# EKG Interpretation Lecture 1 – Identifying the Squiggles, Developing a System for Reading

Reading the EKG – systematic approaches: Quality of EKG – do you need to repeat it? Rate Rhythm Waves, intervals, segments left to right Axis Any changes from old EKG? OR Quality Rate Rhythm Intervals – segments, intervals Axis Morphology - waves OR Measurements Rate, intervals, axis Rhythm Analysis Conduction Analysis Waveform Description EKG Interpretation Comparison with prior EKG is just 3D picture of the heart’s electrical activity using 6 limb leads (electrodes) – I, II, III, aVR, aVL, aVF – and 6 precordial (chest) leads – V1-V6 It is an observation of the electrical impulse as it travels through the myocardium. This impulse has magnitude, direction, and duration and can be considered a vector. Each electrode sees the heart’s electrical impulse differently (direction) If depolarization moves toward a positive electrode, you will see an upright spike on the EKG If depolarization moves away from a positive electrode, you will see an inverted spike If depolarization is perpendicular to an electrode, the spike will be isoelectric (as much “up” as “down”) Magnitude (height/depth) of each spike depends on the mass of myocardium depolarizing Width of the spike is determined by the speed of the paper (standard 25 mm / second) and the speed of the electrical impulse through the myocardium Limb leads look at the heart in horizontal/frontal plane Precordial (chest) leads look at the heart in an anterior-posterior direction RV leads = V1, V2

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LV leads = V5. V6 2 .

Divide the R-R interval into 60 (if rhythm regular) Normal 60-100 Bradycardia < 60 Tachycardia > 100 Rhythm Identify each waveform Identify the relationship between P waves and QRS complexes Does every QRS have a P wave? Does every P wave have a QRS? Escape beats? Premature beats? Premature ventricular contractions (PVCs) Premature atrial contractions (PACs) Normal sinus rhythm is normal P waves in leads I and II should be upright if rhythm is coming from the sinus node 3 . find a QRS on a large black line and count the number of large black lines until the next QRS. more simply. Divide 300 by the number of large black lines = rate.Rate and Rhythm: Rate 3 methods for calculating rate Count all complexes in one strip (10 seconds of recording) and multiply by 6 Count big boxes (if rhythm regular) One complex / big box – rate = 300 One complex / 2 big boxes – rate = 150 One complex / 3 big boxes – rate = 100 One complex / 4 big boxes – rate = 75 One complex / 5 big boxes – rate = 60 One complex / 6 big boxes – rate = 50 Or.

then V1 Abnormal P wave suggests atrial abnormality Left atrial abnormality (enlargement) – “P mitrale” P wave widened. peaked (>2. may have a notch like an “m” (> 2.12 Suggests accessory pathway bypassing the AV node – WPW (Wolff-Parkinson-White) Look for delta wave – slurred upstroke to QRS Prolonged = > 0.5 little boxes) Biphasic P wave in V1 “up” phase most prominent – Right atrial abnormality / enlargement (RAA/RAE) “down” phase most prominent – Left atrial abnormality/enlargement (LAA/LAE) Do they all look the same? Inverted – implies retrograde atrial activation in an AV junctional rhythm PR Interval Measured from beginning of P wave to beginning of QRS interval Represents “time delay” as electrical impulse travels from atria to the ventricles through the AV node and bundles (conduction system) Usually measured in lead II Normal = 0.20 Evidence of AV nodal block 1st degree 2nd degree Mobitz type I (Wenckebach) 2nd degree Mobitz type II 3rd degree (complete) PR depression – indicative of atrial injury in pericarditis Q wave Normal in lead aVR. possibly normal in lead V1 Q waves wider and deeper than 1 little box usually mean infarction of myocardium 3 causes of Q waves: Physiologic – small.12-0.5 little boxes) Right atrial abnormality (enlargement) – “P pulmonale” P wave tall.Segments and Intervals (reading left to right): P wave Activation of atrium / atrial depolarization (sequential activation of right and left ventricles) Evidence of rhythm initiating from sinus node Seen best in lead II. normal septal q waves reflecting normal septal activation Hypertropic cardiomyopathy (large septum) Infarction 4 .20 Short = < 0.

and ending with the superior portion of the left ventricle Measured from beginning of Q wave to end of S wave Measured in any lead.44 (Men).41 ± 0. 0. amplitude.05 (Men).05 (Women) Prolonged QT = > 0. take the widest Normal = ≤ 0. q waves Depolarization begins with the septum.46 (Women) 5 . deep S waves signify ventricular hypertrophy R wave progression Small R waves begin in V1 or V2 and progress in size to V5 (V6 is usually a little smaller than V5) S waves progress in reverse (small in V5 or V6 and larger in V2. extending to the endocardial surfaces.QRS Interval Simultaneous activation of the left and right ventricles / ventricular depolarization / ventricular contraction Axis. V1 a little smaller than V2) The usual transition from S>R to R>S is V3 or V4 Poor R wave progression R < 2 little boxes in leads V1-3 Normal if rest of EKG normal Left ventricular hypertrophy (LVH) Left bundle branch block (LBBB) Left anterior fascicular block (LAFB) Anterior/anteroseptal myocardial infarction (MI) COPD Diffuse infiltrative or myopathic process WPW preexcitation QT Interval Activation of ventricle to end of repolarization Measured from beginning of QRS to end of T wave Measured in any lead Normal varies inversely with rate so should be corrected for rate (not a linear relationship) Corrected QT interval (QTc) = Measured QT interval / Square root (measured RR interval) Normal = 0.10-0.12 Complete bundle branch block (right / left bundle branch block) ≥ 0.10 Delayed / prolonged = > 0.17 Amplitude of QRS depends primarily on size of ventricular chambers and proximity of ventricle to the chest electrodes R wave / S wave Tall R waves.12 Severe myopathy if ≥ 0.10 – intraventricular conduction delay (widened QRS) Incomplete (partial) block = 0.39 ± 0. > 0.

V5. coronary spasm. roughly.digoxin T waves Repolarization of the ventricle In general. LVH. if the QRS is upright. ventricular aneurysm. II. V6 Low. inverted T waves in these leads are abnormal – indicative of abnormal function of the left ventricle Should be inverted in leads V1 and aVR 6 . V6 Flat. downsloping. the QT interval should be shorter than half the RR cycle length J-point – end of QRS complex Early repolarization: ST Segment Measured from end of S wave to beginning of T wave Should slope upward into T waves in leads I. bundle branch block (BBB). depressed ST segments are abnormal Elevation – injury. flat. the T wave should be upright within 60 degrees Should be 25% of the height of the R wave in leads I. electrolyte abnormalities Can herald ventricular arrhythmia Or. pericarditis. sagging. medications . II. early repolarization Depression – ischemia.Medication side effects. V5. congenital.