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EKG – Basic Analysis

Rate
1. Determine ventricular (R-R) & atrial (P-P) rates a. Use or
b. Small box = 1mm, speed = 25mm/sec i. Small box = 0.04 sec ii. Big box = 0.2 sec iii. 5 big boxes = 1 sec

Intervals – use limb leads!
1. Rate 2. Rhythm 3. Axis 4. Intervals 5. Wave form Summary Interval 1. PR interval 2. QRS duration 3. QT interval Normal 0.12 to 0.2 s < 0.12 s (Note: QRS = 0.12 is WIDE!) < ½ R-R interval (estimate);
-

(correction)

 ↑ with ↑ HR in exercise,  ↑ with meds (quinidine, procainamide, phenothiazines)  ↓in M vs F, also ↓ with ↑ serum Ca / Mg

2. Normal = 60-100 bpm. <60 = brady, > 100 = tachy

Wave Form
Wave Q Look for… Wide Q (≥ 0.04s) Low QRS voltage (< 5 mm in limb leads and < 15mm in precordial) Why: “Pathological Q wave”, except if:
 Only in lead III = “diaphragmatic”  In aVR (may have QS / Qr) In V1 (may have QS) Seen in pericardial effusion, Addison’s, severe lung dz (↑ air btwn heart / chest wall), severe obesity, hypothyroid, infiltrative heart dz (amyloid, sarcoid, hemochromatosis)

Rhythm
1. Normal sinus rhythm = normal rate & each P wave followed by QRS

Axis – limb leads only!
1. Determine quadrant using I and aVF 2. Axis is perpendicular to isoelectric lead 3. Interpolate if no isoelectric lead found Left Axis Deviation: DDx
      LVH Inferior MI Left anterior hemiblock WPW syndrome LBBB Normal variant

QRS

Extreme axis deviation
-90°

Left axis deviation
-60°

Normally:
 R ↑ from V1-V4; ↑ from V4-V6  R:S ratio ↑ from V1-V6,  “Transition point”: R>S @ V3-V4 Early transition (R>S @ V2-V3)

aVR

-120°

aVL
-30° 0° 30°

-150° 180°

R-wave progression R
(note – these are non-specific findings)

I

 Leads too far to pt’s left, or  Heart rotated counterclockwise (LV to right)  Leads too far to pt’s right, or  Heart rotated clockwise (LV to left)

Poor R-wave progression (little R V1-3, S>R in V4) Early R-wave development* (R>S in V2)

Right Axis Deviation: DDx
 RVH (COPD, congenital heart dz)  Right ventricular strain (PE, other acute lung dz)  Left posterior hemiblock  WPW syndrome  Normal variant 150° 120° 60° 90°

III Right axis deviation

aVF

II Normal
ST Elevation

 RVH, RBB, posterior MI, WPW syndrome  (* always abnormal if R>S in V1)

Pathology: MI, etc. (worry if >1mm elev.) Normal variants:
 “Junctional” ST elevation (in V1-V3)  “early repolarization” (in V4-V6) o ≤ 2-3 mm, smooth/curving shape Should be within 60-70° of QRS axis, upright in V2-6

Notes:  If wide QRS ≥ 0.12 sec (e.g. BBB), use first 0.08 sec only
 P wave axis should be in normal quadrant  T wave axis should be within 60-70° of QRS axis

Axis T U Size Presence

 Peaked (> 10mm) suggests hyperK  Flat suggests hypoK but nonspecific  Normal variant; can be seen in hypoK