that the axis must
lie in the bottom
right quadrant
(from heart
perspective).
 Axis Determination – Example 2

I aVF II

Once the quadrant

has been
determined, find the
most equiphasic or
smallest limb lead.
The axis will lie
about 90o away from
this lead. Given that
II is the most
equiphasic lead, the
axis here is at
approximately 150o.
 Axis Determination – Example 2

I aVF II

Since the QRS in II

is a slightly more
negative, the true
axis will lie a little
farther away from
lead II than just 90o
(the depolarization
vector is moving a
little more away from
lead II than toward
it). A better estimate
would be 160o.
Precise Axis
Calculation
Precise calculation
of the axis can be
done using the
coordinate system
to plot net voltages
of perpendicular
leads, drawing a Net voltage = 12
resultant rectangle, Since Lead III is
then connecting the most

Net voltage = 7
the origin of the equiphasic lead
coordinate system and it is slightly
with the opposite more positive
corner of the than negative,
rectangle. A this axis could be
protractor can then estimated at
be used to about 40o.
measure the
deflection from 0.
 Normal Axis
• LAD
• Anterior Hemiblock
LAD = -30 to -90
• Inferior MI
No Man’s Land Axis
• WPW – right pathway
= -90 to +- 180
• Emphysema

• RAD
• Children, thin adults
• RVH
• Chronic Lung Disease
• WPW – left pathway
• Pulmonary emboli
• Posterior Hemiblock

• No Man’s Land
• Emphysema
• Hyperkalemia
• Lead Transposition
• V-Tach Normal Axis = -30 to +120
RAD =+120 to +180
Its your turn…….
Example 1
Example 2
Example 3
Example 4
 Normal P wave
 Coresponds to atrial depolarization
 Positive in DI and DII
 Duration: less than 0,12 sec (3 small quadr)
 Amplitude: less than 2,5 mm
 PR interval
 Corresponds to atrio-ventricular conduction
 Normal length: 0,12-0,20 sec (3-5 small
quadrants)
 QRS complex

 Corresponds to ventricular depolarization

 Normal length: lower than 0,12 sec (3 small quadrants)
 QRS complex
 Q wave
 Measure width
 Pathologic if greater than or equal to 0.04 seconds (1
small box)
 amplitude less than 25% of the subsequent R wave
 Intrinsicoid deflection
(R wave peak time)
 reflects the depolarization vector from the endocardium to
the epicardium

 measured from the beginning of the QRS complex to the

peak of the R or R’ wave in precordial leads

 NV < 0.05 sec in V5, V6

 In the presence of bundle branch block or ventricular

hypertrophy, the depolarization impulse takes a longer
than normal period of time to reach the recording
electrode. This delays the onset of the intrinsicoid
deflection.
Intrinsicoid deflection
J-Point
 Junction between the
end of QRS and
beginning of ST
segment
 Where QRS stops
and makes a sudden
sharp change in
direction
J-Point
 Practice

Find the J Point and ST segment

 Practice

J ST
POINTS SEGMENT
 Practice

Find the J Point and ST segment

 Practice

J ST
POINTS SEGMENT
 ST segment and T wave

 Correspond to ventricular
repolarization
 ST segment is isoelectric (J
point is on the isoelectric line)
 T wave is positive in majority
of the leads, but:
 negative in aVR;
 variable in DIII, aVF
(corresponding to QRS polarity);
 possibly negative in V1-V2
(young mainly)
 General rule - T wave should not
be more than 1/2 the height of
the preceding QRS
 ST Segment
 Need reference point
 Compare to TP segment
 DO NOT use PR segment as reference!
 ST Segment Analysis

For each complex, determine whether the ST segment is

elevated one millimeter or more above the TP segment
 ST Segment Analysis

YES YES NO YES NO

 The QT/QTc Interval

Measurement: From the beginning of the Q wave to the

end of the T wave

Parameter: Normal QT intervals range from 0.36-

0.41.

QTc: QT divided by the square root of the R to R

interval; normal values < 0,39 sec males and <
44 sec females
 U wave
 The source of the U wave is unknown. Three common
theories regarding its origin :
 Delayed repolarisation of Purkinje fibres
 Prolonged repolarisation of mid-myocardial “M-cells”
 After-potentials resulting from mechanical forces in the ventricular
wall
 by definition, follows the T wave; usually in the same
direction as the T wave
 U -wave size is inversely proportional to heart rate: the U
wave grows bigger as the heart rate slows down
 The voltage of the U wave is normally < 25% of the T-
wave voltage: disproportionally large U waves are
abnormal
 Maximum normal amplitude of the U wave is 1-2 mm
 best seen in V2 and V3
U wave