EKG Interpretation
The Normal Conduction System
EKG Leads
Leads are electrodes which measure
the difference in electrical potential
between either:
1. Two different points on the body (bipolar leads)
2. One point on the body and a virtual reference point
with zero electrical potential, located in the center of
the heart (unipolar leads)
EKG Leads
The standard EKG has 3 Standard Limb Leads
12 leads: 3 Augmented Limb Leads
6 Precordial Leads
The axis of a particular lead represents the
viewpoint from which it looks at the heart.
Standard Limb Leads
Standard Limb Leads
Augmented Limb Leads
All Limb Leads
Precordial Leads
Precordial Leads
Summary of Leads
Limb Leads Precordial
Leads
Bipolar I, II, III -
(standard limb leads)
Unipolar aVR, aVL, aVF V1-V6
(augmented limb
leads)
Arrangement of Leads on the EKG
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
EKG Distributions
Anteroseptal: V1, V2, V3, V4
Anterior: V1–V4
Anterolateral: V4–V6, I, aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF, and
V5 and V6
Waveforms
EKG Waveforms
Wave or waveform refers to movement
away from the baseline or isoelectric
line [beginning and ending of all waves]
Positive deflection - above isoelectric line
Negative deflection - below isoelectric line
EKG Waveforms
Electrical
impulse
leaves SA node;
produces waveform
on graph paper
One complete
Cardiac Cycle = P,
Q, R, S, [ QRS
complex ] and T
wave
P Wave
Firstwave produced
by electrical impulse
from SA Node
smooth, rounded
upward deflection
depolarization of left
and right atria
0.10 sec. In length
PR Interval
Time impulse travels from SA node through
internodal pathways in atria toward ventricles
time interval from start of P wave to start of QRS
0.12 - 0.20 sec. In length
QRS Complex
Consists of Q, R, S waves
represents conduction of impulse from Bundle of His through
ventricular muscle
ventricular depolarization
QRS Complex
Q Wave = first
downward deflection
R Wave = first upward
deflection
◦ largest deflection seen in
lead I and II
S Wave = downward
deflection after R wave
Measures less then
0.12 sec. [ 3 small
boxes ]
J Point
Pointwhere QRS meets ST Segment
Consideration of ST segment elevation or depression
begins with the analysis of the J Point
ST Segment
Time interval
during which
ventricles
depolarized and
repolarization of
ventricles begin
isoelectric or
consistent with
baseline
T Wave
Follows ST segment
represents ventricular repolarization
slightly rounded, positive deflection
“resting phase “ of cardiac cycle
12 Lead
Leads I, II, III,
QRS is a positive
deflection
aVR QRS is a
negative
deflection
aVL QRS is
Biphasic
aVF QRS is a
Positive
deflection
12 Lead
V Leads
◦ V 1 –QRS is a
negative deflection
◦ QRS progresses
through until V6
◦ V6 QRS is a
positive deflection
◦ This is referred to
as normal R Wave
Progression
Summary of EKG Waveforms
P Wave = Atrial depolarization
QRS Complex = ventricular
depolarization, atrial repolarization
T Wave = Ventricular repolarization
Interpretation
Develop a systematic approach to
reading EKGs and use it every time
The system we will practice is:
◦ Rate
◦ Rhythm (including intervals and blocks)
◦ Axis
◦ Hypertrophy
◦ Ischemia
Rate
Rule of 300- Divide 300 by the
number of boxes between each QRS
= rate
Number of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
Rate
HR of 60-100 per minute is normal
HR > 100 = tachycardia
HR < 60 = bradycardia
What is the heart rate?
(300 / 6) = 50 bpm
Rhythm
Sinus
◦ Originating from SA node
◦ P wave before every QRS
◦ P wave in same direction as QRS
What is this rhythm?
Normal sinus rhythm
Normal Intervals
PR
◦ 0.20 sec (less than one
large box)
QRS
◦ 0.08 – 0.10 sec (1-2 small
boxes)
QT
◦ 450 ms in men, 460 ms in
women
◦ Based on sex / heart rate
◦ Half the R-R interval with
normal HR
Prolonged QT
Normal
◦ Men 450ms
◦ Women 460ms
Corrected QT (QTc)
◦ QTm/√(R-R)
Causes
◦ Drugs (Na channel blockers)
◦ Hypocalcemia, hypomagnesemia, hypokalemia
◦ Hypothermia
◦ AMI
◦ Congenital
◦ Increased ICP
Blocks
AV blocks
◦ First degree block
PR interval fixed and > 0.2 sec
◦ Second degree block, Mobitz type 1
PR gradually lengthened, then drop QRS
◦ Second degree block, Mobitz type 2
PR fixed, but drop QRS randomly
◦ Type 3 block
PR and QRS dissociated
What is this rhythm?
First degree AV block
PR is fixed and longer than 0.2 sec
What is this rhythm?
Type 1 second degree block
(Wenckebach)
What is this rhythm?
Type 2 second degree AV block
Dropped QRS
What is this rhythm?
3rd degree heart block (complete)
The QRS Axis
Represents the overall direction of the heart’s activity
Axis of –30 to +90 degrees is normal
The Quadrant Approach
QRS up in I and up in aVF = Normal
What is the axis?
Normal- QRS up in I and aVF
Hypertrophy
Add the larger S wave of V1 or V2 in
mm, to the larger R wave of V5 or V6.
Sum is > 35mm = LVH
Ischemia
Usually indicated by ST changes
◦ Elevation = Acute infarction
◦ Depression = Ischemia
Canmanifest as T wave changes
Remote ischemia shown by q waves
What is the diagnosis?
Acute inferior MI with ST elevation
in leads II, III, aVF
What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia
Let’s Practice
Normal Sinus Rhythm
Mattu, 2003
First Degree Heart Block
PR interval >200ms
Junctional Rhythm
Rate 40-60, no p waves, narrow complex QRS
Lateral MI
Reciprocal changes
Inferolateral MI
ST elevation II, III, aVF
ST depression in aVL, V1-V3 are reciprocal changes
Anterolateral / Inferior Ischemia
LVH, AV junctional rhythm, bradycardia
First Degree Heart Block, Mobitz Type I (Wenckebach)
PR progressively lengthens until QRS drops
Right Ventricular Myocardial Infarction
Found in 1/3 of patients with inferior MI
Increased morbidity and mortality
ST elevation in V4-V6 of Right-sided EKG
Second Degree Heart Block, Mobitz Type II
PR interval fixed, QRS dropped intermittently
Left Bundle Branch Block
Monophasic R wave in I and V6, QRS > 0.12 sec
Loss of R wave in precordial leads
QRS T wave discordance I, V1, V6
Consider cardiac ischemia if a new finding
Right Bundle Branch Block
V1: RSR prime pattern with inverted T wave
V6: Wide deep slurred S wave
