ECG Made Easy Flashcards
What is a Q wave?
The first downwards deflection of the ECG
What is an R wave?
The first upward deflection of the ECG
What is an S wave?
Any deflection below the baseline, following an R wave
What does each large square (5mm) of an ECG represent?
0.2 s
What does each small square (5mm) of an ECG represent?
0.04s
What is a normal PR interval?
0.12 - 0.2s
What is a normal QRS duration
0.12s
What appearance does a QRS complex have if depolarization is moving predominantly towards the lead?
Predominantly upwards QRS
What appearance does a QRS have if depolarization is moving predominantly away from the lead?
Predominantly downwards QRS
What does a QRS with equal R and S waves indicate?
The depolarization wave is moving at right angles to the lead
What is a normal cardiac axis of the heart?
11 o’clock to 5 o’clock
What is the general deflection location in leads 1 - 3 in a heart with a normal cardiac axis?
Upwards in leads I - III
What ECG changes are seen in right axis deviation?
Negative deflection in lead I
Deflection in lead III becomes more positive
What are some common causes of right axis deviation?
Pulmonary conditions that put a strain on the right side of the heart and congenital heart disorders
What is a cause of left axis deviation?
LV hypertrophy or conduction defect (more common)
- commonly left anterior fascicle block
What is a left axis ECG with negative lead III indicative of?
Conduction defect (more likely than LVH)
What is the general rule for direction of cardiac axis?
It points towards any lead where R wave is larger than S wave
In degrees, what is the range of the normal cardiac axis?
- -30 to + 90 degrees
- with 0 being parallel to the horizontal
What 2 factors determine the shape of the QRS in the chest (V) leads?
- The septum between the ventricles is depolarized before the walls of the ventricles, and the depolarization wave spreads across the septum from left to right
- In normal heart, LV wall has more muscle than right LV wall
What area of the heart do leads V1 and V2 look at?
The right ventricle
What area of the heart do leads V3 and V4 look at?
The septum
What area of the heart do leads V5 and V6 look at?
The left ventricle
What directions are the first deflections in leads V5 and V6 and why?
RS wave (positive deflection first) and is because of the septum depolarisation
Why is S negative in leads V1 and V2?
The main muscle mass depolarized is the LV - which is spreading away from LV leads
What happens to the QRS as you transition from V1 - V6 in a normal heart?
QRS is predominantly negative in V1 and becomes gradually more positive towards V6 (R and S are opposite and equal size in V4)
What is clockwise rotation on the ECG often indicative of?
Chronic lung disease
What normal physiological characteristics can cause right axis deviation?
Being tall and skinny
What does the PR interval indicate?
The time taken for depolarization to from SAN to ventricular muscle
What is first degree heart block?
Long PR > 0.2s
What is the significance of first degree heart block?
It is not important in itself
- but may be a sign of coronary artery disease, digitalis toxicity or electrolyte disturbances
What is the difference between Mobiz 1 and Mobiz 2 (Wenkebach) heart block?
Mobiz 1 - PR gets progressively later and then dropped QRS
Mobiz 2 - Constant PR and then random dropped QRS
What is 3rd degree heart block? (complete heart block)
Normal atrial contraction but not conducted to the ventricles
- slow escape mechanism
What are some causes of complete heart block?
- Acutely following MI
- Chronic state - fibrosis around bundle of His
- Block of both bundle branches
What is the significance of a RBBB pattern with normal length QRS?
Can be either problem with the right side of the heart or a common finding in normal people
What is the significance of LBBB pattern?
Always an indication of heart disease, usually left side
- LBBB prevents any further interpretation of the ECG
What are some ECG signs of RBBB?
McDonalds M in V1 and reversed in V6
MAINLY POSITIVE IN LEAD V1
- wide QRS
- deep S wave
- first deflection is upwards
What are some ECG signs of LBBB?
A wide W in lead V1 and this is reversed in V6
- first deflection is downwards
How does a RBBB impact the cardiac axis?
It does not change it
What other feature is associated with complete heart block?
Ventricular escape rhythms
When is ventricular tachycardia diagnosed?
When the rate exceeds 120bpm
What is the difference between extrasystole and escape beat?
Extrasystole comes early and escape rhythms come late
What ECG features indicated SVE / pre-atrial complexes?
Abnormal P wave and a longer R-R interval following ectopic QRS
What is bigeminy?
Every other beat is a pre-atrial complex (PAC)
What is trigeminy?
Every 3rd beat is a PAC
What is the difference between VEs and SVEs?
VEs do not have P waves - SVEs have abnormal p waves
VEs also generally have wider, uglier QRS
What is another name for carotid sinus pressure?
Sympathetic vagal stimulation of SA and AV nodes
What are promenant ECG features of junctional tachycardia?
Fast QRS complexes with no P waves
What is a general rule for determining whether a QRS is of ventricular or supraventricular (e.g. with BBB)?
If QRS > 160 ms then is likely to be of ventricular origin
- if QRS complex is very irregular, is likely to be AF with BBB
Can fibrillation occur within the ventricles?
Yes
How is ventricular fibrillation identified?
Like atrial fibrillation but larger irregular deflections of baseline
- patient will likely have passed out - is how to distinguish from artefact
How is WPW syndrome identified on ECG?
Delta waves and very short PR interval
What can cause right atrium hypertrophy? and how is this identified on ECG
Tricuspid valve stenosis or pulmonary hypertension
- associated with peaked P waves
What can cause left atrium hypertrophy? and how is this identified on ECG
Mitral valve stenosis
- associated with broad bifid P wave
In a normal ECG, what are the approximate heights of the R waves?
Less than 25mm
What ECG features can a PE show?
Those similar to right ventricular hypertrophy
- e.g. peaked p waves, right axis deviation, tall R waves, RBBB
What is the general direction of ventricle depolarisation?
From the inside to out
Which ventricle occupies the front of the heart anatomically?
Right ventricle
In which ECG leads is the T wave inverted in normal physiology?
V1 (and sometimes V2 and V3)
How can lead malposition be identified?
Completely inverted trace in certain leads
How can you distinguish STEMI from WPW?
WPW has wide QRS complexes
What is an ischemic cause of QRS fragmentation?
Abnormal ventricular repolarization
- due to fibrosis and scarring