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6. EKG BASICS
EKG Basics: How to Read & Interpret EKGS: Updated Lecture Medical Editor: Maxine Abigale R. Bunao

OUTLINE II) APPLICATION AND INTERPRETATION

I) PHYSIOLOGY (A) APPLICATION ON LEAD II

II) APPLICATION AND INTERPRETATION
III) EKG STRIP
IV) APPENDIX
V) REVIEW QUESTIONS
VI) REFRENCES

I) PHYSIOLOGY

(A) PRINCIPLES OF DEFLECTIONS

Figure 1. Physiology of deflections.

(1) General concept:
► Starts at a resting membrane potential: negative
charge
► Application of electrical stimulus towards tissues
► Stimulated tissue  Depolarization: Figure 2. Positioning of Lead II using bipolar limb leads.
o Calcium and sodium ions flood into these cells
 depolarize In Lead II:
o Gap junctions in between cells  electrical o Negative electrode: Right arm
signal propagates from 1 end to another end of o Positive electrode: Left leg
the tissue o Most common lead used in a rhythm strip of the 12
o Flow of positive charges to the opposite end lead EKG
from where the stimulus was applied Tip:
► Repolarization: o Think of the positive electrode as an eye, and you’re
o Flow of negative charges looking towards the negative electrode
o Going towards the eye, positive deflection
(2) Principle of deflections:
o Moving away the eye, negative deflection
Table 1. Principle of deflections.
Type of P wave - Atrial Depolarization
Physiology
deflection Table 2. P-wave or atrial depolarization deflection.
Depolarization  stimulus or flow of Electrical event Physiology
Upward positive charge APPROACHES the
positive electrode
Depolarization  stimulus or flow of
Downward positive charge MOVES AWAY from Depolarization 
the positive electrode stimulus or flow of
positive charge
Repolarization  stimulus or flow of APPROACHES
Upward negative charge APPROACHES the the positive
negative electrode electrode (Lead II)
↓
Upward deflection
Happens when there’s no net
movement of electrical activity
OR movement is perpendicular to Net vector:
the axis of the lead Inferior, Left

Note: If tissue is oriented in a

different direction from the
electrodes  produces an axis of
that lead

Depolarization: • Start of depolarization is at the atria:

Positive
• Stimulus or flow of positive charge ► SA node (top right portion of atria, near SVC)
is PERPENDICULAR to the axis o Has different kinds of pacemaker cells 
of lead generate action potentials
Negative
• Stimulus or flow of positive charge o Spread from SA node to a particular direction
moves away from the axis of that
(i.e. left atrium)
lead
o Mean vector from SA node  AV node in a
Isoelectric • Due to the amplitude from both
downward, leftward direction:
No deflection sides of the axis being equal 
EKG cancels them out ► AV node
(flat) • If normal P wave morphology  Sinus P wave 
generated by SA node

EKG BASICS CARDIOVASCULAR PHYSIOLOGY : Note #4. 1 of 7

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P-R Interval, PR Segment Q wave – Septal depolarization
Table 3. P-R interval and segment deflection. Table 4. Q-wave or septal depolarization deflection.
Electrical event Physiology Electrical event Physiology
No net electrical movement
OR activity is directed
perpendicular to the axis of
Lead II
↓
Flat line, Isoelectric line
Depolarization  stimulus or
flow of positive charge
Net vector:
MOVES AWAY from the
o Positive flow of charge
positive electrode (Lead II)
is NOT moving in a
↓
particular direction
Negative deflection
o No upward/ downward
due to the position of the
deflection
heart

• Depolarization at the AV node: Net vector: average vector

► AV node takes it time with the electrical activity is Right, superiorly (away
from the positive electrode
o Slows down conduction (1 second delay) and
at the right, inferior)
holds the activity within it
► Delay before sends down the action potentials to
Bundle of His, bundle branches, to the ventricles
PR Interval
o Distance from the beginning of P-wave  PR
segment ends
● PR Segment • Depolarization continued from AV node to the Bundle of His:
o Distance from the end of P-wave  beginning of QRS ► Proceeds to Left or Right bundle branch
complex o Left Bundle branch  2 other small branches:
■ Left anterior fasciculars
■ Left posterior fasciculars
► Left Bundle branch primarily depolarizes
Interventricular septum
► Left Bundle branch primarily depolarizes the right
bundle branch
o Oriented upwards due to the shift of the heart
2/3 of the left midsternal line
Q waves
o Physiological part of EKGs
o Pathological when they become:
 larger / wider
 deeper
 at locations they are not supposed to be
o May not even be seen sometimes within the 12-lead
EKG
R wave – Outer and Apical ventricular depolarization
Table 5. R wave or outer, apical ventricular depolarization
deflection.
Electrical event Physiology

From inner to outer ventricular

depolarization  stimulus or flow
AfraTafreeh.com of positive charge APPROACHES
the positive electrode (Lead II)
↓
Upward deflection

Net vector: Left, inferior

o Left ventricle is thicker,
generates more action
potentials  ↑ voltage 
larger positive deflection

• Depolarization continued from Left Bundle Branch:

► Spread outwards to the Purkinje System  apex
 base
► Net vector:
o Larger from the left ventricle, it’s bigger and can
generate ↑ voltage = ↑ positive deflection
o Small from the right ventricle

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 S wave - Outer and Basal ventricular depolarization (B) APPLICATION ON LIMB LEADS
Table 6. S wave our outer, basal ventricular depolarization
deflection.
Electrical event Physiology
From inner to outer
ventricular depolarization,
towards the base 
stimulus or flow of positive
charge MOVES AWAY from
the positive electrode (Lead
II)
↓
Downward deflection

Net vector: Left, superior

o Left ventricle is thicker,
generates more action
potentials  ↑ voltage
 larger positive AfraTafreeh.com
deflection

ST segment Figure 3. Einthoven's triangle.

Table 7. ST segment deflection.
Electrical event Physiology
No net electrical movement
OR activity is directed
perpendicular to the axis of
Lead II
↓
Flat line, Isoelectric line
Einthoven’s triangle
o Method where the heart is situated at the center and
axis of leads are made around it
o Electrode is put on the:
 Right arm
 Left arm
 Left leg
 Right leg – neutral
● Axis of leads

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ST segment
o When the entire ventricular myocardium is completely
depolarized
o All of the charges are positive  no movement, just
waiting for it to be repolarized
o Very important for pathologies
T-wave – Ventricular Repolarization
Table 8. T wave or ventricular repolarization deflection.
Electrical event Physiology

Repolarization  negative
charge APPROACHES the
negative electrode
↓
Upward deflection

Net vector: Left, superior Figure 4. Axis of limb leads.

Table 9. Axis of limb leads.

Lead LA RA LL Axis Waveform
I (+) (-) - horizontal Refer to
(-) (+) downward Figure 4.
• Repolarization: II -
► This event is needed so ventricles can relax and diagonal
Similar
be stimulated again - (+) downward
III (-)
o Back to its resting membrane potential  diagonal
negative voltage
► Positive charge BECOMES negative charge All Leads I, II, III point to the SAME DIRECTION.
o Slight variations because of the axis of those leads
with respect to the vectors
o In general, same waveform.

EKG BASICS CARDIOVASCULAR PHYSIOLOGY : Note #4. 3 of 7

● Lead I and Lead III waveform: (C) APPLICATION ON AUGMENTED UNIPOLAR LEADS
Table 10. Lead I and IIII waveform.
Electrical Electrical Waveform &
event activity Deflection
approaches P wave,
Atrial positive electrode upward
depolarization deflection
Left, inferior
moves away from Q wave,
the positive negative
Septal
electrode deflection
depolarization
Right, superior
approaches R wave,
Outer, apical
positive electrode positive
ventricular
deflection
depolarization
Net: Left, inferior
moves away from S wave,
the positive negative
Outer, basal
electrode deflection
ventricular
depolarization
Right, superior
Net: Left, superior
Negative charge T wave,
approaches
Figure 6. Axis of augmented unipolar leads.
negative
Ventricular electrode, moves
Table 11. Axis of unipolar leads.
repolarization away from the
positive electrode Lead LA RA LL Waveform
aVR (-) (+) (-) Refer to Figure 6.
Net: Superior aVL (+) (-) (-)
Only aVR varies.
● Parts of the heart the leads interpret: - (+) avL & aVF are like
aVF (-)
Lead I-III.
● aVR
o Looks at the heart FROM the RA
AfraTafreeh.com o Net vector of negative electrodes from LA and LL is at
the middle, pointing towards the RA
o Its waveform is the EXACT OPPOSITE of Lead II.
 Important when you talk about rate and
rhythm, determination what is sinus or not,
Figure 5. Parts of the heart Leads I-III interpret. and presence of ectopic foci
o Lead I: High lateral wall of the left ventricle
 Important for STEMI
o Lead II & III: Inferior wall of the heart (both left and Table 12. Waveform of aVR.
right ventricle) Electrical Electrical Waveform &
event activity Deflection
moves away from P wave,
positive electrode negative
Atrial
(RA) deflection
depolarization
Left, inferior
approaches the Q wave,
positive electrode positive
Septal
(RA) deflection
depolarization
Right, superior
moves away from R wave,
Outer, apical positive electrode negative
ventricular (RA) deflection
depolarization
Net: Left, inferior
approaches the S wave,
Outer, basal positive electrode positive
ventricular deflection
depolarization Right, superior
Net: Left, superior
Negative charge T wave,
approaches the negative
Ventricular
positive electrode deflection
repolarization
Net: Superior

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 ● aVL, avF is similar to Lead I-III on most parts.
o There may be small variants.
o Refer to table 10
● Parts of the heart the leads interpret coming from the
positive electrode:

Figure 9. Horizontal plane of the chest (above). Parts of the

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heart the leads interpret. (below)

Figure 7. Parts of the heart Lead avR, avL, & avF interpret.
o aVR: positive electrode is on the RA
 Basal septum
 Right ventricle Figure 10. Part of the heart the leads interpret.
o aVL: positive electrode is on the LA
 High lateral wall of left ventricle Cross section of the thorax
 Like Lead I AfraTafreeh.comoo Leads converge at the AV node & basal septal portion
Each of the leads describe a separate portion of the heart
o aVF: positive electrode is on the LL
 Inferior wall of the heart ● Q waves
 Like Lead II, III o Rarely seen in V1-V3
(D) APPLICATION ON UNIPOLAR PRECORDIAL ● Progression of R wave
LEADS o First positive deflection in QRS
o Recall:
One of the more important leads out of the 12 limb leads
 Small RV vector for R wave
because they can tell us a lot about pathology
 Bigger LV vector for R wave
Unipolar:
 Mean R wave is in between them but leans more
o Only 1 positive electrode that we put on different
towards LV vector
regions of the chest
o Progressively increases / R wave becomes bigger
o Only pick up the vectors that are moving towards
across V1-V6
them or away from them.
Part of the heart Interpretation
Lead
it interprets
Smaller R wave due to smaller R
V1, V2
wave vector
Right ventricle Progressively bigger R wave
since Lead V3 is getting closer
V3
to the bigger LV vector for R
wave
Transition point
V4 Leaning more towards bigger LV
Figure 8. Chest leads placement. vector for R wave
Left ventricle
Table 13. Chest leads placement. Progressively bigger R wave
V5, V6
Chest Leads Biggest at V6
V1 V2 V3 V4 V5 V6 ● Progression of S wave
4th ICS 4th ICS between 5th ICS 5th ICS 5th ICS o Second positive deflection in QRS
(R) PSB (L) PSB V2 & V4 on (L) MCL (L) AAL (L) MAL o Depolarization of bases, moving away from the
the (L) positive electrodes
Note:  direction of electrical activity is superior, right 
o Skip V3 because this is placed between V2 and V4 negative deflection
o Progressively decreases / S wave becomes smaller
across V1-V6

EKG BASICS CARDIOVASCULAR PHYSIOLOGY : Note #4. 5 of 7

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Portions of the heart these leads interpret 1 Large box (thick outline)
o Width: 5 mm
Refer to Figure 9
Table 14. Portions of the heart limb and chest leads interpret.
 More important one
 Measured over time
Parts of the heart Limb Leads Chest Leads
 5 mm = 0.20 seconds
RV aVR V1-V3 o Height: 5 mm
Basal septum V2-V3  Determines the amplitude or voltage
Anterior wall of the -  5 mm = 0.5 mv
V2-V4
heart 1 large box = 25 small boxes
High lateral wall of Lead I, avL o 1 small box
V5-V6
the LV  Width: 1 mm = 0.04 seconds
Inferior wall of the Lead II, III,  Height: 1 mm = 0.1 mv
-
heart avF • Important for measuring ST segment elevation
PR-interval
o Important for pathologies
III) EKG STRIP o Normal: <0.20 seconds = less than 1 large box
o If prolonged, can be due to different types of heart
blocks
QT-interval
o Important for pathologies
o Prolonged width: ~500 ms
AfraTafreeh.com  ↑ risk of polymorphic ventricular tachycardia (type
of arrhythmia)
o Normal in Male: <430 ms
o Normal in Female: <460 ms
ST segment
o Important for pathologies
Figure 11. Sample EKG strip. QRS complex:
o Normal or Narrow Width: <0.12 seconds = <3 boxes
 0.12 seconds / 0.04 seconds per 1 small box = 3
small boxes
 >12 seconds = wide QRS is pathological

Figure 12. Demonstration of large and small boxes'

measurements.

IV) APPENDIX

Table 15. Abbreviations.

AAL Anterior axillary line
LA Left arm
LL Left leg
LV Left ventricle
MAL Mid axillary line
MCL Midclavicular line
PSB Parasternal border
RA Right arm
RV Right ventricle

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 VI) REFRENCES
V) REVIEW QUESTIONS
● Le T, Bhushan V, Sochat M, Chavda Y, Zureick A. First Aid for
1) What lead primarily detects forces moving from head the USMLE Step 1 2018. New York, NY: McGraw-Hill Medical; 2017
● Mancini MC. Heart Anatomy. In: Berger S Heart Anatomy. New
to feet (inferiorly)? York, NY: WebMD.https://emedicine.medscape.com/article/905502-
a) Lead I & aVL overview.
b) Lead II, III, aVF ● Hill M. Cardiovascular System - Heart Histology.
c) V1, V2 https://embryology.med.unsw.edu.au/embryology/index.php/Cardiov
ascular_System_-_Heart_Histology. Rosen IM and Manaker S.
d) V5, V6 Oxygen delivery and consumption. In: Post TW, ed. UpToDate .
Parts of the heart Limb Leads Chest Leads ● Waltham, MA:
UpToDate.https://www.uptodate.com/contents/oxygen-delivery-and-
RV aVR V1-V3 consumption#H4.
● McCorry LK. Physiology of the Autonomic Nervous System. Am
Basal septum V2-V3 J Pharm Educ .2007; 71(4): p.78. doi: 10.5688/aj710478.
Anterior wall of the - ● Standring S. Gray's Anatomy: The Anatomical Basis of Clinical
V2-V4 Practice. Elsevier Health Sciences; 2016
heart
● Leslie P. Gartner, James L. Hiatt. Color Textbook of Histology.
High lateral wall of Lead I, avL New York (NY): Grune & Stratton Inc.; 2006
V5-V6
the LV ● U. S. National Institutes of Health, National Cancer Institute. NIH
SEER Training Modules - Classification & Structure of Blood
Inferior wall of the Lead II, III, Vessels.
-
heart avF AfraTafreeh.com
https://training.seer.cancer.gov/anatomy/cardiovascular/blood/classi
fication.html.
2) In normal ECG, what does the q wave in v6 ● Ostenfeld E, Flachskampf FA. Assessment of right ventricular
correspond to? volumes and ejection fraction by echocardiography: from geometric
approximations to realistic shapes. Echo research and practice
a) Atrial depolarization .2015; 2(1): p.R1-R11. doi: 10.1530/ERP-14-0077.
b) Right ventricular depolarization ● Maceira AM, Prasad SK, Khan M, Pennell DJ. Reference right
c) Right ventricular repolarization ventricular systolic and diastolic function normalized to age, gender
and body surface area from steady-state free precession
d) Septal depolarization cardiovascular magnetic resonance.. Eur Heart J .2006; 27(23):
3) What is the normal direction/vector of the atrial p.2879-88. doi: 10.1093/eurheartj/ehl336. Klabunde RE.
Hemorrhagic Shock.
depolarization? http://www.cvphysiology.com/Blood%20Pressure/BP031.
a) Left-Anterior-Inferior ● Drucker WR, Chadwick CD, Gann DS. Transcapillary refill in
b) Left-Anterior-Superior hemorrhage and shock.. Arch Surg .1981; 116(10): p.1344-53.
pmid: 7283706.
c) Right-Anterior-Superior ● Kaur P, Basu S, Kaur G, Kaur R. Transfusion protocol in
d) Right-Posterior-Inferior trauma. J Emerg Trauma Shock .2011; 4(1): p.103. doi:
10.4103/0974-2700.76844.
4) Where is the lead v6 attached to? ● Campbell RL, Li JTC, Nicklas RA, Sadosty AT. Emergency
a) 4th ICS, left PSB department diagnosis and treatment of anaphylaxis: a practice
b) 4th ICS, right PSB parameter. Ann Allergy Asthma Immunol .2014; 113(6): p.599-608.
doi: 10.1016/j.anai.2014.10.007
c) 5th ICS, anterior axillary line ● Consortium for Spinal Cord Medicine. Early acute management
d) 5th ICS, mid-axillary line AfraTafreeh.com in adults with spinal cord injury: A clinical practice guideline for
health-care professionals.. J Spinal Cord Med .2008; 31(4): p.403-
5) True or False. When using chest leads, you will 79. pmid: 18959359.
notice that the R wave progressively increases from ● Marieb EN, Hoehn K. Anatomy & Physiology. Hoboken, NJ:
leads V1 to V6—V6 having the largest R wave. Pearson; 2020. Boron WF, Boulpaep EL. Medical Physiology.;
2017. "
a) True
b) False

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