Basic EKG For Dummies

R. Javelosa, Jr., MD. FPCP. FPCC

Section of Cardiology Department of Medicine UERMMMC

Cardiac Anatomy

Cardiac Cycle
Step 1: Rapid filling of ventricles

Ventricular pressure drops below atrial pressure

AV valves are open, semilunar valves are closed Rapid ventricular filling occurs 70-90% of the ventricles fill with blood

Cardiac Cycle

Step 2: Atrial systole P wave occurs Atrial contraction Pushed 10-30% more blood into ventricle

Cardiac Cycle
Step 3: Isovolumetric contraction QRS just occurred Contraction of the ventricles causes ventricular pressure to rise above atrial pressure, AV valves close Ventricular pressure is still less than aortic pressure Semilunar valves are closed Volume of blood in the ventricle is EDV

Cardiac Cycle
Step 4: Ejection Contraction of the ventricles causes ventricular pressure to rise above aortic pressure, Semilunar valves open Ventricular pressure is still greater than atrial pressure AV valves are still closed Volume of blood ejected by the ventricles: stroke volume (SV)

Cardiac Cycle
Step 5:

T-wave occurs
Ventricular pressure drops below aortic pressure

Back pressure causes semilunar valves to close

Cardiac Cycle

Step 6: Isovolumetric relaxation

AV valves are still closed Semilunar valves are still closed Volume of blood in ventricles: ESV

QRS P T

The Limb Leads

The Precordial Leads

The Precordial Leads

Sequence of ECG Interpretation

1. 2. 3. 4. 5. 6. 7. Rate Rhythm Axis Hypertrophy Infarction Injury Ischemia

Interpretation Sequence
Check the patient details - is the ECG correctly labelled? What is the rate? Is this sinus rhythm? If not, what is going on? What is the mean frontal plane QRS axis (You may wish at this stage to glance at the P and T wave axes too) Are the P waves normal (Good places to look are II and V1) What is the PR interval?

Interpretation Sequence
Are the QRS complexes normal? Specifically, are there:
significant Q waves? voltage criteria for LV hypertrophy? predominant R waves in V1? widened QRS complexes?

Are the ST segments normal, depressed or elevated? Quantify abnormalities. Are the T waves normal? What is the QT interval? Are there abnormal U waves?

What is the Rate?

Identify an R wave that falls on the marker of a `big block' Count the number of big blocks to the next R wave. 300 / # of big squares or 300, 150, 100, 75, 50 sequence 1500 / # of small squares

What is the Rate?

What is the Rate?

Step 2. What is the Rhythm?

Sinus? Junctional? Ventricular? Pacemaker? AF? VF?

Junctional or AV Nodal Rhythm

Step 3. What is the QRS Axis?

Frontal QRS Axis

Extreme RAD NW axis
Right axis deviation

Left axis deviation

Normal axis

Using leads I and aVF the axis can be calculated to within one of the four quadrants at a glance.

The QRS Axis

Normal axis : both I and aVF (+) Right axis deviation : lead I (-) and aVF (+) Left axis deviation: lead I (+) and aVF (-) Northwest Territory : both I and aVF (-)

Causes of left axis deviation

Left ventricular hypertophy Inferior myocardial infarction Artificial cardiac pacing Emphysema Hyperkalemia Wolff-Parkinson-White syndrome - right sided accessory pathway Tricuspid atresia Ostium primum ASD

Causes of right axis deviation

Normal finding in children and tall thin adults Right ventricular hypertrophy Chronic lung disease even without pulmonary hypertension Anterolateral myocardial infarction Left posterior hemiblock Pulmonary embolism Wolff-Parkinson-White syndrome - left sided accessory pathway Atrial septal defect Ventricular septal defect

Causes of a Northwest axis

Emphysema Hyperkalemia Lead transposition Artificial cardiac pacing Ventricular tachycardia

Step 4. Check the P-R Interval for AV blocks

Second Degree AV Block

Mobitz Type I (Wenckebach) Mobitz Type II

Causes of AV Blocks
Autonomic Carotid sinus hypersensitivity Drug-related Beta blockers Adenosine Ca channel blockers Antiarrhythmics (class I & III) Digitalis Lithium

Metabolic/endocrine Hyperkalemia Hypothyroidism Hypermagnesemia Adrenal insufficiency

Causes of AV Blocks
Infectious Endocarditis Tuberculosis Lyme disease Diphtheria Chagas disease Toxoplasmosis Syphilis Heritable/congenital Congenital heart disease Maternal SLE Kearns-Sayre syndrome Emery-Dreifuss MD Myotonic dystrophy Progressive familial heart block

Causes of AV Blocks
Inflammatory SLE MCTD Rheumatoid arthritis Scleroderma Infiltrative Amyloidosis Hemochromatosis Sarcoidosis Coronary artery disease Acute MI Neoplastic/traumatic Lymphoma Radiation Mesothelioma Catheter ablation Melanoma Degenerative Lev disease Lengre disease

Step 5. Look for Ectopic beats

Atrial? Ventricular?

Step 6. Is there Chamber Enlargement?

Left atrial enlargement

a.
b.

c.

P wave duration equal or more than 0.12 sec. Notched, slurred P wave in lead I and II (P mitrale). Biphasic P wave in lead V1 with a wide deep and negative terminal component.

Right atrial enlargement

a. b. P wave duration equal or less than 0.11 sec. Tall, peaked T wave equal or more than 2.5 mm in amplitude in lead II,III or aVF (P pulmonale). Mean P wave axis shifted to the right (more than +70 degrees).

c.

Ventricular Hypertrophy

Left Ventricular Hypertrophy

Left ventricular enlargement

a. "Voltage criteria": 1. R or S wave in limb lead equal or more than 20mm 2. S wave in V1,V2 or V3 equal or more than 30mm 3. R wave in V4,V5 or V6 equal or more than 30mm. Depressed ST segment with inverted T waves in lateral leads(strain pattern ;more reliable in the absence of digitalis therapy. Left axis of -30 degree or more. QRS duration equal or more than 0.09 sec.

b.

c. d.

e. Time of onset of the intrinsicoid deflection ( time from the beginning of the QRS to the peak of the R wave ) equal or more than 0.05 sec in lead V5 or V6.

Right ventricular enlargement

a. Tall R waves over the right precordium and deep S waves over the left precordium ( R:S ratio in lead V1 > 1.0) b. Normal QRS duration (if no bundle branch block) c. Right axis deviation. d. ST-T "strain" pattern over the right precordium. e. Late intrinsicoid deflection in lead V1 or V2.

Step 7. Examine QRS Duration

Left bundle branch block

a. QRS duration equal or more than 0.12 sec. b. Broad , notched or slurred R wave in lateral leads( I, aVL , V5,V6 ) c. QS or rS pattern in the anterior precordium. d. Secondary ST-T wave changes ( ST and T wave vectors are opposite to the terminal QRS vectors). e. Late intrinsicoid deflection in lead V5 and V6.

Right bundle branch block

a. b. c. d. e. f. QRS duration equal or more than 0.12 sec. Large R' wave in lead V1( rsR' ). Deep terminal S wave in lead V6. Normal septal Q wave. Inverted T wave in lead V1 ( secondary T wave changes ). Late intinsicoid deflection in lead V1 and V2.

Step 8. Look for ST Segment Abnormalities

Localization of Infarction

Localization of MI with the help of EKG

Anterior wall V1 through V6 V1 through V3 II, III, aVF V4R, V3R V7 through V9 V1 through V3 ( ST depression)

Anteroseptal Inferior Right ventricular Posterior wall

Thank you for not sleeping!