EKG

ECG tracings are recorded on grid paper. The horizontal axis of the
EKG paper records time, with black marks at the top indicating 3 second intervals.
Each second is marked by 5 large grid blocks. Thus each large block equals 0.2 second. The
vertical axis records EKG amplitude (voltage). Two large blocks equal 1 millivolt (mV). Each small
block equals 0.1 mV.
Within the large blocks are 5 small blocks, each representing 0.04 seconds.

Normal EKG tracings consist of waveform components that indicate electrical events during one
heart beat. These waveforms are labeled P, Q, R, S, T and U. The following descriptions are with
respect to Lead II.
P wave is the first deflection and is normally a positive (upward) waveform. It indicates atrial
depolarization.
QRS complex follows the P wave. It normally begins with a downward deflection, Q; a larger
upward deflection, R; and then a downward S wave. The QRS complex represents ventricular
depolarization and contraction.
T wave is normally a modest upward waveform, representing ventricular repolarization.
U wave indicates the recovery of the Purkinje conduction fibers. This wave component may not be

observable.
Rhythm

For ventricular rhythms, examine the R to R intervals on the EKG strip. Calipers or paper
marks can be used to fix the distance for one R-R interval and then this distance can be
compared to other R-R pairs. Within this web site, you will also be able to use virtual calipers.
Are they regular, meaning that each heart beat's R-R interval is equal? Small variations of up
to 10% are considered equal. Is the rhythm regularly irregular? For example is there a pattern,
such as increasing R-R durations? Or perhaps groups of similar intervals as illustrated on the
right? Or are R-R intervals completely irregular?
For atrial rhythm, observe the P-P intervals. Are they regular (minor variations can be caused
by the breath cycle)? If P-P intervals are irregular, is there a pattern?

Heart Rate

There are several methods for determining heart rate. Our first method is simple. Count the
number of QRS complexes over a 6 second interval. Multiply by 10 to determine heart rate.
This method works well for both regular and irregular rhythms. In the first image, we can
count 7 QRS complexes, so the heart rate is 70.
The second method uses small boxes. Count the number of small boxes for a typical R-R
interval. Divide this number into 1500 to determine heart rate. In the second image, the
number of small boxes for the R-R interval is 22.5. The heart rate is 1500/21.5, which is
69.8.

P Wave
The P wave represents atrial depolarization. In a normal EKG, the P-wave precedes the QRS
complex. It looks like a small bump upwards from the baseline. The amplitude is normally
0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is 0.06-0.11 seconds (1.5 to 2.75
small boxes). The shape of a P-wave is usually smooth and rounded.
P-wave questions:

Are they present?

Do they occur regularly?

Is there one P-wave for each QRS complex?

Are the P-Waves smooth, rounded, and upright?

Do all P-Waves have similar shapes?

PR Interval

The PR Interval indicates AV conduction time.

In this step you should measure the interval from where the P wave begins until the beginning
of the QRS complex. Calipers, marked paper or counting small boxes methods can be used to
determine PR Intervals. Normally this interval is 0.12 to 0.20 seconds (3 to 5 small boxes) in
adults, longer in elderly people. This interval shortens with increased heart rate.
Also evaluate if PR Intervals are constant or varying across the EKG strip. If they vary,
determine if the variations are a steady lengthening until the point where an expected QRS
does not appear.
PR Interval questions to address:

Does the PR-Interval fall within the norm of 0.12-0.20 seconds?

Is the PR-Interval constant across the ECG tracing?

QRS Complex

The QRS complex indicates ventricular depolarization. Depolarization triggers contraction of

the ventricles.
Because of the larger tissue mass, the QRS complex is larger than the P wave. While the
prototypical QRS complex consists of three wave components, one or two of these
components may be missing.
In this step, measure the QRS interval from the end of the PR interval to the end of the S
wave. Use calipers, marking paper or by counting small boxes. Normally this interval is 0.06
to 0.12 seconds (1.5 to 3 boxes).
QRS questions:

Does the QRS interval fall within the range of 0.08-0.12 seconds?

Are the QRS complexes similar in appearance across the ECG tracing?

T Wave

The T wave indicates the repolarization of the ventricles. It is a slightly

asymmetrical waveform that follows (after a pause), the QRS complex.
Take note of T waves that have a downward (negative) deflection or of
T waves with tall, pointed peaks.
The U-wave is a small upright, rounded bump. When observed, it
follows the T-wave.

QT Interval

The QT interval represents the time of ventricular activity including both depolarization and
repolarization.
It is measured from the beginning of the QRS complex to the end of the T wave. Normally, the
QT interval is 0.36 to 0.44 seconds (9-11 boxes). The QT interval will vary with patient gender,
age and heart rate. Another guideline is that normal QT Intervals is less than half of the R-R
Interval for heart rates below 100 bpm.

ST Segment

The ST segment represents the early part of ventricular repolarization.

The ST segment is the line that from the end of the QRS complex to
beginning of the T wave. Normally the ST segment is flat relative to
the baseline.