ECG Exam Template

The following headings and prompts can be used as template for ECG-based exam questions, such as the FACEM Part II VAQs.

ECG type and recording

• 12 lead vs rhythm strip, rate (normal 25 mm/s)
• Calibration (5mm wide, 10mm high = 1mV)
• Unusual leads – right, posterior, lead grouping format

Rate

• normal 60 – 100/min; tachy/brady
• -cardia (SA node) vs –arrhythmia (not SA node)
• method: 300/RR interval (large squares) or number of QRS complexes x 6 (if 25mm/s)

Rhythm

• Pattern – regular/ regularly irregular/ irregularly irregular
• Seven step approach to rhythm analysis

Axis

• Normal QRS axis -30 to 90/ LAD/ RAD/ NW axis
• Rotation (clockwise/ anticlockwise)
• Methods: 1. Quick look test (e.g. I And AvF) 2. Isoelectric line

P wave

• Present? (esp check II and V1)
• Amplitude + duration: normal <3mm high and wide (LAE/RAE/both)
• Contour: normal — inverted aVR, biphasic V1, upright I,II, aVF, V2-V6

PR interval + PR segment

• Duration 0.12-0.2s normal/ short/ long/ varying
• heart blocks: 1st, 2nd type I and II, 3rd degree
• Depression

Q wave

• Normal: <25%R in I, aVL, AVF, V456
• Pathological: V23 > 0.02s, other >0.03s + >1mm deep

R wave

• Transition: normal V34, early: R>S in V1/2
• Poor R Wave Progression: R <3mm V3

QRS complex

• Duration: 60-110msec normal/ wide; R wave peak time
• Amplitude: normal/ large voltage/ low voltage/ alternans
• Morphology: notched/ RBBB/ LBBB

ST Segment

• Displacement: elevation/ depression (J point vs TP interval)
• Contour: horizontal /upsloping / downsloping

T wave

• Amplitude: normal <2/3 R/ peaked/ inversion/ alternans

QT Interval

• Duration: normal 390-450 or 460msec / long/ short/ QT dispersion
• Method, 3+ QRS in 3+ leads, QTc formulae, caveats

U wave

• normal 10%T or <1.5mm/ prominent/ inversion/ alternans

Additional waves

• DOE: Delta wave, Osborne wave, Epsilon Wave

Chamber hypertrophy

• Atrial – LAE, RAE, biatrial
• Ventricular – LVH, RVH, biventricular

Lethal – do not miss!

• Ischaemia – STE criteria and DDX/ Sgarbossa/ reciprocal change/ Wellens/ aVR
• Quick BRAD Home! (causes of syncope)
• PE
• Electrolytes — hyperK, hypoK, hypoCa, hyperCa, hypoMg
• Tox — TCAs, digoxin

Other tricks and traps

• Dextrocardia, Lead reversals
• Artifacts – tremor artifact
• Pacing spikes – pacemaker malfunction: failure to sense/ capture/ output?

Synthesis

• Leave space to put this at the start of the answer
• Unifying diagnosis, DDx, life threats