EKG Interpretation: Amir Aziz Alkatiri

EKG Interpretation
Amir Aziz Alkatiri

Objectives
 The Basics
 Interpretation
 Clinical Pearls
 Practice Recognition
The Normal Conduction System
Lead Placement
aVF
All Limb Leads
Precordial Leads
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
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
 Ischemia
 Hypertrophy
 Electrolyte imbalance
 Other abnormalities
ECG Interpretation
What is your approach to reading an ECG?

•Rate
•Rhythm
•Axis
•Hypertrophy
•Intervals
•P wave
•QRS complex
•ST segment – T wave
Rate
 Rule of 300- Divide 300 by the number
of boxes between each QRS = rate
Number of Rate
big 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?
www.uptodate.com
(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
Intervals
What is the normal PR interval?
•0.12 to 0.20 s (3 - 5 small squares). Short PR – Look for Wolff-

Parkinson-White. Long PR – 1st Degree AV block
What is the normal QRS?
•< 0.12 s duration (3 small squares). Long QRS - look for bundle
branch block, ventricular pre-excitation, ventricular pacing or
ventricular tachycardia
What is the normal QTc (QT/square root of RR)?
•< 0.42 s. Long QTc can lead to torsades to pointes.

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
P wave
 Always positive in lead I and II
 Always negative in lead aVR
 < 3 small squares in duration
 < 2.5 small squares in amplitude
 Commonly biphasic in lead V1
 Best seen in leads II
P Waves
Evaluate the shape, height and width of P waves.
•Multiple morphologies  Wandering pacemaker or
Multifocal atrial tachycardia
•Notched (M-shaped) P-wave in I and II, > 0.12 s  P-

mitrale seen in severe left atrial enlargement
Right Atrial Enlargement
 Tall (> 2.5 mm), pointed P waves (P Pulmonale)
Left Atrial Enlargement
 Notched/bifid (‘M’ shaped) P wave (P mitrale in
limb leads)
P Pulmonale
P Mitrale
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
First degree AV block
PR is fixed and longer than 0.2 sec
Type 1 second degree block (Wenckebach)
Type 2 second degree AV block
Dropped QRS
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
Ischemia
 Usually indicated by ST changes
 Elevation = Acute infarction
 Depression = Ischemia
 Can manifest 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
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

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
Hyperkalemia
Tall, narrow and symmetric T waves

Hypokalemia
U waves
Can also see PVCs, ST depression, small T waves
Wolff-Parkinson-White Syndrome
Short PR interval <0.12 sec

Prolonged QRS >0.10 sec
Delta wave
Can simulate ventricular hypertrophy, BBB and previous MI
Brugada Syndrome
RBBB or incomplete RBBB in V1-V3 with convex ST elevation

Brugada Syndrome
 Autosomal dominant genetic mutation
of sodium channels
 Causes syncope, v-fib, self terminating
VT, and sudden cardiac death
 Can be intermittent on EKG
 Most common in middle-aged males
 Can be induced in EP lab
 Need ICD
Arrythmias
 Tachycardia
 Bradycardia
Atrial Flutter with Variable Block
Sawtooth waves
Typically at HR of 150
Torsades de Pointes
Notice twisting pattern

Treatment: Magnesium 2 grams IV
Supraventricular Tachycardia
Retrograde P waves
Narrow complex, regular; retrograde P waves, rate <220

Ventricular Tachycardia
Right Bundle Branch Block
V1: RSR prime pattern with inverted T wave

V6: Wide deep slurred S wave
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
Thank You
Any Questions?

EKG Interpretation: Amir Aziz Alkatiri

Uploaded by

Copyright:

Available Formats

EKG Interpretation: Amir Aziz Alkatiri

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

EKG Interpretation: Amir Aziz Alkatiri

Uploaded by

Copyright:

Available Formats

EKG Interpretation

Amir Aziz Alkatiri

What is your approach to reading an ECG?

What is the normal PR interval?

•0.12 to 0.20 s (3 - 5 small squares). Short PR – Look for Wolff-

What is the normal QRS?

What is the normal QTc (QT/square root of RR)?

•< 0.42 s. Long QTc can lead to torsades to pointes.

•Notched (M-shaped) P-wave in I and II, > 0.12 s  P-

ST elevation II, III, aVF

LVH, AV junctional rhythm, bradycardia

Tall, narrow and symmetric T waves

Short PR interval <0.12 sec

RBBB or incomplete RBBB in V1-V3 with convex ST elevation

Notice twisting pattern

Narrow complex, regular; retrograde P waves, rate <220

V1: RSR prime pattern with inverted T wave

Monophasic R wave in I and V6, QRS > 0.12 sec

You might also like