ECG Protocol

Question 1

What is the First parameter to be checked in an ECG ?

Answer 1

First parameter - Rhythmic/Arhythmic + P wave

Do we see A Regular or Irregular rhythm? What is the Pattern?

Mophology and Orientation of P wave, P to QRS Ratio.

P pulmonale - 1st half P amplitude > 2.5 mm

P mitrale - 2nd half P amp ↑ / biphasic P in V1 / P ≥ 0.4 s

Question 2

What is the Second parameter to be checked in an ECG ?

Answer 2

Second parameter - Heart Rate

• Counting the numbers of R waves in 50 Large squares (10 s) and multiplying by 6.
• If there is a Regular Rhythm we can simply divide the counted distance between R waves.

Question 3

What is the Third parameter to be checked in an ECG ?

Answer 3

Third Parameter - PR Interval

• Normally its 0.12 - 0.2 Sec, Looking to see if there is a delay that indicate any block in AV conduction.

Question 4

What is the Fourth parameter to be checked in an ECG ?

Answer 4

Fourth parameter - Mean Electrical Axis

• Lead I and Lead II should be Positive
• If Lead I turns Negative - Right Axis Deviation
• If Lead II turns Negative - Left Axis Deviation
• If Both leads turn Negative - Extreme Right Axis Deviation

Question 5

What is the Fifth parameter to be checked in an ECG ?

Answer 5

Fifth parameter - QRS Complex

• Wide - Most likely Ventricular Impulse origin should be further checked
• Narrow - Most likely Supraventricular Impulse origin should be further checked
• Small - Conduction Problems to the leads; Obesity or emphysema (Pericadial Effusion)
• Large - Ventricular Hypertrophy, WPW, Post. MI or Dexocardia.

Question 6

What is the Sixth parameter to be checked in an ECG ?

Answer 6

Sixth parameter - Pathological Q waves

• Deep or Wide ones could indicate MI, PE, WPW, Bundle Branch Block or Hyperthrophy

Question 7

What is the Seventh parameter to be checked in an ECG ?

Answer 7

Seventh parameter - Bundle Branch Blocks

• RBBB - “Rabbit ears” on V1 R wave
• LBBB - “Notched Tower” on V6 R wave
• Further checking of :Left Anterior Hemiblock or Left Posterior Hemiblock

Question 8

What is the Eighth parameter to be checked in an ECG ?

Answer 8

Eighth parameter - Hypertrophy

• Right Ventricle Hypertrophy: Dominant R wave on V1 (usually with Right Axis Deviation)
• Left Ventricle Hypertrophy: Large R waves in I, aVL, V5-6 and Deep S waves in V1-3 (together more than 35mm)
• R wave Progression :Normally grows from V1 to V5

Question 9

What is the Ninth parameter to be checked in an ECG ?

Answer 9

ST Segment

• Elevated - Consider: STEMI, Left ventricular Aneurysm, Vasospastic Angina, Pericarditis, LBBB, Bruguda Syndrome, High Take off.
• Depressed - Consider: Myocardial Ischemia, Acute Posterior MI, Vent. Hypertrophy with ‘Strain’
• J waves Present - Consider Hypothermia

Question 10

What is the Tenth parameter to be checked in an ECG ?

Answer 10

T waves

• Tall - Hyperkalaemia, Acute coronary Syndrome
• Small- Hypokalaemia, Pericarditis, Hypothyrodism
• Inverted - Could be a variant or part of Myocardial Ischemia or Infarction, as well as ‘Strain’ Pattern in Ventricular Hypertrophy.

Question 11

What is the Eleventh parameter to be checked in an ECG?

Answer 11

QT Interval

• Long - Hypocalcaemia, Acute Myocarditis, Long QT Syndrome, Cerebral Injury, Hypertrophic cardiomyopathic
• Short - Heredetery short QT Syndromes, Hypercalcaemia, Hyperkalaemia, Digoxin effect

Question 12

What is the Twelfth parameter to be checked in an ECG?

Answer 12

Other waves :

• U wave: Hypokalaemia, Drugs; If Inverted than Ischemic Heart Disease, Hypertension, Vulvar regurgitation and dilated cardiomyophathy
• F Wave: Atrial Flutter
• Delta wave: WPW syndrome
• J wave: Hypothermia

Question 13

What is the Thirteenth parameter to be checked in an ECG?

Answer 13

Check S1Q3T

Pulmonary Embolism