ECG READING

ECG Reading:
■ 1. Determine the patients age and gender.
■ 2. Rate and Rhythm
■ 3. Axis deviation (P axis, QRS axis)
■ 4. Check the AV conduction (P wave and PR interval)
■ 5. Check the Ventricular conduction (QRS complex, duration,
ST segment, T wave and QT interval)
■ 6. Evaluate for chamber enlargement or hypertrophy
1. Patients Age and Gender
■ Patient R.M, 6 years old, Female
■ ECG taken on September 2, 2021
 2. Rate and Rhythm

■ A. Rate – calculated by measuring the P-P (atrial rate) or R-R interval (ventricular rate)
■ Lead II is most commonly used to calculate the rate
■ Formula for HR = 1500/# of small squares between R-R

10 small squares

HR =
1500/11

= 136 bpm
Tachycardic
“Rule of 300”
 ■ Rhythm
■ A normal rhythm implies that that the cardiac impulse originates from the sinoatrial
node (e.g. Sinus rhythm)
■ The normal sinus rhythm is characterized by:
1. P waves preceding each QRS complex
2. Normal P axis: P waves must be upright in leads I and avF

Patient R.M: P waves precede each QRS and P waves are upright in Leads I and avF = SINUS RHYTHM
■ Step 3: P wave and QRS axis
■ The electric axis (direction of net electric force in the heart) can change in different
cardiac conditions such as chamber enlargement or conduction disturbances
■ P wave Axis
- Mean vector of atrial depolarization
- Electrical activity is generated from the high RA to the low septal RA and is generally
moving from the right side of the heart to the left ward direction
-Sinus P wave should appear positive in leads I, II and aVf and negative in lead avR

Normal P wave Axis

■ QRS Axis
■ Mean vector of ventricular depolarization
■ Axis should be predominantly left sided ( Newborns = right sided deviation)
■ Abnormalities of Axis can signify ventricular enlargement or conduction blocks
■ Quadrant Method Observing the direction of the QRS axis in leads I and avF

In our patient QRS axis is (+) in both

Lead aVF and Lead I

Which is a normal QRS deviation

■ 4. Check the AV conduction (P wave and PR interval)

• P waves are usually symmetric and mound shaped

• Biphasic and notched p waves can be seen in children
• Examining P waves is important for the diagnosis of atrial enlargement
• Best assessed in lead II

Tall and peaked P waves

>3mm (3 small sq)

Wide and notched P waves

in lead II, >0.10 sec in
children
Patient RM – P waves were less than 3 mm and not greater than 1 mm (0.10 sec)
No atrial enlargement noted
PR Interval
• Best assessed in Lead II
• Calculated by measuring the beginning of P wave to the first defection of the QRS
• Normal value for the PR interval depends on the HR and age
• Usually <0.2 s in older children and <0.13 sec in newborns

Patient R.M -
Shows PR interval of 4 small boxes or 0.16 seconds
Which is prolonged PR interval for her HR and age bracket (N=0.12)

Prolonged PR intervals – can signify Myocarditis (rheumatic fever,

viral, diptheria) digitalis or quinidine toxicity, congenital HD,
myocardial dysfunction or hyperkalemia
Step 5 : Check the Ventricular conduction (QRS complex, duration, ST segment, T wave
and QT interval)
■ QRS complex duration
-measured from beginning of the Q wave to the end of the S wave
-best assessed in V5, usually <0.12s or 3 small boxes

2 small boxes or 0.08s - not prolonged

■ QT interval

QT = 0.28 (7 small boxes)

RR = 0.44 (11 small boxes)

QTc = 0.28/0.44
QTc= 0.63
Prologed QT interval
Normal QTc is 0.40s
Step 6 Evaluate for chamber enlargement or hypertrophy :

Patient RM = S waves in V1 <20mm, T waves in V5 and V6 <25 mm (<25

small boxes, 1 small box = 1 mm) , non inverted T waves, Q waves <3 mm
ECG reading

■ Sinus Tachycardia
■ Prolonged PR interval
■ Prolonged QT interval